Most of us in the healthcare IT believe the ARRA (stimulus) bill is a Good Thing for the industry in general. Many existing companies will be able to sell more products and many new companies will be formed to create electronic medical records solutions. I was talking to Dr. Bill Cast last week about EMRs and what he and other physicians thought about them in general and I got some great feedback. Dr. Cast is a practicing Otolaryngologist, and is a past member of the AAO Board of Directors and AMA Delegate from Otolaryngology. He has been a lobbyist for the Indiana Malpractice Law and founding Chairman of Dupont Hospital in Fort Wayne, Indiana, a managing partner of his medical practice, and President of several multispecialty ambulatory surgical centers. He was editor of Medical Business Review, an economics newsletter for physicians. He is currently CEO of www.nomoreclipboard.com, a personal health records company. I invited him to share his thoughts about why physicians aren’t in love with EMRs which should form some good input for companies looking for ways of improving their own solutions. Here’s what he had to say.
You may ask what qualifies me to speak. First, I am a physician in a six doctor practice who for eight years has been digital, using a fully-featured EMR. Our old record room is now an employee lounge serving Peet’s Coffee. I live in an Indiana city in which 65% of physicians use some form of EMR in their offices and in which a regional health information exchange serves 95% of all providers. Our two hospital systems have EHRs. I’ve practiced in four states, served in the U.S. Army as a surgeon and have worked intermittently in a VA Hospital over a 6 year period. Lastly, I’m CEO of a personal health records company, a spin-off of an EMR company. And so, I’ve seen lots of software installations and talked to lots of unhappy doctors.
How do we know doctors hate EMRs? Look at anemic adoption rates. Big clinics and large physicians’ groups lead the way in buying them, but the most optimistic statistics say that fewer than 50% of even large groups have EMRs. Overall, perhaps 20% of physicians have EMR, but for small groups the best guess is 5%. And, when such features as e-prescribing, e-visit, and PHR integration are considered, it is likely than less than half of physicians use their EMR for little more than their own templates and a few favorite features. The majority of physicians have voted with their feet.
In the business community it is common to hear doctors referred to as computer-phobic and “in denial” about the benefits of computing. That is wonderfully ironic when heard alongside chronic complaints that doctors are overly eager to use expensive technology: lasers, cryro-probes, fiber optics, MRI and PET scanners, stents, and implants. The fact is that doctors love high-tech. They have reason to hate EMRs but not computers and iPhones. This was confirmed at a HealthVault meeting in Redmond when a physician panel member, representing a leading medical association, was asked: “Why are physicians so recalcitrant to use EMR?” He responded: “They are not recalcitrant; they are in open rebellion! Why? Because the software you give them is garbage.” (He actually used a mild expletive.) “It slows them down!” Thus, the problem is better defined: it is not so much that the software is too expensive, but that doctors can’t afford it.
Most physicians receive their first scars at the hands of hospital software. The truly unlucky have experienced a software installation with conversion from paper to EHR. The experience I will share is instructive and metaphoric. I’ll mention no brand names, because the story could be as true for any company. The disaster began on a Monday morning. Following that regrettable morning, I witnessed over two months of computer downtime at a six-hundred bed, general hospital, during which time hired messengers carried paper reports from floor to floor, from lab to ICU. The new system choked when millions of bytes of information were ported from the database to the new system the previous Sunday. Several ICU nurses quit after weeks of frustration and found new employment. And when the crash was fixed, the new product was a negligible improvement for phsicians. For off-site use, a Citrix interface made access to records agonizingly slow. Inside the hospital, computer locations, while no longer in dark hallways, became inconveniently distant from patients’ rooms, dictated by HIPAA privacy requirements. Paper charts remained near patient beds, awaiting eventual digital scanning, but lab and imaging results were often not on the chart but on a computer down the hall. The dollar cost was millions.
