Yves here. Replying on the work of the health care and IT experts writing at Health Care Renewal, we have been writing about how electronic health care records are a danger to sound medical practice. Among other things, they are designed for billing, not diagnosis or treatment, force doctors to waste time dealing with pages of mechanical drop-downs, and distract them from paying attention to patients. One of many examples over the years: the ECRI Institute puts health care information technology as the top risk in its 2014 Patient Safety Concerns for Large Health Care Organizations report. Note that this ranking was based on the collection and analysis of over 300,000 events since 2009.
By InformaticsMD. Originally published at Health Care Renewal
I’m certain when the information technology hyperenthusiasts and non-clinical management information systems “experts” and pundits get the technology all figured out, this burnout crisis will end.
It will be about the same time as Zefram Cochrane invents the warp drive in Bozeman, Montana just prior to first contact by the Vulcans. That is in 2063 or so.
Experts declare physician burnout ‘a public health crisis’
January 22, 2019
Experts from leading U.S. health organizations deemed physician burnout “a public health crisis” in a recent report.
“Physician burnout has received some attention in recent years, but not enough. As a result, it is both poorly understood and getting worse,” Andrew R. Iliff, MA, JD, lead writer and program manager at Harvard Global Health Institute, told Healio Psychiatry.
“Like the blind man describing an elephant, people have described the challenges in front of them, including unhelpful electronic health records and a looming physician shortage,” he continued. “We believe it is important to frame this as a systems problem, requiring systemic solutions in order to avoid further adding to ballooning health care costs and undermining the provision of care.”
In their paper, experts from Harvard T.H. Chan School of Public Health, the Harvard Global Health Institute, the Massachusetts Medical Society and the Massachusetts Health and Hospital Association recommended ways to address the prevalence of burnout among physicians and other health care providers. Recommendations included:
- appointing an executive-level chief wellness officer (CWO) at every major health care organization;
- providing support for those experiencing burnout; and
- improving the efficiency of EHRs.
More on that third Pavlovian, formulaic, hackneyed, health IT amateur-proffered bullet point in a moment.
… The usability of EHRs must be addressed through reform of certification standards by the federal government; improved interoperability; use of application programming interfaces by vendors; and increased physician engagement in the records’ design, implementation and customization, according to the report.
“Certification” standards are useless towards the stated ends. Interoperability via API’s is not the major issue, either; fundamental operability and, ultimately, clinician burden is.
It is also far too late in the game for “physician engagement” to make any difference. People in my specialty, myself included dating back to the 1990’s – and me on this blog starting ca. 2004 – had been calling for clinician (and especially Medical Informatics) leadership (not merely “engagement”) of health IT.
I note that the original title for my health IT academic site, still residing here, was “Preventing Medical Errors: Medical Informatics and Leadership of Clinical Computing.” The original ca. 1999 site is partially archived at http://www.ischool.drexel.edu/faculty/ssilverstein/informaticsmd/index_org.htm.
Little has changed, and the worst predictions I’d been making about the healthcare IT bubble/experiment (see query search https://hcrenewal.blogspot.com/search/label/Healthcare%20IT%20experiment) seem to be reaching unfortunate fruition.
Regarding the “efficiency” bullet point above: quite seriously, from the perspective of this trained-by-the-pioneers Medical Informatics specialist, the “efficiency of EHRs” can only marginally be “improved.” This is due to both technical and political reasons. The systems are far too complex, with far too many templates, widgets, options, “tricks”, “gotchas” etc. (with user manuals hundreds of pages long for each, that cause even my eyes to glaze over), too embedded, too protected by the industry, especially those involving legacy code, and too entrenched by politics – to name just some of the issues making major reform of the systems themselves impractical.
