Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

Cape Cod

The e-Patient

The eminent philosopher Yogi Berra has captured the essential problem with the current fascination among our legislators and government bureaucrats with Electronic Medical Records (EMR or EHR). “In theory, there is no difference between practice and theory. In practice, there is.”

In my mind I have an image of the well-intentioned men and women who are developing the next generation of EMR. I see them as this generation’s equivalent of  a pre-Foundation Bill Gates, or Steve Jobs before the black mock-turtle tee shirt. All nerdy and earnest, focused on the software solution to a problem they’ve read about. They peer out at the world beyond their screens, convinced of their ability to solve a problem they view from 30,000 feet, perhaps dreaming of becoming wealthy should they succeed.

I also have a picture in my head of the legions of un-elected bureaucrats in state capitols and in Washington who have latched onto this notion of EMR as the panacea, the magic solution to the American “Healthcare Crisis”. Equally earnest, white-paper educated omniscients convinced that a technical solution is all that is missing from the equation. They deal each day in the business of spending tax revenue and the legislative give and take that eventually results in a state or federal budget.  Their time is spent with eyes glued to their laptops and their Blackberries, only seldom establishing eye contact with another of their kind ,and only then if absolutely necessary.

In THEORY this EMR thing is a no-brainer, isn’t it? Who wouldn’t think so? A true EMR is a system of record keeping for medical data in which all of the information is entered digitally and stored in hard drives instead of paper charts. Every time a patient is seen by a doctor or a nurse-practitioner his entire medical record is there for the viewing. No lost pages. No missing data. No struggling with the abysmal handwriting of the busy specialist who saw him for an emergency at 4:00 AM. What’s not to like about that?

In THEORY a universally applied EMR should also create some economic advantages in our healthcare system as well. We would theoretically need fewer billing assistants since all of the charge information would flow automatically from the medical record to the billing system, and from there straight to the payer. There would be few, if any billing errors since the coding and reporting requirements for each insurance company (or the federal government) would be built into the software. Since all of the information about medical outcomes would now be instantly available we would now be able to evaluate competing treatments and determine objectively which ones work and are therefore worth their cost to provide.

Unfortunately it turns out that Yogi Berra is not only a philosopher, but in this instance he is also a genius. You see, in PRACTICE all of this theory falls apart because of a rather messy and unpredictable variable in the system that the EMR designers and the all-knowing bureaucrats just can’t remove from their programs or their systems: all of the patients and all of the healthcare workers are PEOPLE. People who are sick and become patients. People who don’t want to be sick and try not to be patients. People who come to work fresh and adequately caffeinated, and people who are really patients that particular day and don’t know it, spilling their Starbucks on the keyboard.

Computers and the software that runs computers reduce work and increase efficiency in their optimum usage. They enhance the experience of all who encounter them “in the wild” when they fulfill their potential. At the same time that we have all of this talk about the urgent need to get every doctor’s office and hospital computerized coming out of one side of the collective mouths of the “reformers” we also hear out of the other side of the need to improve the patient’s experience when she goes to see her doctor or when she is in the ER. Those same bureaucrats and policy “experts” scampering through the legislative ant hills who extol the virtues of computerized efficiency also demand more time for patients from doctors and nurses, time  spent one-on-one in providing medical care. Not too much time, though; these budget-watchers  also bemoan the existence of so-called “concierge” practices, the ultimate expression of patient-centered medicine, because this model reduces the pool of doctors available to provide care.

The only conclusion that one can reach is that none of these EMR developers or policy developers has ever been a patient in an office or a hospital with an EMR!

The most important entity in the exam room or in a hospital room when an EMR is in use is the computer. The bigger the institution the more this is true. Mandatory questions must be asked in sequence and data entered in order. Imagine your doctor or her nurse as the best-educated data entry clerks in America and you get the idea. And it doesn’t matter whether it’s a computer and a keyboard or some sort of handheld gadget, the eyes of the doctor is on her screen, NOT her patient. The doctor has a relationship with her computer; the patient has a relationship with the back of the doctor’s head.

And you know what, it takes time to enter all that stuff. Much more time than it takes to jot down a couple of notes or a little data. Where will that time come from? Well, either it comes out of the time devoted to looking and listening, or it comes from decreasing the number of patients a doctor can see each day. Fewer employees necessary to run the computerized office? Really? What other customer service business has successfully reduced the number of people involved in providing that service to the satisfaction of its customers? It’s also really expensive to buy and implement and maintain an EMR. We’re talking about Billions of dollars up front and every year hence. Where will this money come from as doctors and hospitals struggle to remain afloat?

The EMR fails “in the wild”. It fails in PRACTICE to do either of it’s most important tasks; it neither increases efficiency nor does it improve the experience of the user. An EPIC fail (pun most definitely intended for you Epic users).

