One of my favorite conference speakers, Lexington, S.C., family physician Allen Wenner, M.D., who created Primetime Software’s Instant Medical History software, often jokes that many of his contemporaries “need to die” before we see much change in the way physicians practice medicine. I’m increasingly convinced that he’s right.
It’s, of course, older doctors, that seem to be the most resistant to change. They also happen to be the ones most likely to hold leadership positions, if for no other reason than their seniority.
That’s why I’m so troubled by the attitude of physicians such as Arvind Goyal, M.D., a family physician in Rolling Meadows, Ill., who’s on the faculty of Chicago Medical School/Rosalind Franklin University in North Chicago, Ill., and is a past president of the Illinois State Medical Society. Last week, the Chicago Tribune published a lengthy, scathing letter from Goyal, in which he thoroughly trashed electronic medical records based on a negative experience he had with “a popular brand of EMR” at a Federally Qualified Community Health Center.
Goyal brought up some salient points about what can go wrong with a poorly implemented EMR. “The system was slow generally, froze up a few times a day and crashed every few months, requiring us to reschedule patients. Pricey service calls, multiple system updates, periodic shutdowns, user training and hiring of a full-time IT expert at a significant cost helped some, but the dissatisfaction persisted,” he wrote.
He ticked off the standard laundry list of why physicians struggle with EMRs, including the argument that “documentation and accessibility of information in EMR is more time-consuming than paper records.” Forgive me if I’m wrong, but that sounds like a workflow problem more than a technology problem.
“Federal incentives for adoption of EMRs come with complicated bureaucratic requirements,” he added. Perhaps, but will you still be making that argument when Medicare and then private payers start requiring EMR usage as a condition of reimbursement?
“Data backup is a prudent need and often requires an additional investment.” Well, duh, but isn’t that true of your home computer as well? Your practice management systems?
But Goyal really stepped over the line when he repeated one of the greatest fallacies in medicine, that doctors know all.
“In my successful suburban solo family practice of several years, I did not use electronic medical records. Knowledge of each patient I served was on the tip of my tongue when an emergency-room doctor seeing one of my patients called in the middle of a night. I was available 24/7 with few exceptions. The paper records were organized such that I was able to access clinical details quickly when needed,” Goyal wrote.
How can knowledge of each patient be on the tip of his tongue if he’s woken up in the middle of the night and his precious paper files aren’t right there next to his bed? Is his memory that good that he knows every pertinent detail of every patient, even when still in a haze from an unexpected wake-up call? Yeah, nice try.
Furthermore, it’s great that Goyal is available to other doctors around the clock in case of an emergency, but is he available to patients? Medicine is changing. It’s supposed to be about patients, not physicians. But some physicians still wrongly believe they know everything and will do just about anything to cling to the status quo.
In case you haven’t noticed, the status quo isn’t so good.
Where did you go to medical school Neil? I have awakened many physicians with Dr. Goyal’s skill and recall in the middle of the night. If I were an IT professional reading that letter, I might ask myself, how and why have we failed to serve doctors in their mission?
I’m not a physician. But even the smartest, sharpest doctor can’t possibly recall everything he/she has ever learned or observed. As a patient, I find it arrogant for any physician to take the “I know better” attitude.
[…] Thursday (at least for a few more minutes), which means I’ve got a new post on the EMR and HIPAA blog. This week, I lash out at yet another member of the medical establishment for rehashing many […]
EMRs are not faster than human memory and facts present in an EMR can actually be obscured by some of the “data” present.
I constantly amazed old patients over the years with recall of odd facts about them. It made an impression at one time and it stuck.
I have never seen a committee design anything that fit everything. A high-speed aircraft is just so much junk on an interstate highway. This may sound off topic, but for medical systems different specialties have different needs and this analogy applies to that “everything.”
Meaningful use is a government concept and has little to do with taking care of patients.
I agree that this doctor did some grandstanding with his praise for himself, but I also agree that EMRs need to be held up to the highest standards possible, and when they are bad, they need to be fired.
I hate the status quo mindset and this is the main reason I committed my life to hopefully having a positive impact on consumer health care empowerment. This physician no longer has to be awaken in the middle of the night by the ER doctors questions about his patients current medications, medical conditions, allergies, blood type, emergency contacts and phone numbers, etc.. Get with the program, the consumer not the “expert” doctor is now empowered 24/7 with mobile, remote, interoperable personal health records. Go back to sleep doctor and wake up to the bottom up transformation movement and let go of you need to be in control.
Great article. Gerald Theis: ditto…could not have said it better!
EMRs are not faster than human memory and facts present in an EMR can actually be obscured by some of the “data” present.
I’m sure you’re aware of the astronomical rate of medical and prescription errors, leading to untold death, suffering, and expense, that we’re currently suffering using the “What do I remember about this patient out of my hundreds off the top of my head,” method.
