The Electronic Health Record and the Realities of Clinical Practice

In response to its last post on the EHR, the Disease Management Care Blog received this sharply written perspective from Kerry Givens, who is a physician in private practice in central Pennsylvania. The DMCB thought it deserved it's own postng.

This is from doc who is really trying to make the much vaunted electronic health record work in that place that seems to be largely unknown to our nation's health information technology intelligentsia - a place called "the real world." This real world is a place where docs want to do the right thing, are not afraid of computers, are skeptical of non-clinicians and have to manage the other moving parts of running a business. It would appear that the real world is promising to be a lot messier when it comes to EHR installs than the current regime would have us believe......

As a physician running a smallish 5-provider practice, I just spent four painful days looking at EHR applications at a national conference---including several programs that have just received formal government approval as having satisfied the meaningful use guidelines.

I have a big problem with meaningful-use guidelines. It seems that they were concocted by federal attorneys and think-tank consultants---the same kindly folks who enriched everyone's lives with HIPAA. As it looks to me, few physicians were asked to contribute during the crafting of the current EHR "recommendations." Am I alone in that concern? Any time attorneys and policy wonks are allowed to administrate other professions with impunity, mandating their vision of how the rest of us should do our jobs better (and on a deadline, no less), there is a fundamental disconnect with reality, if not outright system failure. Last I checked, attorneys don't take care of patients or disease.

Now, about current small-practice EHR offerings. My disclaimer: I am not a computer neophyte. I have owned and built countless PCs since the mid-1980s, have reviewed software professionally, learned how to code database languages back in the day, and am comfortable working within with multiple operating systems. EHR software to me looks like someone took the worst parts of freeform databases, contact managers, and spreadsheets, put them all in a blender, and then let a toddler smear this slurry on the monitor. All of the programs I saw had migraine-inducing, shotgun-blast screens caked beyond belief with pull-down menus, radio buttons, flashing alerts and a general sense of chaos. Linear data entry is nonexistent as you leap from screen to menu to different screen to menu etc. At no time did the word "ergonomic" enter my mind during countless frantic demos I witnessed. The standard company reassurance was "you get used to it after a few months." The same can be said of many chronic diseases. Not encouraging.

The other grim EHR decision that countless small practices face: taking on electronic medical record-keeping may require them to scrap their practice management/appointment/billing software. The EHR absolutely should feed off the same database, since one of its alleged benefits is to assist in correct billing/coding, recalls, etc. Generally that only works (or works well) if the two programs are written by the same company. So if your current practice management software doesn't include a worthwhile, snap-on EHR option, the upgrade ride suddenly gets a lot bumpier. Anyone who has lived through migrating from one appointment/billing system to another has knows what I mean. Small practices don't have, and cannot afford, dedicated IT teams to work out the kinks in such a transition. Layer those costs (and psychic trauma) onto the big hardware/software upgrade expense of EHR, and that $44,000 carrot-on-a-stick from Medicare looks a little scrawny to me.

The EHR is just another in a growing list of "look what we did!" fait accompli policy from misguided, politically-appointed brainiacs who are dangerously out of touch with real life. We need to scrap the current EHR mandate, re-evaluate the entire process with physicians and hospitals at the table, and get rid of the current ticking-clock timeline altogether. In the meantime, the attorneys should, for a refreshing change, scent-mark the only arena they really understand---the legal system. Hey guys---where's that tort reform everyone keeps talking about?

Until then...God help us all. AGHHHHHHHHHHHH.

Image from Wikipedia