Dreaming of the EHR

The Dream:

I am at the APA convention.

It is in a crummy hotel attached to a mall. I am going down to the street level in an elevator and it stops at a level where there is a big cinema complex. An 8 year old boy runs excitedly into the elevator and jams in to my left. The elevator is crowded. He looks at my name badge and says: "What would George Dawson say if the Watson computer said he wasn't doing a good job?"

I glance down at him and say: "George Dawson would not care."

The kid says: "That's not good" and laughs intensely.......


It is all a dream. I had that dream early Saturday morning. It doesn't require detailed analysis. That last thing I did on Friday was try to review a 22-page paper record that was generated by a modern electronic health record (EHR) system. With the exception of a few paragraphs it was largely unintelligible. It contained bits and pieces of information. I was looking for imaging (CT, MRI, ultrasound reports) and ECG data, but instead could find only a few lines that summarized fewer results. There were no dates - no hospital admission or discharge date.  Although the hospitalization was longer than a week - there was no medication administration record or MAR - showing the specific dates when medications were changed.  There were no comprehensive reports that I am used to seeing for the past 30 years from Radiologists. There was no discharge summary. The documentation was basically unacceptable as a source of clinical information and yet it was created by a very high end, enterprise wide EHR system. It brought back a memory of a mandatory meeting I had with a "coding specialist" about 10 years ago. That person let me know that I had "passed" the documentation review in that I had ticked off the necessary "bullet points" so that documentation specialists would approve my EHR note for the day and the associated billing document that had to be submitted with each note.  She showed me how I could do things faster by ticking off a series of check boxes and electronically signing the note.  She was shocked when I told her that I really could not sign my name to that document because there was no sign that an intelligent human being had seen the patient.  For all of these reasons, very poor documentation in the EHR is always on my mind.

My attempt to read the last report may have been enough of a reason for the dream, but I also spent time on Thursday with a colleague who really dislikes the EHR for additional reasons. We regaled our spouses with tales of incomprehensible reports.  In addition, his reports require a synthesis of many imaging, lab, and clinical reports.  He previously used a system where all of the reports showed up in a queue and he could go down that list in chronological order to dictate the report.  In the new system, he has to go to tabs to find all of the reports he is looking for.  Some of these tabs are hyperlinked and the reports don't load very well.  In the end, he and his colleagues end up printing out all of the reports on paper so they can dictate then more efficiently without having to search for what they need in real time in the EHR.  That reminded me of an experiment I did about 8 years ago with the same EHR.  I went in and read all of the clinical notes looking for chronic diagnoses that were not addressed.  I came up with an additional 8 diagnoses from 340 clinical notes buried in the EHR. There is generally no good way for physicians to mine data on their own patients to make sure that they have done the most thorough assessment of their problems.  On the other hand administrators can get detailed numbers of mouse clicks by nurses in primary care clinics and rate their productivity in terms of mouse clicks, screen views, or tasks completed.  My colleague's theory was that the current EHR is selected for the administrative capabilities like monitoring doctors or nurses rather than any inherent advantage for medical staff.  The major evidence for that is that many EHR vendors have permanent staff in the hospital and they are making constant modifications to the EHR.  In many cases there are meetings of all the physicians in a particular department about these modifications.  The hospitals and clinics purchasing these systems are purchasing incomplete products that require what seems like constant revisions.

It has been about 15 years since the blight of the EHR hit physicians.  It was originally called the electronic medical record (EMR) but I suppose some business type decided that they could really solidify the corporate stranglehold on medicine by eliminating the word "medical" from another phrase.  Corporate psychology also dictates that they give the impression that they are maintaining health rather than treating medical problems.  That is another good reason for eliminating the word medical from the corporate lexicon.

The marketing of the EHR has been masterful.  The political hype promised untold savings.  National candidates seemed to suggest that we could actually "save" enough with the EHR that it would cover a substantial part of American health care inflation.  Any physician involved in the implementation phase of enterprise EHRs knew that was a bold faced lie.  There is no way that annual multimillion dollar a year licensing fees as far as the eye can see are going to save anybody any money.  In fact, I am certain that many clinics and hospitals have had to cut staff and services just to bankroll the EHR. Nobody has ever followed the money on the EHR debacle as far as I know.  Congress is well known to invent businesses and turn people into billionaires overnight.  All it takes is a few Congressional mandates about the need to use an EHR and electronic prescribing.  There is no mandate to keep things cost effective of make sure that independent practitioners can afford it.  There are mandates to implement EHRs and electronic prescribing and the White House brags about it.  The following graphic and text are from a White House document on the EHR entitled: More than Half of Doctors Now Use Electronic Health Records Thanks to Administration Policies.