The situation should never have gotten this far, predicted as far back as 1969 by EHR pioneer Dr. Donald A.B. Lindberg (http://www.nlm.nih.gov/od/roster/lindberg.html), who wrote that an effect of the “over sell” even occurring then has been “the feeling that logic compels us to build total hospital information systems like military command-and-control systems … and other grotesque concepts too numerous to mention.”
| Lindberg in 1969. From Collen, “A History of Medical Informatics in the United States: 1950 to 1990” |
What is needed is a significant downgrading of required clinician (physician/nurse) interaction with these “command-and-control systems”, including data entry, and the use of clericals to perform those functions. See my August 2016 essay “More on uncoupling clinicians from EHR clerical oppression” at https://hcrenewal.blogspot.com/2016/08/more-on-uncoupling-clinicians-from-ehr_91.html
One last quote from the Healio article:
… Burnout not only causes physicians suffering, it also can adversely impact patients. Prior research has shown that burnout may does increase the risk for medical errors. [Fixed the academic equivocation – ed.]
Put more simply, physician and nurse burnout can kill you.
If a healthcare organization cannot afford the appropriate clerical help to avoid clinician burnout, then they cannot afford an EHR.
Finally:
Can I now say “I told you so?” without the health IT industry sockpuppets coming out of the woodwork? (http://hcrenewal.blogspot.com/2010/01/more-on-perversity-in-hit-world.html)
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I’m probably crossing wires here, but wasn’t the combination of technology and free market innovation supposed to release us all from so-called red-tape and bureaucracy? Wasn’t there supposed to be some invisible appendage that would take care of these bothersome interferences that regulated our lives?
Or maybe, just maybe, if the goals of any system are geared to one end only, it’s just possible that regulations and the regulated don’t disappear but that the onus is shifted onto different people so that costs are reduced, labour devalued, and efficiencies extended beyond that which can be efficiently tolerated by an individual in order that costs are reduced and consequently more and more income streams upwards. /s
Of course the average punter who can still afford services has to deal with a plethora of red-tape and wasted time (maybe more so) in this neo-liberal economic age.
And it’s not only physicians but such people as teachers who are experiencing the joys of neo-liberal epidemics, and I’m sure others can point vital and valuable work and workers whose jobs are becoming more, shall we say for sake of decorum, devalued.
Of course, thats the ‘theory’. But the reality of these systems is that they have one primary purpose – to enforce managerial control over specialists and professionals.
As an IT consultant friend of mine put it – when you order an IT system to run an organisation you can ask for one of two things – (a). you can specify a system that increases employee productivity and effectiveness – or (b) you can ask for a system that produces metrics and increases management control over those employees. You can’t do both, because the amount of inputting required for system (b) makes it counterproductive for system (a).
Its very clear – and this is a particular problem in the public and general public service sectors – that systems of type (b) predominate. They don’t improve employee performance, because thats not what they are intended to do. They are designed to increase the control and power of senior managers. They do this very well (hence you see the rocketing compensation for professional managers in medicine, education, etc).
Thanks PK. I was (for the most part) being sarcy. It’s more valuable, though, to have an insider’s knowledge of how the systems are conceived to control rather than to liberate. Your input clarified as to why certain choices are made.
But still, I can’t help but think that the current use of technology and bureaucracy are organised and operated to ensure the entire social system makes services and information scarce commodities whilst also reducing costs so that more money flows to those who already have the money. This tendency seems to be increasing as govt. services are replaced by private profit making operations. I’m probably, as usual, over-egging the pudding.
I’ve been using computer technology since the early 1980s and remember fondly using DOS command line instructions on computers and a laptop (long before laptops became ubiquitous). One felt like one had some sort of input into the process and as sense of control. Back then, I really looked forward to the further development of technologies. No as much anymore. Now I just see myself doing work for banks, shops, the council and travel agencies via technologies, and all for free. One of the things I really look forward to when returning home this year is meeting people on check out lines, in banks and so forth. I’ll enjoy it while it lasts. It’s bound to “modernise” even in the remote corners of the Mid North West over time. (boy, do I sound like an oldster)
Yes, I’ve had similar experiences. Back in the 1990’s I worked for a major project management company in a very large scale project. The cutting edge tech system developed for the project failed (at allegedly a cost in ten figures), so they revived an old DOS based data management system and appointed a DocCon person in every unit to manage inputs and outputs. It worked very smoothly and very efficiently and did so at minimal cost. They also had the foresight to hire a few retired people from the projects forerunner who’s sole role was to sit there and answer questions from staff about what had happened before. Far more useful than any database.
