Sunday, October 30, 2011

EHR Adoption is Like Treating Cancer

EHRs are not ready for prime time. EHR benefits are questionable and there are documented instances where patients’ deaths were directly attributed to an EHR. EHRs are cumbersome and slow. They are unnecessarily complex and built on very old technology. The people who build EHRs have no concern for the end user and therefore EHR usability is pretty abysmal. And EHRs are expensive to buy and expensive to maintain, not to mention that they can completely derail your practice through loss of productivity. The fact that some users seem to do well with their EHRs, and even derive some joy from using them, is not a valid counter argument since most users are not so fortunate and through no fault of their own. There really is no excuse for such failure in this day and age. Just look at the iPad and the iPhone. You can walk into any Apple store and 5 minutes later walk out with a fully functional product with a delightful, intuitive interface, loaded with hundreds of interchangeable apps that even a three year old can use right out of the box. All for a few hundred bucks.

If you happen to be diagnosed with cancer, you will most likely be subjected to years of unpleasant treatments. You will be injected with poison and irradiated with more poison. You will lose your hair, suffer bouts of vomiting and diarrhea and be physically debilitated to the point where you cannot leave your bed. You will most likely have to go through painful surgeries, take all sorts of medications that were shown to kill thousands of rodents and never recover your old self again. And this entire ordeal will cost you a medium size fortune. The fact that some lucky patients go on to win the Tour de France is not really an acceptable rebuttal. Most do not. And there really is no excuse for such incompetence in this day and age when one little pill can cure you of an yeast infection in 24 hours and a $4 course of antibiotics will render you as good as new if you happen to develop a sinus infection. Not to mention the innumerable vaccines that will miraculously prevent you from contracting the plague.

Yes, this is a farfetched analogy, but replacing paper charts with an EHR is not like playing Angry Birds, and if you want a fair chance at survival, you have to tolerate the side effects imposed by the current state of technology. Just like you cannot postpone your cancer treatment until the doctor from Star Trek figures it all out, you cannot postpone transition to EHR until EHRs are “ready for prime time”.  And make no mistake, in today’s reality, paper charts are as big a threat to the survival of an independent medical practice, as any garden variety cancer is to a human body. Paper charts will gradually and irreversibly deprive your practice from the nutrients and oxygen needed for survival, i.e. reimbursement, until it shrivels and dies, or it gets absorbed into a larger organism. The common wisdom seems to favor these outcomes. I do not. If you are one of the fewer and fewer physicians who has no desire to either shrivel or practice Wal-Mart medicine, here is one way to think about your current EHR predicament. [Note: Considering the gravity of the situation, you would be well advised to seek a second opinion.]

Diagnosis – Look around you. EHRs are slowly gaining ground. You would be hard pressed to find a medical group of significant size that does not have one. Data collection is not as voluntary as it is being portrayed, unless of course you think that you are overpaid and can easily absorb cuts in reimbursement. You can choose to make believe that this too shall pass and once Obama is no longer calling the White House home, all will be as it was. Alas, computerization of medical records has bipartisan support, and it always did, due to a rare alignment of powerful financial interests and progressive ideology. If you want to continue the practice of medicine, you will need to use the tools of the trade. For better or worse, both the trade and its tools are being redefined. Barring a global disaster, the chances of spontaneous remission are nil.

Staging – How bad is it doc? Well, it won’t kill you tomorrow, but the longer you wait, the harder and more expensive it will become, the fewer the choices and the lower the chances of a good outcome. Both public and private payers are experimenting with new reimbursement methods. These pilots, or projects, are cropping up everywhere, supported by grants and all sorts of tax payer monies. The goals may be different and the rules of engagement are certainly different, but these arrangements have one thing in common. They all prefer that you generate and consume large amounts of clinical data in electronic format. You will need an EHR for that.

Treatment – A physician-centered approach to the problem suggests that you should be informed of your options and allowed to make a decision based on your personal and cultural preferences. Since medical practices are not people, you may choose to euthanize your practice. This may make perfect sense if your practice had a long and productive life and your medical career is in its twilight years anyway. A less terminal option would be to allow your practice to be hooked up to the machinery available in large health systems. You will still have to use an EHR, but your new employer will undertake the mitigation of most side effects. There is a slim chance that someday you may be able to remove the tubes and resume private practice, but while your medical career can survive indefinitely, your practice as you know it now is not likely to recover. Or you could make a stand and fight for your independence.

Prognosis – By definition there could be no blinded trials for EHR utilization, and by omission there are no randomized control trial results to learn from. The anecdotal evidence suggests that many thousands of physicians in independent practice are surviving just fine after EHR implementation. Some would say that they are doing better than ever now, and others have resigned to the new ways of doing business. For most, the life threatening problem has been transformed into a manageable chronic condition. It must be noted however, that a significant number of physicians is currently in need of life-support from health systems and hospitals, and many of these are post EHR implementation. We cannot be certain, since there is almost no literature on the subject, but it is highly probable that practices suffering from a relapse have had multiple comorbidities to start with and/or developed other life threatening conditions since. There are no guarantees of course, but if you have an otherwise healthy practice, a positive outlook and a supportive environment, chances are good that transition to EHR now will enable your independent practice to survive and thrive for many years to come. And the opposite is also true.


  1. >> "there are documented instances where patients’ deaths were directly attributed to an EHR"

    Since you don't get any more specific about this, I can only guess that you're referring to software bugs in an EHR as being responsible.

    But a more indirect (and perhaps unrecognized) way that EHRs can contribute to poorer (or even fatal) patient outcomes is that practitioners, upon installing an EHR, expect that the EHR (e.g. the computer) will pick up part of the work that only they (as humans) can do: treat the patient.


  2. Thomas,

    The reported incidents involving EHRs can be traced back to bugs or poor implementations. I wrote about this last year here.

    I agree with your observation, since there seem to be complaints regarding EHRs not alerting practitioners on fatal doses or incorrect meds, for example. However, I do believe that the hope is to eventually have the software serve as a safety net for human errors. I do not believe it should take over, and relieve people of the need to know, think and execute, but there are concerns out there that this may be the ultimate goal.