Tuesday, March 31, 2015

No Information From The EHR - An Ongoing Problem

Like most physicians - I like the concept of an electronic health record (EHR).  It is just that the real EHR as it exists is a far cry from the concept.  The proponents of the current EHR,  especially those who want it mandated by legislative activity continue to brag about the savings and all of the benefits.  Any physician looking for information or an ability to enter and move information without ending up in a click fest of mouse clicks knows the reality.  Any physician looking for a note that reflects an intelligent conversation between a physician and a patient is also left wanting.  Reading the electronic or printed out version of the EHR usually results in very choppy documentation.  Lists that are the result of not very intelligent coding by EHR IT engineers, notes produced strictly to meet billing and coding bullet points, and notes produced because they could be rapidly compiled with features like smart text.

All of this can be a nightmare for a compulsive physician like myself who wants to use all of the relevant information in patient care.  My career has been treating patients with complex medical conditions who are also on complicated combinations of medications.  Many have known heart disease and take combination of medication that can adversely affect their cardiovascular status and interact with psychiatric medications that I prescribe.  All of that needs to be considered.  Since ziprasidone (Geodon) hit the market in 2001, psychiatrists have been preoccupied with the QTc interval.  The QTc interval is the electrical interval that corresponds to the contraction and relaxation of the left ventricle.  In cases where this interval is too long it predisposes the patient to ventricular arrhythmias some of which are potentially fatal.   The FDA had a warning on ziprasidone about the potential for QTc prolongation and subsequently came out with warnings about citalopram.  In the course of clinical practice, many psychiatrists had already encountered this issue with older antipsychotic medications and tricyclic antidepressants.  The FDA makes these pronouncements but gives physicians no guidance on what to do about the clinical situations.  I have a practice of looking at ECGs and any Cardiology evaluations that have been done.  That is the only way the QTc interval can be determined and even then there are various factors that can affect it.

Rather than order an ECG, I will ask whether they have already been done and get the patients consent to have them faxed to me.  That result is frequently disappointing, especially in the case of the EHR.  I will often get a series of cryptic sheets, that look like a sparsely populated medical record.  There are often no coherent notes from physicians or if they are there, they do not contain standard information that I am looking for.  I have never seen an ECG tracing contained in these stack of records.  The best I can hope for is a brief note that lists an impression like "NSR - no acute changes."  An added bonus would be an actual description of the critical intervals.  For the tracing at the top of this page it would say:  "PR interval - 164 ms; QRS duration - 100 ms; QT/QTc - 434/415 ms."  That is really all of the information I need to know.  But the most important issue with the EHR is that all of this visual information is usually lost, unless I submit a second or third request and it usually has to say "send me the ECG tracing."  The medium that purports to provide a lot of information to physicians and put it at their fingertips is a bottleneck.  By the time I see the information I need to see, it is not necessary.  I have moved on and not recommended a treatment that I could have recommended if the ECG was normal.  That practice has been reinforced by getting an ECG after the fact and realizing that not only was there a prolonged QTc interval, and it was read that way by a Cardiologist but reported as "normal" in the EHR.

I will be the first to admit that there is minimal evidence that my tight QTc surveillance has saved any lives.  But my threshold is really to prevent any complications.  I am not treating acute heart conditions.  I am trying to make sure that I don't cause any by the medications that I prescribe, by ignoring a critical drug interaction, or by not recognizing the significance of a patients physical illness and how it needs to direct the therapy that I prescribe.

That doesn't end at ECGs.  I would throw in imaging studies (CT and MRI), EEGs, and even routine labs.  If the EHR is supposed to convey the maximum information why wouldn't all of the visual information of an episode of care be included?  Why can't all of the brain imaging studies be sent along as a disk or e-mailed to me?  Why do I have to read a 200 page fax and try to reconstruct all of the lab results  in a coherent manner that are spread randomly across those pages so that I know what happened in the hospital?

The EHR as it currently exists is a tremendous burden to physicians.  It takes far too long to enter data and quality notes about care are rare.  If you happen to lack online access to the program where the record is constructed, good like trying to piece together the information that you need for clinical decision-making.  Politicians are good with ideas, but none of them seems to be aware of the real problems that exist in these systems.  Despite that lack of knowledge they continue to insist on the wide implementation of these systems and that is really a tax on physicians that is being used to subsidize the development of EHRs and fund this industry.

Hopefully that will pay off someday, but the current problems have been there for at least a decade and there are no signs that they will be going away soon..

