The Coming Physician EHR Revolt

From my blogging viewpoint I’m sensing a growing discontent among doctors that is starting to really heat up. I can’t quite predict when this discontent will reach a boiling point that will start to boil over, but the fireworks are coming. As I’ve watched the past couple years, doctors were first overwhelmed with all the government regulations. They were confused by everything was coming out and really just didn’t know where healthcare IT and EHR was headed. That overwhelmed confusion is slowly turning into a reality that many doctors are realizing is changing how they practice medicine. If you’re not seeing this, then you might want to get out and spend some more time with your casual every day doctors.

One doctor emailed me today suggesting that doctors were being literally “eaten alive” as they are working harder to provide patient centered care. It would be a disservice to doctors if we don’t take the time to acknowledge and understand the enormous pressures that many doctors are feeling right now.

Here’s a quick look at what I believe is the perspective of many doctors I connect with on a daily basis.

Regulations
Everywhere doctors look they’re getting hammered by new regulations. I recently heard Shahid Shah say, “We’re experts in the industry that spend all day thinking about the market and regulations and even we have a challenge understanding what’s going on. Now think about the doctors and adminstrators which have challenging day jobs and only a small amount of time to understand the regulations. They don’t really understand the details of what’s being regulated.”

This is a reality for many doctors and practices. Is it any wonder that many are happy to sell off their practices to major hospitals? I’m sure that many do so just because they’re tired of trying to understand all the changing regulations they’re required to know.

If we look at just the healthcare IT and EHR related regulations you have: meaningful use, ACOs, ICD-10, 5010, and Obamacare/Healthcare Reform. Any one of those is a challenge to understand and implement. Yet doctors and hospitals are dealing with all five of them simultaneously. Not to mention doctors being asked to participate in HIEs, being graded and rated online, engaging with empowered patients through social media, and embracing a new technology savvy culture while reimbursement lags behind.

Is it any wonder that doctors feel overwhelmed, overworked, and unsure whether they want to continue being doctors. Is this going to lead to a real shortage of medical professionals?

EHR Discontent
Since this is an EHR blog, we should spend some time on the growing discontent with EHR software. I hate to dwell on this, because EHR is going to be the future of clinical documentation. It’s hear to stay and no amount of belly aching and moaning is going to stop EHR software from becoming the de facto standard for clinical documentation. However, just because this is the case doesn’t mean we should ignore the realities that so many doctors are facing when it comes to EHR software today.

Many doctors see EHR as a major time suck. Their EHR software requires them to work longer hours and/or see fewer patients. Overtime this usually improves, but we have to acknowledge the initial productivity hit that pretty much every EHR implementation sees. Some clinics never get back to their previous productivity. We’ve discussed the reasons for this over and over again on this blog. We’ll save the list of reasons and ways to avoid those issues for another blog post. However, until all 300+ EHR vendors solve the EHR productivity issue, we’re going to hear more and more stories of how much of a time suck an EHR is to many doctors.

Not all doctors see it this way. Many doctors can’t imagine their practice without an EHR. As we’ve been covering in our EHR Benefits Series, there are a lot of benefits to having an EHR. Many of the benefits we’ve already covered in that series are ways that a clinic can save time thanks to an EHR. However, it can take time for a new EHR user to get up to speed where they can speak the EMR language well. It’s not easy learning a new language, and so this adds to the growing discontent that many doctors feel towards EHR.

Template EHR and Copy Paste
Many EHR vendors have implemented a complex set of templates that doctors can use to be more efficient. It’s a thing of beauty to see a full template pulled into a patient’s chart with a single click. A full patient physical documented with a single click sounds like it should save the doctors a lot of time and make them more efficient. In fact, many have argued that template based EHR documentation is a great way for doctors to achieve higher reimbursement levels since they are better able to document the actual care they’re providing. In the paper world they would have passed on the higher reimbursement because they didn’t have the time or desire to document all of the items they examined and so they just accept a lower reimbursement level. EMR templates made it possible for doctors to finally be reimbursed for all of the care they provided a patient since the templates made it easy to document.

