For those of you who read this site and don’t read EMR and HIPAA, you should go and read this post called Paper Has Healthcare Spoiled. While some might see it as an anthem for paper in healthcare, as I said in the comments of the post, it’s really an attempt to help EHR vendors see some of the advantages of paper and hopefully they’ll find ways to get those same benefits from EHR.
A Davis (who I believe is a doctor) also offered these insights in response to the post:
There’s no doubt that for one patient, in one office, paper is the absolute leader over EMRs in terms of ease of use. When considering multiple patients in multiple locations, the potential advantage of the EMR is easily seen.
The challenge is to transfer the benefits of paper to the EMR. That challenge has gone largely unmet, and it is the primary reason why uptake of EMRs among physicians has been so poor.
Medicine is a very personal undertaking. Physicians treat patients one at a time, and that’s how patients want it. That treatment is detailed, can be very personalized/customized, and documentation of that treatment varies to meet those individualized demands. EMRs, in their current state, are not user friendly to that type of documentation. While the government, insurers and hospitals are interested in aggregate data, physicians are not – at least not in the exam room, where their documentation occurs.
For an ever-shrinking number of physicians, typing is a problem. The problem is self-resolving over time.
For every physician, the “hunt and peck” mode of documentation is a problem. There are many variants – check boxes, radio boxes, drop down lists, “type ahead” automatic completion, etc – but there are hundreds, if not thousands, of locations in any EMR where the physician is required to choose among multiple options in a list. And there is no efficient way to do it. In a paper chart, the required entry simply flows from the tip of the pen. In an EMR, the physician’s attention must shift to the appropriate entry field, the mode of selection must be determined, the proper entry must be found and selected and, often, it must be confirmed, by clicking, by tabbing to the next field, etc. It takes a few seconds longer than simply writing the word and, when multiplied by the dozens or hundreds of times it must be done in a single patient encounter, the time lost becomes significant. Despite this limitation, it isn’t the method of data entry which is the primary problem.
The issue is how much data is required. Because hospitals and physicians are forced to accept fixed payments from the government and insurers, the natural evolution of EMRs as patient care tools has been altered. Rather than innovating to meet the needs of doctors and patients in the exam room, EMR vendors were forced to focus on the billing aspects of the EMR in order to justify their fees in a fixed-price economy. Therefore, EMRs are designed to elicit the information needed to justify the highest allowable payment rate from any given patient encounter. This is good for office and hospital economics, but is actually counterproductive to patient care.
For a given patient problem, the EMR doesn’t change the physician’s diagnosis and treatment decisions, but it does slow down the visit process by asking, typically, for more information than the physician needs for those decisions in order to get the required billing justification info needed to maximize the “billing code” for the patient encounter. This process is not only counterproductive to efficient care, but also increases the cost of medicine overall.
This problem is not inherent to the difference between paper and EMRs; rather, it is the result of the development of EMRs in a government-constrained environment. But it matters, because it is the basis of the very real fact that most physicians would prefer to use paper over an EMR. Until EMR vendors are able to innovate with the goal of improving the documentation needs of patients and their physicians, rather than government and insurers, paper will remain the medium of choice in the exam room.
As I’ve said for years, the biggest problem with legacy EHR software is that they’re big EHR billing engines.
Watch for more posts on EMR and HIPAA covering how healthcare is spoiled in other ways as well.