George Dawson, MD, DFAPA  


  1. If it wasn't so awful it would be hilarious. Like the Keystone Cops.

  2. Recent HealthCareReneweal article on same subject:


  3. EHRs are implemented so poorly that is apparent even to patients.

    What type of medical record places the negative result (h.pylori) front and center while burying the positive result (grade C esophagitis) under enough menus that you watch your physician visibly frustrated and obviously embarrassed while trying to find it?

  4. Good take on it. I tweeted your article.

    1. Thanks Dinah - As pointed out above there are more and more articles out there with this theme. Unfortunately the oligarchs are experts in inventing new businesses. Some of the current EHR vendors are already "too big to fail". Despite annual licensing fees of millions of dollars per year and an ability to reject customers on the basis of whether or not they can afford these absurd fees - the output of that system is unintelligible and inferior to my handwritten notes from the 1980s.

      In my home state the oligarchs are demanding all physicians implement the EHRs despite that one small problem.

  5. That's the problem with the "I don't need your vote" argument. The EHR vendors and other oligarchs don't need your vote or my vote and they act like it. They can use the same "above it all" and successful in their career argument to ignore valid criticism.

    Don't get me wrong, I think you are spot on about the antipsychiatry crowd and I agree with the substance of your rebuttal. Notice how they have been REALLY REALLY hoping that they can blame a plane crash on an SSRI. In effect they are doing the exact same thing they always accuse pharma of...coming to a preordained conclusion. But I think they need to be defeated on the merits of the argument, not on claiming some dismissive privilege than anyone not running for office can claim.

    By the way, Tim Cook isn't above all criticism because he doesn't need our votes. He sells iPhones in Riyadh, where being gay can get you the death penalty. So regardless of how anyone feels about Indiana, he's still a hypocrite. He should be pressured not to sell his product in four countries where being gay is a capital offense. I think that is a winnable argument.

    1. I think that there is a difference. The oligarchs pretend that there is a "free and fair" election and that somehow everybody's vote counts. They produce the illusion of needing votes and the illusion of humility while recklessly manipulating the masses.

      In the case of physicians and psychiatrists in particular, I would be shocked to learn that any psychiatrist believed that they personally or the profession had that kind of power. I think physicians and psychiatrists in general realize that we are so politically ineffective that we have minimal impact on a group of third rate oligarchs that run the medical specialty boards. We let them kick us around and pretend that we like it. I don't think that puts us "above it all" like Congress. How could we be - we would not end up being the targets of Congress?

      The only thing we are "above" is the mindless criticism of people who have no idea of what we do, no idea how difficult the work is, and no scholarship in the field.

      I hear you very clearly on the SSRI issue. I posted a link to the previous post "Homicide debate going off the rails" that was conveniently ignored. I have a new set of numbers to post this weekend if I can organize them in time. No implication of causality as the usual disclaimer - but a much more realistic look at the problem than personal anecdotes, power stories and extremely vague theories.

      I did not mean to suggest that Tim Cook is a flawless human being to all observers. At some level he is working with the same business ethics common with Big Pharma. I think he did come up with a good argument that reflects on personal accountability and expertise and why that is "above" the opinion of outsiders with mixed agendas and significant conflicts of interest.

  6. Well I'll give you this...we are in no way accountable to an organization like CCHR...and as far as I'm concerned no we don't need their vote. I was delighted to see the HBO documentary Going Clear and if you haven't you should.

    Where I get angry about "I don't need your vote" would be something like that recent obnoxious email from ABPN and ABMS on the MOC issue that you probably got about two weeks ago. Basically ABMS said, we hear you, but tough, go pound sand, and ABPN pretty much said since ABMS told us to pound sand, there's nothing we can do.

    But they are just being tools. The AAN and the endocrinology association went to bat for their people and made it clear that they had better damn well listen. The ABIM indicated they are listening and dropping some of the more nonsensical requirements. They might not need your vote, but no one likes being ridiculed or sued. These people can be shamed into doing the right thing.

    The EHR tools are more ruthless and apathetic. They could give a damn about doctors. But if we organized they would.

    Some of these antipsychiatry people obviously have serious issues that are patently obvious from their self incrimination, but if you point that out, you're just being a meanie and that just feeds the beast. I agree that in many cases it's a waste of time so I understand where you are coming from. This latest speculation about Germanwings really pissed me off. As I pointed out elsewhere, being agnostic until the facts come out means never having to say your sorry. But to some of these people even a neutral stance for them is proof that you are a tool of big pharma.

  7. "Where I get angry about "I don't need your vote" would be something like that recent obnoxious email from ABPN and ABMS on the MOC issue that you probably got about two weeks ago. Basically ABMS said, we hear you, but tough, go pound sand, and ABPN pretty much said since ABMS told us to pound sand, there's nothing we can do."