Sounds great doesn’t it? Well, it did until the government realized that EHR software often drove up their costs. This shouldn’t have been a surprise to anyone in the EHR world. I’ve been writing about the ability to increase your reimbursement rates from EHR for over 7 years. However, instead of the government choosing to acknowledge something that was apparent to many in the industry, they decided to blame the increased costs on, you guessed it, dishonest doctors.

Think about the message that we’re sending doctors. First the government tells doctors to start using EHR. Then, the government calls those doctors dishonest for using the tools that the government told them to use. A doctor recently described their perspective is like being stuck in a pit with sly hyenas all around ready to take their bite out of them.

Add in all the recent discussions about copy and paste in EMR’s, and it shouldn’t be any wonder that doctors are gun shy. When they implement technologies to try and make things more efficient they get their hands slapped or even worse.

Reduced Reimbursement and Penalties
In the midst of all the things mentioned above, doctors are also getting hit with reduced reimbursement rates. This is particularly true for those in the general medicine area. They’re being asked to do more to improve patient care, reduce hospital re-admissions, treat the whole patient, etc and they’re getting less reimbursement.

Plus, now the EHR penalties are hanging over their head if they choose to not show meaningful use of a certified EHR. I still have my doubts that the EHR penalties will be enforced. I expect there will be a whole series of exceptions offered up which make it so pretty much all of the doctors avoid the penalties. However, that’s still unknown and many doctors see those EHR penalties as just another slap into the face.

Data Data Data
Most doctors see the push for EHR as a way for someone to get at the data in healthcare. In many ways, they’re right. EHR’s were first created as big billing machines to get at the financial data. Now with meaningful use, EHR’s are repositories of other healthcare data. The data is being used to optimize reimbursement (rarely a good thing for doctors). The data is wanted for population health analysis. The data is wanted for public health needs. The data is wanted to be able to facilitate ACOs. Everyone wants a piece of the healthcare data it seems.

The problem from a physician perspective is that everyone wants that data, but it’s not often clear how that data is going to facilitate that doctor being a better doctor. In many cases it won’t and there’s the rub. Almost every doctor I know wants to improve healthcare. So, they don’t have any problems supporting initiatives that improve healthcare, but I think that most of them also sit back and wonder at what cost.

Audits
I don’t know anyone that likes audits. Yet, most doctors are surrounded by a wide variety of audits. RAC Audits are on the way. HIPAA audits are possible and HIPAA is always lingering in the back of most doctors minds. Especially when you start talking about technology and HIPAA. There are so many unknowns that there’s no place of comfort for those doctors who want to be compliant. Most make a best effort and then push it out of their minds as they try to provide great patient care. Next up our meaningful use audits. You can be sure they’re coming.

Solutions
I wish I could say that I have a bunch of really good solutions available. What does seem clear to me is that most of the challenges that doctors face revolve around the current reimbursement models that we have today. I’m not sure we can fundamentally change those. One interesting option that’s emerging is concierge medicine.

Every doctor I know loves the idea of concierge medicine. When you tell them they don’t have to worry about reimbursement, insurance companies, etc, you see this huge weight lifted off of their shoulders as they wonder what life would be like for them if all they did was provide the best patient care to those who came to their office. The problem with concierge medicine was highlighted in a tweet I saw recently that said, “Concierge Medicine – Does it really work?”

The answer to that question is: it’s still too early to know for sure. Although, my prediction is that concierge medicine will work in certain situations and communities, but won’t be able to provide the widespread change of reimbursement that we need for healthcare to alleviate doctors concerns.

When it comes to EHR, concierge medicine is quite interesting. None of the mainstream EHR vendors really work for concierge medicine since they’re all focused around reimbursement and concierge throws that out the window. Plus, think about how few of the meaningful use requirements a concierge medicine clinic cares about. In fact, implementing many of the meaningful use and EHR certification requirements gets in the way of the concierge doctor’s workflow. I expect many doctors would love a concierge focused EHR software.