Health care as we practice it here is becoming too complex for the human brain to handle alone. Multiply that complexity by at least 10 to get a sense of what medicine is going to look like in the next century. How are doctors going to remember everything off the top of their head when we get into genetic sequencing and genotype-specific medications, which is just around the corner? If you want a less exotic example, just look at ICD10.
I agree Meaningful Use as it currently stands is more for bean-counters and pencil-pushers than for doctors and patients. This is only step one. The real work (and the real potential for improved clinical outcomes) will come only after they’ve cajoled the majority of us over to the EHR side and we’re all able to work the data in the ways that we all need to. It’s a long road still.
I don’t wake up the doctor at night for facts. I have plenty of those in my EMR. I wake her up for the gestalt. Which just goes to show how limited an EMR is in helping us with the nuances of patient care. Many IT professionals just can’t grasp this kind of non-binary thinking. No amount of “natural language processing” is going to get you there. Neil and Gerald are fairly missing the point.
But I have also met some truly great clinical informatics folks who will–instead of mocking a person who for all you know may be a brilliant diagnostician–ask us how you can help us help the sick and dying.
When you start asking how you can rise to the level of attention to detail, understanding and compassion of the great doctors, then you will know how to make products we will praise. Until then, you may go back to lambasting your straw men.
Brian, let me clarify, I am referring to a patent pending PHR not an EMR. The IOM Report on adverse events in the US is a tragedy with so many avoidable deaths and medical errros. These hundreds of thousands of adverse events are due most of the time to the lack of medical data at point of care. Our mobile health technology solution displays vital data at point of care during a personal medical emergency “at the scene.” Better yet,… the innovative technology securely transmits vital medical data PRIOR to the persons arrival in the ER doors!
http://m.mycrisisrecords
Jerry, that sounds like a good product and I wish you luck. If you’re going to sell it, doctors will have to interpret and use the data. Otherwise there is no point. I would suggest you reconsider the message for marketing purposes. Instead of telling doctors to let go of need for control (which shows a lack of understanding of what we do and why), I would consider telling doctors you can help them to save lives when seconds count. We don’t care about your thoughts of “bottom up” or whatever. If it helps, we’ll use it. If it doesn’t help, you’re dead in the water. Just like EMR.
Dr. Goyal complains about the need for data backup. I think he should be thankful that a backup finally exists for his medical records. Where’s the backup for paper? In his mind, perhaps? That probably wouldn’t suffice in a court of law.
[…] thanks for reading my recent post at the EMR and HIPAA blog. It’s sparked the kind of lively debate I’ve been hoping for […]
I’ll give my business to the doctor who acts more like a scientist and less like an oracle. I’ll give my business to the doctor who doesn’t spout off the top of their head, and makes decisions based on data. We’ve got a long way to go toward serving up the right data at the right time, but the underlying principle absolutely stands.
There’s a fascinating psychological block at play here. I think doctors are used to being authority figures, not just a provider of a service. Many of them aren’t used to having their judgement, or the process that went into that judgement, held up to scrutiny or review. They aren’t used to being asked to adjust their workflow.
In a related issue, many doctors aren’t used to and aren’t ready for the empowered patient doing their own homework and coming to a collective decision instead of just doing what the doctor dictates them to do.
Brian is totally right about the gestalt. That’s what separates patients with an internet connection from doctors with an experience connection.
What good is gestalt if you’re at home and the patient’s records are in a file cabinet miles away?
Great conversation. I forget that when Neil writes the post I don’t get the email with the updates. I’ll have to fix that.
I think it’s fair to say that some doctors do grandstand and have a hard time relying on something or someone else for care. Actually, I think this is part of the human condition. When we’re suppose to be the expert we don’t want to show any sort of vulnerability or need to rely on someone else. Men are especially good at this. Not all doctors are this way, but it’s a challenge for many.
It’s also fair to say that software providers haven’t provided the software for improving patient care that they should have been providing. The focus has been far too much on billing and not enough on workflow and improving the doctor and patient experience.
Either way, both parts of the status quo need help.
Gestalt does not need electronic medical records.
[…] of this takes me back to Neil Versel’s posts about Clinical Decision Support and doctors resistance to CDS. There’s no doubt that the Watson technology is another form of […]
To Neil,
Physicians have been trained to do COGNITIVE thinking.
first, we gather information(history)
second, we physically exam the patient(physical exam)
third, we come up with possible differential diagnosis
fourth, we order tests to be run
finally, we come up with the best treatment.
To master these 5 steps we go through many painful years of schooling and training for the purpose of cognitive thinking. Doing both cognitive thinking and mechanical work (EMR)at the same time can be very dangerous. Because some of the cognitive and critical thinking are jeopardized due to shifted attention to mechanical work.
If the whole country wants EMR and EHCA(electronic health care algorithm/health care cookbook), then why do we need physicians? Get rid of all the doctors including myself, let’s get on with EMR and EHCA and have the software engineers and allied health care workers run the health care of this country. This will be much simpler than arguing about EMR.
Don’t you think so?
Not at all. Clinical decision support is just that, support. The doctor makes the decision, but with the assistance of a computer.