    Could not agree more. That has been the stance of the ABPN and the APA from square one: "There is nothing we can do about this. We have to comply with the ABMS". I think that the revolt against this hegemony may have traction and and result in many resignations from the APA and other professional organizations, movement to the new CME based recertifier, and retirements. At some point, there will potentially be enough docs uncertified by ABMS that administrators will need to rethink their credentialing standards.

    I be interested to see what you think about my pilot safety and SSRI piece.

  8. Dr. Paul Tierstein took on Dr. Nora who wrote the ABMS email in NEJM a few months ago and pretty much destroyed her in the debate:


    Note my comment...Dr. Nora is also a J.D....if this is such a great idea how come she isn't pushing it for her attorney colleagues.

  9. If they can't protect White House computers, they sure as hell can't protect your EHR data on the cloud:


    I say we go back to paper files in a metal cabinet. At least they need to physically break in, Ellsberg style...

    This is something valuable that cash pay does buy the patient...

    1. I think the politicians will not stand for any cash pay model in the future. In Minnesota right now there is an initiative to mandate all small and even solo practitioners to have an EHR. They don't say it now, but I know how these guys think. At some point there will be mandated interoperability with a DHS data base. Initially it will be for uploading PHQ-9 scores (all clinics are currently required to report these in Minnesota.) But eventually they will be able to launch some Matrix-like software to get what they want from every private practice.

      And if all of those private practices just went out of business? To these bureaucrats that would be an added bonus. All physicians be "managed" by an MBA (or possible somebody with a GED) accountable to poor business and government practices and a complete lack of ethics.

  10. That's effectively making psychoanalysis a crime. I don't the the elite would allow that and I don't think the courts, as awful as they sometimes are, would either. You still have to have cash pay for services not covered under CMS like elective plastic surgery or psychoanalysis. Even many of the European countries have a private health care options for those who can afford it.

    I'm obviously not a big fan of Big Government but they won't go that far simply because they want to opt out of their own mess. That's why Senators and Presidents send their kids to Sidwell Friends. Maybe if Sidwell Friends were illegal, that would force them to run better schools.

    1. Mark my words - this has been a 30 year battle led by megalomaniacs who believe that they should run medicine without any knowledge about it. It is pretty obvious to me that they will say or do anything to that end. They don't want any competition for a third rate healthcare system that is all administrative smoke and mirrors.

  11. I hear you but their hypocrisy and selfishness when it comes to their own family exceeds their megalomania. Precisely why Hollywood celebrities support the public schools but would never consider actually sending their kids to one.

    They are a venal bunch and they will want to move to the front of the line and get special treatment. There is no way they will EVER wait their turn in the Medicaid line. They want plastic surgery, fertility treatments, derm and (their version of) psych private.

    In an odd way I hope they go over the top and you're right so we can get right to open rebellion and stop this death by a thousand cuts.

    1. "I hear you but their hypocrisy and selfishness when it comes to their own family exceeds their megalomania."

      I figure that's what medical vacations are for. That and the fact that they can save a ton of money by going out of the country.

    2. In the long run maybe twenty years from now, the irony is that you will have to go private...Medicare will be insolvent...70 b in unfunded liability is the end of the Ponzi scheme....

    3. Sorry, trillions, not billions.

      Well under that dystopian scenario, the private physician would basically be Robert De Niro in Brazil:


      Practicing craft as an outlaw because we're sick of filling out forms...

  12. Megalomania with a twist...Jonah Goldberg wrote this a couple of days ago:

    "Megalothymia is a term coined by Francis Fukuyama. It’s a common mistake to think Fukuyama simply took Plato’s concept of “thumos” or “thymos” and put a “mega” in front of it because we all know from the Transformers and Toho Productions that “mega” makes everything more cool.

    But that’s not the case. Megalothymia is a neologism of megalomania (an obsession with power and the ability to dominate others) and thymos, which Plato defined as the part of the soul concerned with spiritedness, passion, and a desire for recognition and respect.

    Fukuyama defined megalothymia as a compulsive need to feel superior to others.

    And boy howdy, do we have a problem with megalothymia in America today. Everywhere you look there are moral bullies utterly uninterested in conversation, introspection, or persuasion who are instead hell-bent on grinding down people they don’t like to make themselves feel good. If you took the megalothymia out of Twitter, millions of trolls would throw their smartphones into the ocean."

    Or read any of the sanctimonious articles about idealistic healthcare from the rent-seekers....like EHR or the intermediaries...

    I should be careful, the megalothymic KOLs in the APA will lobby to put it into DSM-6