The other solution is likely going to be EHR vendors yielding to the idea that they’re the database of healthcare. Once they make this decision, EHR vendors can really open up the proverbial EHR kimono and let outside developers really make their EHR useful for doctors across all specialties, all regions, all sizes, and every unique workflow. One company can’t satisfy every doctor the way a community of empowered developers can.

No One Feels Bad for Doctors
I’ve written about this idea before, but almost no one feels bad for what most people think of as “well paid doctors.” Far too many doctors are still driving around Mercedes and BMW’s for most people to feel too bad for them. Compared to many people who don’t have a job at all, I don’t feel bad for them either.

While we don’t have to feel sorry for them, that doesn’t mean we shouldn’t acknowledge the pressures that doctors are facing. Plus, I see this only getting worse before it gets better. As an entrepreneur, I see this as a tremendous opportunity. Plus, I see a number of companies that are working to capture this opportunity. However, far too many companies are blind to this physician discontent. I’m not sure if it’s purposefully blind, ignorantly blind, or arrogantly blind, but many are ignoring it. As I predicted in the beginning of this post, I see this reaching a boiling point soon which leads to some fireworks.

Let me highlight what I’m talking about using the words of a doctor’s message I literally received in my email as I was writing this post:

EMR’s are making it more and more difficult to practice medicine. They used to be fun and helped my daily work. Now, they are getting so complex that is takes much more time to do them. MU is becoming a nightmare for physicians.

About the author

John Lynn

John Lynn

John Lynn is the Founder of the HealthcareScene.com, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference, EXPO.health, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.

23 Comments

  • Great post John. Your observations are no doubt astute ones. As you mentioned, one of the biggest issues is the productivity drain most current EHR solutions have on physicians. All of the other pressures (i.e. regulations, reimbursement changes, reform, etc.) would likely be a lot easier for physicians to take if their EHR solutions actually made their jobs easier. Unfortunately, all too often this is not the case. This needs to be a major area of focus for both the ONC and the EHR vendor community going forward.

    By the way, I like the new look of your site.

  • I highly doubt that ONC and other EHR vendors (especially those that currently dominate the market) will focus on usability for physicians. There is too much at stake money wise that there is no interest to cater to the needs of physicians. For to do that would require a major overhaul of their platform, associated technologies, and a likely loss of market share. The current legislation and associated MU criteria are catered towards preserving the needs of those vendors in an unfair manner, pushing away smaller, innovative, and forward thinking solutions. I do welcome the unrest coming from physicians (myself included) as I believe EHRs should be a clinical tool to facilitate clinical tasks and not to hijack them and the physicians who use them.

  • Well thought out article. Right on point for many. Hopefully, this starts to resonate in the wider community. Love the idea of possible innovation that may come out of this, although agreed it will be a long haul and uphill battle until this all shakes out.

  • At the crux of the issue is our decision in this country to use the physician’s note as the source for billing. You pull this out of the equation and suddenly we physicians can start using the EHRs to manage patient’s and population health rather than documenting minutia that often serves no purpose but to enhance and support the visit code.

    Regulations won’t permit logical distribution of documentation work without adversely affecting the visit codes and so much of the potential time savings are eliminated by pushing more and more keyboard work to the physician whereas in the paper world it wasn’t possible to isolate who did what so work could be efficiently distributed.

    IMHO the problem isn’t with the EHRs but with our reimbursement system that pays for leaves rather than trees.

  • The waste of turning doctors into distracted data trolls will be increasingly untenable as fees for services wane. In the fashion that most EHR systems have been implemented, physicians end up spending an average of around 80% of their time doing tasks that don’t require a medical license. Proper EHR workflows and implementation drops the waste to about 20%, and it is far less waste than with the legacy dictation-paper approaches. Efficient and meaningful usefulness of information technology at the point of care is going to be the only tenable, long term approach.
    Let the revolution begin!