I’ve had a recent experience where an almost antique data management system was replaced by a full bells and whistles version with all sorts of whizzy features that nobody could work out why anyone would need them. Someone did a measurement and found that each input of data took a member of staff 20 minutes, in contrast to the sub-five minutes of the older system. Nobody could explain how that helped anyone. It did, however, produce very lovely looking graphs that purported to show how hard (or not) everyone was working.
IT systems are either “enterprise” driven or “clinically”. Namely a test result may not be accessible but billing has already processed it. Until we eliminate the inefficient Insurance Industry we wont ever move forward.
Private Insurance has failed on it’s two principle charges. Price and effectiveness of purpose. IT systems are dominated by these failures.
When I worked in medical IT many years ago, management used to get very twitchy whenever we met with clinicians to gather requirements. They did everything they could to prevent it in the first place (“just talk to me, I’ll tell you the requirements”) and when we pushed for it, they limited the scope severely and insisted on review and veto authority over any of the recommendations.
I always thought this was odd and wondered why they didn’t like it when it was so obviously fundamental to meeting user needs. Now I get it. We were trying to build a type (a) system, but they wanted type (b). We were talking to the wrong users.
In fairness, clinicians are constantly in a hurry and don’t like record keeping, so there was always something of a chicken and egg problem in that clinical systems tended not to be all that well maintained or consistent in comparison to financial systems, which means there’s always a temptation to use the better/higher quality data even if it’s not quite fit for purpose. But that would have been fixable with enough will. It was apparent even from the limited conversations I had that there was huge appetite among clinicians for systems that saved them time and helped them do a better job. When we managed to hit on something that met that description, you could see their eyes light up. Unfortunately those were the ones that always seemed to end up on the cutting room floor.
Hence “command and control” system. The term “EHR” is an anachronism. These systems are not filing cabinets replacing the paper record, but enterprise command-and-control systems through which every transaction of the care process must pass, and be monitored and controlled at the whims of the management.
Over the past 30 years, the American solution to almost everything has been to add complexity. As our political system gets more polarized, it is impossible to throw anything away and rethink from scratch. So things just get added on and it has even become impossible even to pass bills that correct obvious legislative drafting errors. As a result, much of our economy today is simply a series of pilot systems and over-engineered second systems as defined by Fred Brooks in “The Mythical Man-Month” in 1975.
https://en.wikipedia.org/wiki/The_Mythical_Man-Month
Roy Poses writes very well but I see that he needs to do more work on his Star Trek cannon which I can help him out here. We actually live in the Star Trek Mirror universe – sort of like the Bizzaro World that Justin Raimondo claims that the 9/11 explosions dropped us into. Here is a video clip that shows that we actually live in the Star Trek Mirror Universe-
https://www.youtube.com/watch?v=qXw6hC7hxBA
It seems that there is no activity that information technology hyperenthusiasts do not try to jam themselves into – at an enormous profit to themselves. Turning highly trained and experienced doctor into tarted-up data clerks is not a good use of resources. No matter how crappy the interfaces are now, by the time that people are used to them it will be time for “an upgrade” with an enormous price-tag attached. I notice that the recommendations by that Harvard mob in the paper are to do with making the doctors fit the computer interfaces and not the other way around. Sooner or later they are going to have to make up their minds which is more important for a medical system – satisfied doctors or happy information technology hyperenthusiasts. I have read about the interfaces used and they are junk and ill-thought out. Even if you – somehow – farm out this data entry work to clerks which is not likely as the doctors have all the needed answer then that still leaves you with medical practices with large overheads Time for a major rethink. Either that or go back to paper.