The problem with the White House statement is that despite spending about $3 billion dollars a year and in some cases $44,000 per physician,  the value of the EHR for the reasons already stated remains in question.  It is very handy to be able to pull up lab results and x-rays on a computer screen.  It is also very handy to be able to send electronic prescriptions to any pharmacy in the country.  On the other hand, it is reasonable to expect that a multimillion dollar piece of software will write a report that any hundred dollar database software from the 1990s could write.  That same software should be capable of allowing physicians to search their own patient results for quality and report writing purposes.  In the end we are left with very expensive, high maintenance systems, and massive amounts of information that is either buried in storage because it is not easily accessible or because it is worthless and generated primarily for justifying a billing document.

That is one of the many real costs of having a health care system run by bureaucrats and politicians.  


George Dawson, MD, DFAPA


Attribution:

Photo at the top of this blog is by Paco Burrola on Flickr and is used courtesy of this Creative Commons license.

Doubling Down on The Miserable Patient

The need for managed care and the efficiency of the electronic health record are two of the biggest myths in the American health care system today.  Here is what really happens.....

I have had the occasion to be a miserable patient for the past 6 weeks.  That is what happens when you have asthma and nothing works or at least nothing seems to work very well.  Throughout the course of the illness I have dutifully kept my primary care physician up to date, but so far I have ended up seeing 6 different physicians over that time.  I received prescriptions for three different inhalers, a nebulizer machine, and two different varieties of nebulizers - albuterol and levalbuterol.  Hundreds of dollars of medications not covered by my health insurance that don't work or cause significant side effects.  The levalbuterol was prescribed because it was supposed to have fewer side effects and it worked out just the opposite and caused significant side effects with a heart rate up to 140 beats per minute.   I needed to take these treatments 3 times a day followed by another inhaler.  This is a story of what should be a very simple task of getting enough medicine to keep breathing and in this case it is the albuterol sulfate nebulizer solution.  For anyone not familiar with this product it comes in disposable 3 ml plastic vials.  You just crack it open and pour it into a nebulizer machine and inhale the solution until it is gone in about 5-10 minutes.

The nebulizer ampules come packaged inside a foil envelope inside a box.  The prescription on the other side of this box reads: "Nebulize 1 vial every 6 hours as needed for wheezing or shortness of breath."  Assuming that I continue to use them at a rate of 3 vials, that is about 90 per month.  About a week into it, I noticed I had just a couple of vials left and called the pharmacy to get more.  This is how it went (M=me, P=pharmacy, from memory and not a transcript):

M:  Yes - I am calling to refill a prescription for albuterol nebulizer solution (details given)
P:   Sorry but you have no refills on that prescription we will have to fax your doctor (reads MD name)
M:  That was the urgent care doctor, my doctor's name is Dr. Smith (details given)
P:   Well we will have to fax him then.
M:  I think you may have made a mistake on the original prescription since the paperwork I have from urgent care says that I should have gotten 75 vials and I only got 25 (see lower left corner of the label)
P:   No that is correct, we dispense them by volume rather than number.  The insurance company mandates that we do it that way - like cough syrup.
M:  That doesn't make any sense to me.  Each one of these vials is supposed to be a single dose and if I am taking three a day that is 90 vials per month.
P:   The only other way to get more vials is if your doctor writes "90 vials" on the prescription that he sends us.....
M:  He already wrote 75 and you gave me 25.
P:   No he has to write "75 vials" and spell out "vials".

At that point, I leave both a voicemail and an e-mail through the health plans messaging system for my personal physician to send in a new prescription for 75 vials of the solution.  The next day we are having one of the largest snow storms of the year and I am commuting 80 miles a day on glare ice and no visible road surface.  My commute time is 2 to 3 times normal.  I call ahead to make sure the prescription will be ready:

M:  I am calling about that albuterol nebulizer solution.
P:   We got the prescription from your doctor, but the insurance says they won't approve it because it is too early.
M:  What do you mean it's too early?  I am using it exactly as directed and you are only giving me 1 weeks worth of medication at a time.  How can it be too early?
P:   Well that's what they are saying....
M:  Look - I need this medicine to breathe.
P:   OK the medicine is approved.

