American College of Physicians: Internal Medicine — Doctors for Adults ®

Monday, December 21, 2015

Health care IT: I was duped

I was playing golf with some friends. The Boston area had been having a bit of an Indian summer, and we were lucky to still be getting out there (long may it last). The conversation during 1 of the holes turned to health care information technology, when my friend, who is also a physician, told me about his experiences with a (certain famous) new electronic medical record that's just been installed in their hospital. I remember this same friend telling me a few months ago that he was looking forward to the change, anticipating that it would make his and his patients' lives better. He turned around to me after taking his swing and said, “You know what, it's all been a big disappointment.” That was a profound thing to say, as I'm sure it sums up how hundreds of thousands of physicians across the United States feel about their EMRs.

A desperate disappointment indeed. There was so much promise and hype a few years ago and nobody really wants to go back to the bad old days of piles and piles of paper charts. So what went wrong? An excellent recent article published on the social media blog KevinMD, sums it up here, as does a parody video by ZDoggMD. In a nutshell: health care information technology interferes with the doctor-patient relationship and physician workflow in ways that nobody could have imagined. Disaster might be too strong a word, but then again maybe it's not, as statistics show that many physicians now spend an absolute minority (as little as 10%) of their day engaged in direct patient care. Physicians are intelligent on-the-go people and definitely not your average clerk or desk worker. Most of us went into medicine with very noble aims and won't accept our job being changed so much from what it is supposed to be.

This is of course a topic I've written a lot about, and readers may be surprised to hear that I was a huge advocate for health care IT as little as 5 years ago. The story goes something like this. I had been an attending physician for almost 3 years, loved my job, was involved in teaching and above all else saw medicine as a calling. I was approached to take part in a huge new project that the hospital was undertaking: creating a Computerized Physician Order Entry system that would revolutionize the way we put in orders for our patients. In my naivety, I hadn't even heard of Meaningful Use or federal incentives for my hospital. So I put my head down and got right to work.

I helped design and implement the CPOE system that our hospital would be using. At first this consisted of weekly meetings, but quickly became more intense. On a personal level, I met some fantastic folks and befriended people from the world of IT, consulting and hospital administration, enjoying the feeling of broadening my own horizons at the same time. I promoted what was happening to my physician colleagues and even made videos explaining what the new system would entail. It was several more months before we were ready to launch and thanks to intense investment in IT support by my hospital, the process went relatively smoothly. After that, came medication reconciliation and electronic progress notes—but by then I had already moved to another hospital in another state.

On my subsequent travels up and down the country, I've worked with almost every major IT and EMR system, and have unfortunately seen the train wreck unfold. I've witnessed seasoned physicians (and nurses) despair and in some cases almost bang their heads on the table as they struggle to navigate the inefficient and cumbersome systems placed before them. I've seen them spend ever less time with their patients. I've seen them moan about the lost productivity and not being able to see as many patients. I've seen patients complain to me in droves about how their doctor never even looks at them in the eye any more. Oh where oh where did it all go wrong?

Looking back, the warning signs were there from the start. Many of the other physicians leading the charge to expand health care IT had no interest whatsoever in clinical medicine. In fact, many of them were looking at it as their passport out of frontline patient care, and am sure are now sitting comfortably in ivory towers contemplating the wonderful world of “big data,” “connectivity,” and “cloud solutions.” I remember 1 of them openly telling me when I once made a suggestion that a certain method wasn't going to make things faster for the physician, that health care IT “isn't being designed to make things faster and more efficient for doctors.” I remember one of the external consultants proudly telling me that their IT solutions represented the way of the future and that he had seen older (and no doubt popular) physicians in previous hospitals leave their practice altogether because of their new electronic medical record.

Now I look back and remember that promise of a brave new world of health care IT. One that I thought would be seamless, efficient and user-friendly. One that would be as simple and pleasant as using my iPhone to place an order in a few seconds. One where I could spend more time seeing patients and less time writing notes. Oh my, I was so duped.

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.

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Anonymous Anonymous said...

EMRs have added 2 to 3 hours per day, increased the volume of notes by 2 to 10 times while decreasing the useful information by 1/2. I have seen patients extubated for days with "doing well on ventilator" charted, med changes not recognized, then the inaccurate information acted upon at transfer, daily pasting of 12+ diagnosies with no real thought processes or decent plans laid down, no paring of inactive issues, consultant notes impressions (WHAT MATTERS THE MOST) a string of ICD 9 / 10 codes without any ACTUAL CONSULTATION, etc, etc. Fortunately, I am in year 28 of practice and can retire away from this madness. By the way, will the last general internist turn the lights out in 2025?

December 30, 2015 at 2:10 PM  

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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