I write the informatics pieces for HC Renewal.
The intent isn’t to convert a doctor into a data entry clerk, but to eliminate his/her profession entirely … with AI. This will happen, the medical profession is a medieval social system for those who don’t want to be attorneys or Catholic priests (those three being the reason why have universities at all). “Clerical” originating in lower Church orders of those who could read and write.
The AI won’t work well, but it will be justifiable as a cost reduction. The wealthy will always have access to good doctors.
No, they will not. Several problems:
If we make doctoring into the same kind of work situation as butlers, very few will seek to become a doctor. The risk / reward proposition for spending 7-10 hard years in becoming good at a service that might be unwanted is not very good.
Second, we don’t know if a doctor is actually any good until after some time and maybe some patients have passed away! Who of the ultra-rich are going to be the test dummies to see if the new family doctor is viable?
Third, we very need different doctors at different times and for different occasions. It is not cost-effective to keep a pool of doctors at the ready for every possible situation.
Fourth, The kind of AI we currently understand enough to build is mostly flimflam and bullshit, good at spotting correlations, absolute crap at divining what those correlation mean and if they indeed mean anything. There are some domain-specific AI tools that are becoming good (http://blogs.sciencemag.org/pipeline/archives/2019/01/18/automated-route-finding-and-patent-busting), however “medicine” is not a small enough domain to build a good AI-tool for.
Fifth, The data for treatments, cures and whatnot is too narrow to be any good at all if only Wealthy are treated with “the latest cures / medicine”. We need millions of people to divine if something works and is safe.
Basically, the current system with hospitals holding pools of doctors; surgical procedures and medicine applied to a vast number of test subjects is in fact perfect for the wealthy because it allows them to rent the best qualified doctors for exactly when they need them, for whatever the situation and not carry all the cost of training, verification and maintenance.
More at threads here: https://twitter.com/brianrahmer/status/753938315083128832
https://twitter.com/brianrahmer/status/701089531232186368
Northwell Health might try developing a sophisticated computer program that would remind a primary care doctor to follow up on a lung mass instead of forgetting about it until an unrelated x-ray prompted removal of cancerous growth 2-3 years after it was found. If it was more aggressive the patient would be dead.
They might develop a computer program which would prompt the patients primary care physician to stop in for 30 seconds and say hello to her patient (e.g. “customer” for the MBAs) who is in for surgery, something she has not bothered to do for 5 surgeries in past 5 years or so.
Perhaps they can develop a sophisticated computer program that would not discharge a confused, disabled patient, er, customer to an empty (as far as they knew) house a couple of days after removing part of a lung.
Perhaps they can develop a sophisticated computer program that does NOT steer same patient to their captive home healthcare division (not done until days after negligent discharge), and disclose what incentives the person who did that received, or what pressures and incentives the surgeon faced in forcing a premature, unsafe discharge.
Perhaps we can ban MBAs from getting within 1000 miles of managing health care, and just relegate them to destroying the financial system every 15 or 20 years.
https://www.mountauburnhospital.org Here is a good example. This used to be a friendly, well-run local hospital that was my first choice for me and my family. Now I wouldn’t go near the place even in an emergency. It is a mess from the point of view of patients and physicians. A constant circus of the latest schemes from consulting and IT firms hired by the suck-up-to-the-board MBA CEO to cut costs and increase efficiency while paying herself $2 to $3 million every year.
Randomly clicking through their site which brags about patient safety, their patient fall numbers and infection rates are in many subsets 1.5-2x the state average.
When (not if) I get cancer, I intend to go through the most lengthy and costly treatments available, simply to penalize United “Healthcare”, and I will let that CEO know why his/her bonus is 23 dollars smaller that year.