It should be a surprise to lay persons that physician participation in selection of hospital equipment and software is too often minimal. While much of the blame may lay with physicians themselves, doctors’ frame of mind is usually that “we were not consulted.” Actually, a few probably were consulted, but hospital-staff dynamics being what they are, tends to involve doctors who are the more technically aware, enthusiastic and amenable to becoming digital. To that disparity in physician cyber-skills, add the fact that software does not burden physicians equally. Even badly designed hospital software is OK for some practices and some specialties. But, if you are a renalogist or pulmonologist making rounds on numbers of very sick patients, the math is simple. Many ICU patients are on a dozen medications. With order-entry requiring serial drop-down menus, each 5 second addition of point and click may add 10 seconds to the entry of each medicine and treatment. An extra 2 minutes per patient costs an unproductive hour for each 30 patients. If patients need few medicines, enjoy short stays with few I.V. fluid orders and no changes in ventilator protocol, a physician may not object to the restrictions of a rigid algorithm. But for rounding-doctors who previously have enjoyed the ease and legibility of pre-printed order sheets, digital order entry has been disastrous to schedules.
Physicians know that better exists. They have experienced Google, Amazon and e-Bay. Game lovers know that Electronic Arts’ “Tiberium,” now 15 years old, exceeds the capabilities of their professional health care software. They know from Yahoo and MSN the value of configuring a home page suited to delivering niche-information of their own preference. They know from using Word and Word Perfect that they can create precision documents merely by tweaking a template. They know they can use voice commands to make a phone call on their Blackberry. They know that they can find drug information more easily on Google than proprietary software. They suspect that if their EHRs and EMRs had physician-specific home page functionality, that they could drop and drag orders, answer FAQs, dictate letters, and save time with templates with many fewer clicks. Ordering medications should be as safe and uncomplicated as using E*Trade.
Today most EHRs and EMRs are invasive both to workflow and finances. While high cost is a significant barrier to physician adoption, workflow disruption remains the killer deterrent. Most proprietary softwares offer a limited palate of practice options, mostly one does things their way. I recently went to the site of a web-based “Health-e-EMR” provider and watched the flash video demonstration. The demo patient, a return visit for an office visit, was typical enough: an obese, diabetic female smoker with a pulmonary problem. Everything was point and click: select, enter, click, read, post—again and again, over and over. The visit timed out at 30 minutes (their calculation, not mine) not including the time spent by a nurse’s clicks and front-office clicks. Allowing for physicians’ differing styles and based on difficulty, I’d expect this visit to take half that time. The record created was excellent. In private practice, at two patients per hour, and at this level of complexity—say 12 to 14 patients per day—one should expect bankruptcy. One would make a better living running a Dairy Queen. The moral may be that such software should be used only by physicians on salary. Also, many doctors do not want to sit in front of a patient looking into a laptop rather than the patients’ eyes. And they suspect that, if vendors respected service and product improvement as much as chasing new sales, their complaints would result in minimally invasive software.
A sign at a dry-cleaner’s shop reads: Low Prices, High Quality, Fast Service: Pick One. The point of EMR design is not to “pick one.” And, I am not advocating modeling medical practice after that in a remote mission clinic where the only record is a toe-tag, although I should recognize that mission outcomes are remarkably good. In the real world you get what you measure. If the metric is the chart, and you are willing to sacrifice time, then have at it. Also, in the real world, physicians are not usually on salary with no increment of production payment. Physicians do not hate high-tech and they do not hate computers. They hate wasting time; they cannot afford it, and neither can our health care system.
Let me close by saying that the federal software stimulus will be good only if the government standards ultimately endorsed, properly guarantee interoperability and avoid paradoxically funding software that is not only too expensive but that also create silos of proprietary isolation. Properly begun, stimulus is likely to fully return government’s investment through efficiency—not immediately, but over several years. Our office covered EMR acquisition in about 5 years. We did not spend $44,000 per physician. As best stated by M. Lynn Marcus in the MIT, Sloan Management Review, “The Magic Bullet Theory in IT-enabled Transformation,” we confirmed that the key to physician satisfaction is flexible software that does not dictate workflow choices. New software is not the goal; the goal is an information system with a good measure of flexibility. To perfect this system, one will need to reserve a measure of their stimulus funds for training, equipment and employee re-tasking. The good news is that after a period of adjustment to accommodate differing practice styles, one creates a shrinking record room, no piled charts, and fewer employees or employee hours spent finding, pulling and re-filing records. And one finds many unexpected conveniences. One cannot put a price on taking call from one’s home with rapid web-based access to the patient’s office chart at 2 AM.