  • I’m a bit late to this comment party, but I do want to contribute.

    🙂

    Regarding whether technology platform or incentive environment is to blame (reminds me of nature vs nurture debate), both play their part. However I don’t think folks appreciate just how much role technology has played in this fiasco.

    “The problems of Meaningful Use are entirely predictable through the lens of the infamous Iron Triangle anti-pattern of software development. Attempting to bring too many features to market too soon usually results in unstable, less usable, and hard to maintain software.

    Wait, you say. Why can’t we add resources? You can. Up to a point. At the beginning of a software project, adding the right programmer or two can be helpful. The problem is, as the number of personnel grows, you run into Fred Brooks’ most enduring law: “Adding manpower to a late software project makes it later.”

    There is no way out of the Iron Triangle. You can only make it bigger. It should be renamed the Carbon Nanotube Triangle (strongest, lightest material known). You can change the triangle’s shape by shifting emphases among features, schedule, and resources. And you can change its size through technological innovation. So far we’ve been trying to do the former, mostly via stakeholders asking, begging, demanding that we slow down. Some innovators nibble at the problem, creating workarounds and crafting end-runs: EHR-lite, EHR-extenders, mEHR etc.

    The only way to increase the size of the Iron Triangle (to deliver more and better features sooner) is to change what economists call the “factors of production”. In this case the factors are the software technologies we use to attempt to meet the requirements of Meaningful Use.”

    Fixing Our Health IT Mess: Are Business Models or Technology Models to Blame?

    http://chuckwebster.com/2013/01/healthcare-bpm/fixing-our-health-it-mess-are-business-models-or-technology-models-to-blame

  • I’m pretty sure I’ve portrayed much of this discontent in my of my posts. Take the EHR out of the picture and guess what? Docs are still pissed off that they have to work more to make the same amount of money due to reduced reimbursements.

    There is a saying among airline pilots that, no matter how good things are, there is still plenty to bitch about.

    I’d argue the revolt began back when docs blatantly ignored HIPAA – too confusing, “they can’t expect me to understand all of this…”

    It continues today with attestation numbers being made up…especially attesting that Core Item #15 was actually completed.

    There is this foot-dragging revolt and feeling (I believe) of, “go ahead and pile all of this BS on me, threaten to close my practice. When you then have a doctor shortage, remember what you did to cause it.”

  • Great article. EMRs are a great concept as long as they make it easier to practice medicine. But when the government steps in and forces command-driven legal constraints, things get quickly out of hand — not the fault of the EMRs.

    In the high-tech world, where things *have* to work correctly and seamlessly, it is largely because the government stays out of the way, and an industry consortium works out the details. But when government introduces complex regulations to “fix” a problem — Sarbanes-Oxley, Dodd-Frank, and Obamacare come to mind — bigger businesses can generally absorb the additional overhead; it’s the small businesses the get screwed. And of course the problem at root remains.

    Welcome to the Regulatory State.

  • Some good additions to the conversation. Someone emailed me in response to this post that patient accountability is another thing that’s a big challenge for doctors. I think that’s worthy of its own post.

  • Sing it, John! All the EHR implementation stories I’ve heard/witnessed/reported have been (dare I say it?) epic in their ability to grind all work processes to a halt. That’s not peculiar to any one vendor, it’s an across-the-board issue.

    The cause, I think, is what I call “vendor-itis” – the disease that afflicts almost all enterprise-level software development. Bloated code, an inability on the part of the vendor to really understand the workflow and process of the end-users, lock-in (works fine inside the bubble, but woe to those who try to move data outside that bubble).

    I feel like I’m in a late ’70s/early ’80s flashback to old-school MIS tape-drive systems development, when the “Bang Head Here” wall hanging became popular. “Meaningful Use” doesn’t seem to equate to meaningful usage by doctors or patients. Payers might be happy, since the systems seem to have been created to deliver a steady stream of billing codes to them. However, what is it doing to improve quality and effectiveness of care?