The crooks at United Healthcare won’t care. They’ll cheat other people by not honoring claims so that the CEO can make much more.
My fervant wish for you is not to get cancer. American cancer treatments put the poor patient through a lot of pain and suffering to extend one’s life a few years at best. My own opinion is that the treatments are bogus.
Quite timely. Two days ago the doctor came in the room carrying his laptop
and phone, quickly shakes hands, then sits down and hectically starts
copying something from the phone to the computer. He then frantically types
on the keyboard while asking how I’m doing with x y and z from the distant
past while totally unaware I had visited a specialist the day before, the
referral made by his trusty PA. At this point I wondered if his
hyperactivity was chemically induced. The physical exam: look in ears,
listen to chest. Then a prescription which turned out to be $450 not
covered by Medicare plan D. It was for a condition that had cleared up
years ago.
Speaking of the specialist and trusty PA, they both have something in
common: they do NOT bring a computer in the room. They give me handwritten
instructions which they discuss with me.
My ophthalmologist’s practice converted to EHR in the past 6 months. There can be little doubt that it has slowed and crapified care. He always had a tech doing the handwritten notes, now she is on the laptop. Where it most obviously causes problems is the necessity of using the various pull-downs to compare the current and past visual field tests or retinal scans. There is no screen equivalent of having the images side-by-side in paper form. And even if these side-by-side images were displayed, the rendering on a laptop would be crap. The ophthalmologist would need a 42″ TV screen to do it effectively.
Or maybe AI will replace to doctor and machine learning will compare the images and other data – NOT!
The other crapification example is from my GP. I was in for a minor acute rash, which he quickly identified and provided a script. However, we spoke about some completely non-medical topics of interest to us both for another 5 or 10 minutes. I ended up with and additional $125 bill in addition to my co-pay. Needless to say, should he ever ask about my family or work, I’m gonna make damn sure he has logged out of his laptop!!!
Precisely. Those of us unfortunate to need medical care in the first place must get in line behind a crappy GUI demanding physician attention. Loaded with default (canned) denials of pain, depression, rashes etc., and a drop down list that spits out imaginary cancer diagnoses like the proverbial roach motel, easy in, never out. Doctors too befuddled with software to remember the patient in front of them, his history or current complaint.
I wonder how the French, who can send a fully equipped critical care unit to your living room, or a child care attendant to your home the same day you call so mom can go shopping or stroll the Bois De Bologne, deal with the IT blight?
Rest assured that Macron and his minions (wait, he’s a minion, too) are assiduously working on EHR crapification and privatization
Am I the only one who can’t read the text on that horribly low-res, pixelated photo? The book the page is from is on GoogleBooks, but it turns out only a few pages are accessible. I looked up the Lindberg article cited in that page, “Lindberg DAB. Computer failures and successes. South Med Bull 1969;57:18-21.” but I can’t find that journal anywhere. It would be nice if the author took the trouble to upload a legible scan of that page
See the image at the original healthcare renewal post at
https://4.bp.blogspot.com/-ixNa8XIsu8Q/XEjPdeEzDUI/AAAAAAAADVg/BgxlDg8IzCcpCdn66d2bM359EUgtcFqXwCEwYBhgL/s1600/collen168.jpg
Being a retired DP programmer & marketer and married to a practicing Family Medicine doc for the last 30+ years I can attest to the crapification of the business. When investigating the possibilities of getting involved in the EHR 20 years ago, the data then indicated that the health providers would spend an additional 3 hours per day doing unpaid computer catch-up work. These estimates have proven to be correct even today. The industry has indeed subverted the most highly trained medical professionals into unpaid data entry clerks.
The EHR were forced upon providers by the Federal government and by insurance companies, who benefited from the more detailed data, but understood nothing about patient/doctor interactions. To make the situation more impossible is the new Medicare requirement that all Medicare patients cannot take up more than a 20 minute visit. This move combined with the EHR will drive decrease patient care and drive more of the conscientious doctors out of the business.