I am questioning what is happening here.  I know she was not on line with the "insurance company".  Why did she suddenly change her mind on giving me a medication that I am essentially paying for out of pocket?  Do they have a secret directive that tells them to only give up the medicine if the patient appears to be in respiratory distress?  Why does the high deductible insurance have anything to say about this anyway?  They are policing my prescriptions for non-addicting medication and they have become an obstacle to my health care.   It made me think about all of the "Dear Dr." letters that are sent out by pharmaceutical benefit managers (PBMs) and managed care organizations (MCOs) where they claim their want to "partner" with physicians to improve the overall health care of the patient.  It is typically advice about drug interactions.  They rarely have the drugs right and never have the accurate prescribing physicians correct.  Is this how "partnering" improves my health?  Was she just bluffing to keep insurance company money off the table?  Are big retail pharmacies that intimidated by managed care?

I didn't have time to figure it out.  The snow was still coming down and there was a question about whether or not I was going to make it with four wheel drive.  An hour and a half later I pulled up to the pharmacy drive through and picked up a thoroughly stapled bag containing the vials.  I tore it open in the parking lot and my suspicions were confirmed.  There was another box of 25 - 3 ml vials, not the 75 I had requested or the "75 vials" that my physician was supposed to have ordered.  Two days of work going through the most sophisticated electronic health record available and nothing had changed.

This is one isolated example of a sequence of events that probably repeats itself tens of thousands of times per day.  It doesn't take much to realize that the combination of obstacles and ineffective medications that occurs by this process is a windfall for both the managed care industry and the pharmaceutical industry.  If you decide that you want to investigate it and find out exactly what went wrong, that is a full time job.  If you want to file a complaint with the state (What - a wheezing asthmatic needs nebulizer solution?) you may not ever be able to get that accomplished.  From working both sides of the prescription process, all that I know is the system is set up to obstruct care.  These unnecessary processes waste everyone's time and money.  It doesn't matter if there is an electronic health record if it means the patient is driving 40 miles back and forth to the pharmacy per month instead of 10, making another 6 calls through time consuming automated telephone queues and paying another 3 copays.  This activity is all based on the false premise that an electronic health record, an algorithm or a business strategy is more important to your health care in the long run than your physicians input.

Nothing could be further from the truth.  

George Dawson, MD, DFAPA

Supplementary 1:  It is one week since the original post and the pharmacy/insurance company insisting on dispensing me one week of nebulizer solution instead of one month as requested.  I called in for a refill yesterday and asked if it would be for one week or one month.  The pharmacist told me exactly the same thing they did last week - they have to submit a request to my physician for the correct number of ampules.

To briefly review, that request has been made by me four times (twice to MD office by phone and secure e-mail and twice to the pharmacy).  They did tell me I could pick up another weeks worth of the medication while I wait for the larger prescription.  I went ahead and did that and have not heard anything on the other prescription 24 hours later.

Let's get rid of worthless documentation

I just became aware of this article by Lucy Hornstein, MD on modifying the current documentation process and found it to be quite exciting because I have had very similar thoughts for some time:

I may be a fellow dinosaur, but I could not agree more.  The vast majority of documentation especially in the EMR is worthless largely because of the proliferation of stereotypical documentation to fit business and government requirements.  The businesses wanted to slow us down at least until they figured out that they could literally reimburse us for whatever they wanted irrespective of the billing code or note.  The politicians want all the bullet points because of the erroneous notion that coders can actually read a note and objectively  decide on the correct code (they can't) and therefore they can fight fraud. 

In the meantime, vast areas of hard drive space are occupied with worthless data because of these notes and the trees die anyway because requesting the information results in an EMR driven telephone book sized tome  with very little information (if any) on each page.

The only thing worse is the EMR driven initiative to rapidly assemble a massive note from existing data using smart text and a few key strokes.  I was on a committee once where we reviewed 10-16 page daily progress notes compiled in various fonts.  The majority of each note was already listed in the record.

I can recall working on a very busy neurosurgical service where we saw 30 patients a day (6-10 in the NICU) and did all the documentation in 2 - 3 hours before going to the OR.  All of the progress notes for the entire hospitalization generally fit on one page.

I have been thinking about Dr. Hornstein's approach for some time and have come to the same conclusion.  The current notes and coding system is basically driven by paranoia and not patient care.  Any EMR system worth its salt should be able to display all of the daily relevant data and provide a check box so there is documentation that the attending reviewed it all and signed off instead of the physician doubling as scribe and displaying it all (after a flurry of mouse clicks) in a massive note.  The actual note needs to reflect the fact that an intelligent life form visited the patient and there is a thoughtful analysis and plan. 


That doesn't happen by filling up templates in an electronic medical record.

George Dawson, MD, DFAPA