In the end the only winners in this EMR game at the present time are regulators and third-party payers. When we put all of the advantages of EMR in THEORY  into PRACTICE the losers, once again, are patients and their doctors.   With the present state of technology we will spend more money to buy systems that will decrease our efficiency and reduce the quality of experience that both our patients and doctors will  have when healthcare is provided. And we haven’t even touched on the difficulties of maintaining the confidentiality of all of that information, or whether or not you can really pigeon-hole all of those messy, unquantifiable individual patients into tidy little  treatment groups.

I have another picture in my mind, a picture of Yogi Berra in his doctor’s office. Yogi’s getting on in years you know. Probably has a couple of medical problems; probably taking a couple of medicines, too. Can’t you just see him, all ears and nose and those huge glasses underneath a vintage Yankees hat?

“Doc. DOC! Who ya lookin’ at? Hey. HEY DOC! I’m over here!”

5 Responses to “The e-Patient”

  1. September 3rd, 2009 at 3:09 pm

    dwayne.. says:

    Our pediatrician is on an EMR system, tablet PC’s and all. After several reminders, they finally no longer show us the growth chart, they just tell us that the kids are OK. I am a technology guy, in a similar space (content management) to EMR and I think that deployment of solutions, and impact to processes are sometimes overlooked. I mean, they start out with good intentions, but is the patient experience REALLY reviewed and analyzed? And what about system failure, there needs to be more thought put into, “OMG, the systems are down, what do I do now..!!!” EEK. It happened, I saw it, I laughed, then I got pissed. Why, no alternate reasonable process identified. It was like time stopped and couldn’t move forward until the systems came back online. Think people, patient experience, alternate manual processes might make sense! Adios.

  2. September 4th, 2009 at 8:20 am

    Beth W. says:

    I really like the way our office implements this tool. We have paper for the Dr and tech to write on like the “old days” and then at the end of the day this paper is scanned into the patients chart. Each paper is then verified to be in the correct place, is shredded and voila! Shredded paper for me to use in my bunny cage!
    The info is then easy to access from home, any computer in the office, and is backed up every night. We still do billing by hand, entering it into an electronic system but we therefore have one of our most fun office workers, biggest morale boosters and biggest laugh getters working for us! And we provide a job in a tough economy.
    I made sure when we thought about this that our Dr.s could look at the patient. I have always resented a doctor who spends more time looking at his/her typing screen than at me. Did you really see that tear in my eye, that worry on my face, that pain in my grimace while you were typing? I didn’t think so.
    Beth W.

  3. September 8th, 2011 at 4:27 pm

    Jim winkler says:

    Okay, contrarian voice here. The patient experience has pretty much sucked for decades. And it royally stinks when you are asked to grab a clipboard and fill out a health history form that my doc should already have, in an easy to look at system. Many doctors don’t look at patients pre EMR as they are too busy scribbling, finding the Rx pad, and moving onto the next patient. The EMR concept has flaws and I don’t know of any policy wonk that sees it as a panacea. But healthcare is a $2.5 trillion industry that is ass backwards technologically. A lot of that is driven by the insurance mess we have for sure, but the reluctance to embrace EMR is annoying. The patient experience is driven by the doctor and his/her style and approach, not by paper vs laptop. Te experience depends on whether or not my doc will answer my questions, let me talk, and give me options.

  4. September 9th, 2011 at 6:27 am

    darrellwhite says:

    Not surprisingly, Jim, I both disagree and agree. Let’s start with common ground. It is EXCEEDINGLY annoying that my world is so technologically backward when it comes to this, but is that all so surprising? No standard platform. No interoperability. Declarations about what is ‘needed’ from above, from people who’ve never been in the trenches seeing patients. Heck, even the EASY part (insurance form submission) is a cluster. EMR should have been bottom-up (and the better programs started that way) and not command-amnd-control, top-down.

    The reluctance to embrace EMR is partly due to that, and partly due to cost. Come on…with overhead growing and income dropping, who but the “non-profits” that already shift $$ away from doctors and staff can afford EMR? My investment in 2005 was ~$150K, and would have been >$300K if I’d gone with one of the programs that would comply w/ “meaningful use”. EMR as presently constituted is an efficiency nightmare. I’ve not talked to a single ophthalmologist who did EMR w/any program other than the one we have who DIDN’T have a minimum 40% decrease in patients seen for a minimum of 3 months, and most have to decrease patients seen for upwards of a year. Hmmm…sign me up.

    Lastly, your comment about the patient experience being poor historically is spot on, but the inference that somehow EMR will magically make this better? Come on. The REQUIREMENT that the EMR be filled in by the doc will MAGNIFY the frustration for the patient by further decreasing the amount of minutes the doctor spends lestening to you, talking to you, looking at and paying attention to you. This crushes the spirit of docs who want to maintain eye contact and really give you their attention, and simply makes the experience worse if you are already sitting across from a doc who gives traditional “shitty” care experience.

    “The patient experience is driven by the doctor and hisher style and approach, not by paper vs. laptop.” True, agree. But the EMR of today is a net negative addition in most cases for all of the reasons I noted in the post, your annoyance from both 30,000 and 3 feet notwithstanding.

Leave a Reply