I can see change in the business in my own care with the new doctors coming up, as one eye is always on the clock, to determine how quickly they can get out of the room. This statement is made even as I’m one of the patients that have very few questions and and only present with one problem per visit in order to streamline their operation. My daughter who is now in Family Medicine residency for all of the altruistic reasons, is questioning her career choice, given the current situation.
As I see the business model developing, I’m guessing there will be more and more Physician’s Assistants and Nurse Practitioners taking on the primary care physicians’ clinical role. My guess is that practicing primary care doctors will become more supervisory personnel. This is not a great solution, as they still will be the one liable for their underlings diagnoses and decisions, so the workload will not decrease, merely change.
Also, currently there are a myriad of non-billable services provided by primary care docs to their patients, such as letters to employers, letters to the state, reporting and explaining lab results, etc. IMO these will be dropped or become chargeable services in the future.
My understanding of the 20-minute limitation is that this is limited to patients who opt-in to a program called Chronic Care Management. As a Medicare patient, I have never been told that I am limited to 20 minutes. To the contrary, any “new patient” visit is routinely booked for 40 minutes
Yep.
My mom gave me her checkbook register from mid 1961 to mid 1962, and totaling up all the checks to Dr. Evers-our family physician for 4 kids, it came to $88 for one year. They were usually in the amounts of $6 or $7, with one gigantic $14 payment, probably for a hernia or something.
Back then, being a doctor was considered one of the wealthiest professions and it seems to me like they earned peanuts, and now they bill you up the nose (not their fault-the insurance co’s bear a heavy hand) and many seem caught up in the hamster wheel, trying to outrun it.
Back then, they also didn’t have MRI’s, robotics performing surgeries and heart valves that can save lives. I am the first to argue that there is far too much waste and bloat in our healthcare system, and that we need to completely gut the entire system, but comparing 1962 to today is absolutely ridiculous. Some doctors (specialists) are still very wealthy; neurosurgeons and orthopedic surgeons can earn anywhere from $500k per year to millions, and some private practices have figured out how to scam the out-of-network system to make even more money (having each dr in the practice be out of network with some insurance carriers, and making sure they scrub in or assist, even for a few minutes, so that they can charge out-of-network fees to get higher reimbursements).
There is over documentation and burnout, but at the same time, there is no ability for the various EMR systems to have one cloud to share information, so if you go from one practice or hospital to another, they cannot share records and important information, making the entire system redundant and flawed (still requiring offices to transfer data to others, wasting time).
“The entire POINT of Health IT“
“[T]hat which aids accurate dx reasoning is the entire point of “health information” and the technology that makes it available to clinicians. Anything that hampers that priority is to be identified and eliminated — e.g., poor workflows (including those emanating from lousy HIT UX), useless administrative / compliance data burdens, myriad other distractions, etc…”
and
“…data mongers who want every morsel of information as structured data… even though they don’t have the slightest idea of what to do with it that would be meaningful for patients.”
It’s likely to only get worse.
Looks like par for the course to me. Transitions to computerized systems are frequently rocky. Even transitions *from* computerized *to* computerized. Example: Agilent split from Hewlett Packard, whose IT infrastructure of databases to contact vendors, manage warranties, etc. would cost $40 million to duplicate. The new system was to be much simpler to maintain and much cheaper to initiate (technology had come a long way since HPs original systems)…but it would *not* have all the capabilities of the old system.
One other note: It was very explicit that Agilent was looking for ways to lessen the expense of the generous benefits HP employees enjoyed. I got the impression screwing the employees was a big motivator for the split. “Never let a crisis go to waste” (either Rahm Emmanuel or Naomi Klein said that, right?)
Seems like I noticed that implementing the ACA required implementing EHR which was wiping out the smaller clinics. This also seemed to speed up consolidation. Every clinic and hospital in my county is now owned by Francisan.
Just more corportization, finacialization, and crapification.