  • Let alone the extreme inefficiency of EMR, the generated documents are a waste of time to read. I’ve not found one EMR generated document from an ER or speciaty office that is worth any more than throwing in the trash can. An ER will send you 8 pages on your patient, and you’re lucky if you find one paragragh where a human being actually took the time to enter something useful. God forbid that doctors and nurses should actually see their patients and give good clinical descriptions of their observations and examinations. You can’t fit a round peg in a square hole, and that’s exactly what EMR is all about. What really gripes me is who is all of this for?–insurance companies?– they seem to run every thing else. And, really, what interest does the government have in mandating how helath care providers see their patients?– don’t tell me that it’s for better patient care because I’m sure they could care less. Finally, the medical school professors that taught me 25 years ago would roll over in their graves if they knew how the medical profession just rolled over and let government and insurance companies tell them how to conduct a doctor-patient relationship. I’m eager to be part of any revolution that would put health care providers back in the driver’s seat where they belong. Thanks for this opportunity to get this off my chest!!!!

  • I have an outside looking in perspective as I’m similar to the author Mandi, whom is ‘just a geek!’ like myself; she has written some great articles I enjoy perusing. I’ve experienced an Ortho practice implementation and now a Cardiology. I work directly with and around Physicians all day everyday. I’ve worked in the hospital and know many of their processes/challenges related to IT and how it affects EHR/EMR access. Being in IT, I think our implementations have gone well because the relationship between IT and clinical is very strong. That’s not normally the case. I’m presenting many a-times speculative views on the future and providers responding with their likes and dislikes. I’ve noticed some strong, casual and opposite responses to that similar of Dr Spencers’ remarks. Initially, I thought this was a generational thing. The younger Providers would accept this inevitability and the older generation, not so much. That isn’t necessarily the case. IT is IT as well, its not clinical, therefore we get sidestepped when the real deal should be tying the 2 together, and closely. I’d like to think our Physicians have gained alot of self sufficient knowledge from my interaction with them and vice versa. I’m learning how I can improve a clinical process through the use of our EHR and am not afraid to challenge the Providers with that ‘wont work well because’.

    The 30,000 foot view for me personally is this obviously is just the beginning of a larger project. That being, HIE implementations, the cross-routing of information on the backend while leaving business locally, alone and less disruptive. This is all for the intermingling of data locally, statewide, eventually nationally and maybe if Im still alive, globally where bits of data can be transferred and accurately presented within seconds rather than waiting to pull a chart and getting it faxed. The reality is it’s a painful process to get there and will be for quite some time. I try and tell my Providers that we’re in the trenches in the here and now so that your kids can have the way the system was intended. A tool that is fast, efficient, scaled (relative to what it’s now). I realize that’s all subjective but we can dream right? To Providers: Think of this as a tabula rasa. It’ll be awhile before the scripts are written and in stone.

  • I recently retired from a very busy primary care practice. I retired rather than using emr. My management company had introduced an emr product to my practice and I diligently trained myself on their system. Unfortunately I came to the conclusion emr wouldn’t let me practice medicine and still have fun doing so. There were three things that bothered me. First was the fact that I could not integrate medical and psychosocial aspects of care and make any meaningful use of the progress note that was generated, Second was the depersonalization that occurred when I turned my back on the patient to type in notes or finish a progress note.The third was the fact that the emr was being used to enhance coding and thus was not primary care friendly. There were other issues but these three interfered with my style of practice and I wasn’t willing to compromise. Doing so would have changed the whole dynamic I had worked so hard to accomplish between me and my patients.

  • Well written article, you detail all the hurdles the physicians are encountering. I spent six months helping a clinic transition to EMR and there was Huge pushback from the doctors. As for Obamacare, listen to Dr. Elaina George ( Google her ) who describes what it is like to be a physician these days….

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