The above example is as clear as it gets in terms of illustrating the problem with electronic health record (EHR) software and associated hype and government mandates. The idea that we need an EHR is a given, and I am not arguing that point. I am arguing that the current software is inefficient, on par in many ways with software I was using on my PC in the 1990s, high maintenance, and a tremendous burden to any physician who has to use it. It is also vastly overpriced with no end to that overpricing in sight - largely due to a monopoly of manufacturers and the use of a licensing model for the software. And like practically every process in medicine these days, the implementation and actual use of EHRs is a highly politicized process that is far removed from the people who have to use it every day.
In the above example, I am tasked with a basic titration of gabapentin according to a recent research protocol (1). All of the doses used are generic 300 mg capsules of gabapentin for the purpose of simplification. The dose is titrated over 3 days to 300 mg TID (three times a day) or 600 mg TID. People reading this may have picked up prescriptions with instructions typed out on the label about how to increase the dose to a therapeutic level. In settings where a particular medication is used repeatedly and across a large patient population, the rate of titration and capsule side may need to be varied but the concept is the same.
The question is how do I get this information to the pharmacy so that the medication can be dispensed to the patient in the most effective manner. In the "old days" of paper records or the early hybrid models where all of the orders and medications were entered into a text based computerized record, I would enter the orders onto a paper order sheet. From there the pharmacist would either write up a parallel record for what the pharmacy needed to do or enter it into computerized pharmacy software. An MAR (medication administration record) would be used by nursing staff to record the administration and time of administration of every medication. There was a set of checks and balances because every dose of medication was checked at some point by a physician, a nurse, and a pharmacist. In the 1980s and 1990s, clinical pharmacists would often have close relationships with the inpatient nursing and medical staff. Those relationships were instrumental when it came to dosage changes, using novel medications, and making sure that all of the medication was given as scheduled. The entire chain of events in the case of a low dose gabapentin prescription would start with a very simple handwritten order like the one below:
That is all written in my notoriously bad handwriting but I think it is perfectly legible. I wrote it to show in two places that the capsules used here were all 300 mg and how they can be increased over three days. More importantly, I turned on a stopwatch just as I started to write this order and it took me 1 minute and 50 seconds.
Compare a recent effort using an EHR. The scratching in red at the top of this post is basically a worksheet on how to enter the medication without making a mistake. The overall titration is the same (except the starting dose is 300 mg three times a day), but there are large differences. In this case the physician is responsible for entering the medication into the pharmacy record and MAR at the same time. The convenience with which that can be done is software dependent. With the available software there are only two possibilities - add a new line of gabapentin doses to the HS, AM and Noon doses respectively over three days or rewrite the adjacent blocks of gabapentin doses and ultimately the 600 mg TID dose. The difference is that the first procedure involved three steps and the second procedure four steps. Each step also involves writing in the "Comments" section on each order to make sure that there is no confusion and that multiple doses of gabapentin do not end up being given over the course of the day. For example in the red diagram for the single gabapentin 300 mg dose at the bottom of the column on the 28th I might enter: "This is a single gabapentin 300 mg dose in the AM on 7/28/2016. It is a one time dose". Using any standard EHR will generate four or five separate orders for these simple titrations. My first time through using the top method took me 30 minutes and at the end I had broken into a cold sweats. I had to double check all of the text orders against my sketch (boxes and U-shaped checks) and the MAR. I ended up calling the pharmacist and giving him a verbal version of my sketch as a back up. The second method took me a total of 15 minutes.
This very basic example illustrates some huge problems with the EHR:
1. Fewer people have hands on the medication orders - There may of may not be an immediate double check by the pharmacist. Nursing staff are no longer entering the MAR and double checking how it looks. The entire task and all of the associated time has been shifted to the physician. When this happened, clinical pharmacists also disappeared from the floors. The hype was that we have a newer and safer systems. It should be apparent from my example that more can go wrong with the EHR titration than more traditional methods, even if there is a clinical pharmacist at the other end reading and approving hundreds of these order entries.
2. More and more time is added to the physician - The EHR is a classic example of how numerous jobs including billing and coding, transcribing, and now data entry that used to be done by a pharmacist has been added to the physician's burden over the years. It is as if physicians have unlimited time for all of these additional tasks. The time constraint has to increase the likelihood of errors in the EHR. If you have 5 or 10 minutes between patients and have to add even a mildly complicated order - it can easily take up twice that amount of time. Administrators view this as a plus, because other jobs can be eliminated and physicians never get paid for administrative time. By now it should be apparent that the enterprise wide EHR is such a financial burden on organizations that jobs need to be eliminated to pay for it - often many more jobs than the physician workload has assumed.
3. The software itself has 20th century sophistication but without the report writing capabilities or data analysis - anyone who used spreadsheet or database software in the 1990s is used to the intensive data entry approach used in the modern EHR. Should an extremely expensive, federally mandated piece of software be this clunky to use? Should it take me 5-10 times as long to enter an order with this software as it did by writing it down on a piece of paper? Should the final report of a hospitalization be a phone book sized incoherent document with very little information density? I don't think that any of these constraints should apply. I did not include the time it takes in direct conversations with a pharmacist to clarify what was entered in the EHR. Every home computing environment these days is at least partially object/icon based to minimize typing where possible. In the case of medication entry, the obvious solution would allow the physician to point and click medications on the MAR with no typing. Select the medication and dose and enter it directly into the MAR with a few mouse clicks. That would easily beat my time for writing it out and it would be more accurate than either of the approaches that I wrote about here.
I can only speculate about all of the business and political incentives in place that has resulted in the current EHR environment. A lot of them have been clearly documented on the Health Care Renewal blog by searching EHR. That search will also reveal a number of safety concerns and the inescapable political factors that currently exist in a healthcare environment that routinely ignores the concerns of physicians in favor of those with no medical expertise.
George Dawson, MD, DFAPA
1: Mason BJ, Quello S, Goodell V, Shadan F, Kyle M, Begovic A. Gabapentin treatment for alcohol dependence: a randomized clinical trial. JAMA Internal Med. Published online November 4, 2013. doi: 10.1001/jamainternmed.2013.11950.
2: Brett Boese. Mayo Clinic tries to avoid physician burnout. Rochester Post-Bulletin. July 29, 2016. Link.
Timely article on Mayo Clinic concerns about burnout and the EHR. The Mayo Clinic is currently in the process of conversion to Epic EHR and will "go live" on various dates between the summer of 2017 and fall of 2018. Tait Shanafelt was interviewed about a study he co-authored on the EHR showing the clerical burden led to decreased job satisfaction and burnout. Responding to a number of strategies to reduce physicians clerical burden his conclusion was: "The specific strategy probably used likely matters less than recognizing that physicians should not be doing this and finding a practical way to have this task completed by support staff."
3: Shanafelt TD, Dyrbye LN, Sinsky C, Hasan O, Satele D, Sloan J, West CP. Relationship Between Clerical Burden and Characteristics of the Electronic Environment With Physician Burnout and Professional Satisfaction. Mayo Clin Proc. 2016 Jul;91(7):836-48. doi: 10.1016/j.mayocp.2016.05.007. Epub 2016 Jun 27. PubMed PMID: 27313121.
4: Shanafelt TD, Hasan O, Dyrbye LN, Sinsky C, Satele D, Sloan J, West CP.Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc. 2015 Dec;90(12):1600-13. doi: 10.1016/j.mayocp.2015.08.023. Erratum in: Mayo Clin Proc. 2016 Feb;91(2):276. PubMed PMID: 26653297.