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Explore This IssueApril 2015
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I consider myself relatively young, not in my 20s (thank heaven, although unfortunately not yet done with the occasional and annoying bout of acne), but not yet having crossed the 40 mark. The age issue being perhaps settled, I do not belong, nor do I want to belong, to that young marketing group that seemingly wants to spend 99% of the day gazing into, or otherwise distracted by, some sort of electronic device. Yes, I have my necessary gadgets and spend what seems like far too much of my workday in front of a computer. That is an inescapable and, occasionally, useful part of my job: researching references or study materials, checking e-mails, getting news updates, etc. However, it seems that electronic tools and gizmos too quickly have shifted from being appurtenances, toys or tools to being the predominant focus of our workaday world.
I recently began working at my first real job after completing a fellowship. This process is stressful enough for anyone transitioning from specialty training to the end result, a “grownup” specialist position. Along with all the excitement, any new job always seems to bring at least equal shares of the unexpected good and the unexpected bad.
The downside to almost any new medical job nowadays is having to become acquainted with yet another medical record system. In the modern medical environment, doctors not only have to possess a solid base of medical knowledge—periodically reproven or revisited via CMEs or maintenance of certificate credits—but also must function in the ever-changing, often perplexing world of electronic health records (EHRs). On a daily basis, I question what EHRs really have to do with performing what is, at least in theory, my primary role of caring for the sick, ailing and injured
The Inescapable Reality
One day I was doggedly trying to learn my way around the new employer’s system. All seemed blurry, so I got engaged in a phone conversation with an EHR technician. While waiting for something to boot, recover or search, I commented about poorly designed EHR systems and expressed a longing to return to using plain old reliable pen and paper. In response, I was informed that EHRs are simply a new, inescapable reality to be reckoned with and that there’s no turning back. (I expect the unspoken cerebral response was more like, “You had better adjust quickly so you can keep that job and do what you’re supposed to do. Now cease whining, and stop bothering me.”). I could not place enough candles on the cake to express how old I felt.
Two years ago, when I began a fellowship at a very large university, I quickly had to learn the ins, outs and peculiarities of three different EHR systems, none of which were remotely efficient, intuitive or compatible.
A few months ago, while the dreaded disease was a hot media topic and seemingly on every broadcast, I heard that EHRs were partially to blame for poor communication between a nurse and physician caring for Ebola patients. I briefly, quietly hoped that this incident might generate some outcry and create enough public attention to allow the return of paper medical records.
No such luck.
Nevertheless, the Ebola EHR story illustrated the idea that old-fashioned verbal communication remains critical, and EHRs may be so inherently complex that instead of allowing better access to information they promote the opposite.
Poorly Organized; Difficult to Access
In my experience, the electronically stored EHR information is too often poorly organized and difficult to access.
For example, the two EHRs with which I had to cope during my fellowship bore the same name and were from the same vendor, but, despite all the goodies, they did not talk to one another.
As a medical trainee, you quickly become paranoid when learning the new computer system may take more time than caring for the patient. But you have no choice, and—one way or the other—after hours of otherwise productive time, you learn to deal with it to the extent that you may finish your documentation before your next shift starts or the day ends.
I dream of an EHR that might allow me to treat a patient while looking them in the eye instead of into the sightless eye of the computer screen.
One can spend time tweaking the program to create templates, or so-called “favorites,” in an attempt to ease the use of these products—in theory, the EHR vendor’s job.
The vendors arguably have some of the world’s most educated and intelligent consumers (in no way including this author) providing them feedback and, by way of in-office modifications, improving their product for free, without a dent in the cost of the software. Picture this: You buy a sandwich from a fast food restaurant, and it does not meet your reasonable expectations, failing to perform at even an acceptable level of culinary mediocrity. So you wander back to the kitchen, don an apron, show them how you really want your food prepared and still pony up and pay the full bill before pulling out of the parking lot. In this respect, the predicament of the patron hungry for a fast, simple sandwich and the patron hungry for a simple, fast EHR are not dissimilar.
1 Job–4 EHRs
At my new job, I yet again had to learn one office EHR, a different hospital EHR and at least two more with which I must become familiar to become a full member of the local rheumatology coverage team. Of course, none of these programs talks to another. You must log into each system separately, and each has a different password and security requirements. Simply remembering what are recommended to be different passwords is a full-time job.
Lost Patient Time
While it seems ages, it has not been too long since the EHR made our acquaintance. Less than a decade ago, I worked in a busy clinic when it acquired its first EHR. I recall that we lost a tremendous amount of patient time learning how to use the highly touted and expensive new system. The next thing I knew, we had the vendor’s certified technological representatives lurking about. In theory, they were there to help us, but they somehow always managed to be on break or at lunch or using the bathroom and, hence, were never around when needed.
One day, we logged on and saw only an ominous dark screen where our notes should have been safely stored, forever lost in a black hole of electronic patient data. Then, a month later, after enormous loss of money and time that otherwise could have been devoted to patient care, a whole new system was purchased.
Driving Rheumatologists Out
It’s sad that this EHR critique jumps from the keyboard of a relatively young physician. It’s not surprising when you hear the same complaints from mentor-level rheumatologists, with years of wisdom and experience, who leave their chosen profession due to EHR issues.
During my recent job search, I was upset to hear two independent rheumatologists describe to me how much trouble they have with EHRs. One retired early in order to avoid the issue altogether, and the other was looking to hire a young, presumably tech-savvy, associate to handle the headaches of transitioning from paper to EHR. I find it disturbing to have lost even one well-qualified doctor due to EHR issues at a time of both primary care and specialty shortages.
But here we are, and we have no choice but to function in a less-than-optimal system. I really don’t care who would realize the profit, but my hope would be to someday have, if not one universal EHR, at least one system through which they all must be able to quickly and easily communicate with one another. I dream of an EHR that might allow me to treat a patient while looking them in the eye instead of into the sightless eye of the computer screen.
As the younger generation of healthcare providers, we should find the will and the way to advocate for what is best for both patients and physicians. If EHRs are here to stay, we ought to reject the poor designs and promote and share the better. Let’s not be buried under the software junk: You breathe because you have to, but it’s hard to rise to the top of your game.
Katarzyna Gilek-Seibert, MD, is a staff rheumatologist at Roger Williams Medical Center, Providence, R.I., and affiliated with the Boston University School of Medicine, in Boston.