“You’re 56,” I say, speaking to a new patient. “Have you had a colonoscopy?”
“Yes, I did, right when I turned 50,” she says. “Isn’t it in there?”
“Well,” I reply, awkwardly. My shoulders hunch over my laptop screen, my hands scrunching to conform to the too-small keyboard. I click and open a dropdown menu. A long list of folders appears, representing scanned-in notes. The folders are differentiated only by date. I start opening them. Right-click. Enter. Oops, ophthalmologist. “X” for close. Right-click. Enter. Nope, that’s a bone density scan, which should have been scanned in under “radiology.” “X” for close.
My patient is getting impatient, and I don’t blame her. “Well, can’t you just search for ‘colonoscopy’?” she asks.
I felt like an elephant had just stepped on me. Our patients, I realized, had no idea how embarrassingly backward a computer-based charting system could be. Electronic medical records (EMR) or electronic health records (EHR) systems are sold with a Jetsons-like promise of a better future. See your patient’s chart from anywhere! Instantly transfer records to a specialist! Electronically prescribe! But in their current form, EHRs are very different from easy-to-use iPads, and my patient had called the software out on one of its many failures.
One big reason doctors and hospitals have adopted EHRs is money. The American Recovery and Reinvestment Act of 2009 authorized Medicare to pay sizable annual payouts – up to $18,000 in the first year – to doctors who start using EHR systems. Medical centers that could invest in the software and training – and financially absorb several weeks of low patient-visit rates – did so. Harvard physician Ashish Jha, writing in the policy journal Health Affairs, reports that more than half of U.S. hospitals now have at least a basic EHR. But, according to Jha, adoption of EHR was far less – “dismally low” – among institutions that don’t qualify for the money, such as nursing homes and psychiatric hospitals.
It’s no wonder there are holdouts. Electronic health records slow doctors down, even after the software is familiar. I’ve watched my own whip-smart doctors cringe, poke and apologize their way through learning EHR systems. Screens loaded slowly. Awkward pauses interrupted the workflow. I didn’t get to chat with my doctors. They were too busy right-clicking and searching for the right place to enter the data.
Many of the doctors I have spoken with over the years have responded with similar frustrations. They throw up their hands in frustration when patients complain: “The doctor was just looking at the computer and not me.” We know. But, if we don’t look at the computer to make sure we’re typing in just the right little box, the cardiologist won’t have the foggiest idea why this patient was referred. A 2013 study found that half of all EHR-using primary care doctors surveyed were spending an extra hour of work on the computer per half-day of patient care.
When I see a patient in an office that still uses paper charts, the interaction – and the medical record – change. I take swift notes as the patient talks. If, in the middle of discussing her earache, she says, “Oh, I almost forgot to tell you, my mom was just diagnosed with diabetes,” my pen zips over to the relevant area on her intake form. I’ve recorded the new information in seconds. While she continues, I flip her chart to a form – unique to my practice – that contains all her information I might want to see again someday: medications that failed, social issues such as a stressful custody battle, her strict vegan diet.
A quick scribble and her mother’s diabetes will not be forgotten. The note will change my approach to this patient in the future. Freed from time-consuming hunting and clicking, I’ve made more extensive notes on her visit. All of this happens while making real eye contact and getting to know the patient. In an EHR system, entering a bit of family medical history would require me to stop, save, click out of the screen, find where to enter family history, comb through a dropdown menu of 50 different descriptions for diabetes, then another menu of possible family relationships. After all that work, the “front page” of her electronic chart won’t say a word about diabetes.
EHRs do have some advantages. They speed up prescribing and warn doctors when a drug might not be the best choice for the patient. But too often the process of using these good features ends up lost in clunky, illogical software. As someone who studied computer programming and constantly rewrites EHR code in my head, I find it unbelievable that a computer program would flag a drug’s pregnancy risk for a male patient. The saddest part is that a truly intelligent EHR system could literally save lives and increase productivity.
Why, then, aren’t EHRs as easy to use as paper charts? The answer lies in their design. EHRs are designed for medical coding and billing, not efficient patient care. All that endless hunting and pecking to click the right boxes turns doctors into unwilling medical billers, and efficiency suffers as a result of this “second job.” A 2009 study in the Journal of Ambulatory Care Management found that, while coding and revenue improved somewhat after EHR implementation at a pediatric practice, the staff still needed on average 15 more minutes per patient – even two years after implementation. Sadly, after all that work, many doctors don’t even trust the EHR system to properly code the visit.
A colleague recently told me that he was no longer turning up his nose at offers to moonlight in urgent care settings. “The pay’s increasing,” he said. “No one wants to deal with the EHR, plus a lot of doctors are just retiring early.”
Technology is supposed to make our lives faster and easier. We routinely use beautifully designed technology products elsewhere in our lives. All the information and talent to make a great EHR clearly exists. In a world of elegant solutions such as Google and Facebook, doctors and patients deserve a beautiful product that helps rather than hinders our work.