DISCUSS: Electronic medical records: bad, ugly, and dangerous?

25 Oct 2009 - 8:44am
4 years ago
16 replies
1241 reads
kimbieler
2007

There's a fascinating article in the Washington Post this morning
about the failure of electronic medical records in U.S. hospitals and
clinical settings: http://bit.ly/2Rb7lG

There are obviously a lot of culprits in this story -- design isn't
the only issue. But I'd be interested in hearing back from any of
you who've worked on medical records or devices. Do the issues and
problems presented here sound familiar? If so, how did you overcome
them?

You may need an account to read the article, so I'll summarize the
main points:

- There's a strong incentive to adopt EHRs: Under Obama's stimulus
program, hospitals and physicians can claim millions of dollars for
IT purchases, and will be penalized if they do not go digital by
2015.
- While some studies show that electronic records reduce mistakes and
benefit outcomes, anecdotal evidence suggests major problems.
- Complaints about existing systems include: Faulty software that
miscalculated intracranial pressures and mixed up kilograms and
pounds and a computer system that systematically gave adult doses of
medications to children.
- Small, often unwilling, user base: Barely 8 percent of U.S.
hospitals have even a basic electronic medical system. Only 17
percent of physicians use electronic records, and many of those are
uninstalling them.
- Data entry takes too long: Physicians spent nearly five of every 10
hours on a computer. "I sit down and log on to a computer 60 times
every shift. Physician productivity and satisfaction have fallen off
a cliff."
- Poor design and usability: "I can't tell from the medical display
whether a patient is receiving 4mg or 8mg of a certain drug. It took
us two years to get a back-button on our [EHR] browser."
- IT-related mishaps are hard to quantify: Electronic medical records
are not classified as medical devices, so hospitals are not required
to report problems. Many health IT contracts do not allow hospitals
to discuss computer flaws.
- EHR systems are mission-critical: "The system crashed soon after
it went online. I walked in to find no records on any patients. It
was like being on the moon without oxygen."

Comments

25 Oct 2009 - 4:24pm
david.shaw6@gma...
2004

Hi Kim,

Thanks for the link, I'm going to have to go read this.

I work in the health care space (including a medically regulated product),
although not in EHR's. However, I do get to see some of the things going on
from a holistic perspective. This is a very interesting area, one with
issues and opportunities. The fact that EHR's are not regulated contributes
to some of the items the article points out. Right now I see the main
driver of going to market as being cost. If/when EHR's become medically
regulated, you'll see a much bigger influence on usability and design. The
CFRs (Code of Federal Regulations) that do relate to regulated products HAVE
to have an audit trail as to why the design is what it is. As well, you
have to prove to the FDA that your product won't cause harm to a user. And,
if there are any scenarios within reasonable use of the device that could
cause issues, you have to prove how you are going to mitigate them. It
really speaks to heavy user centric views. In fact, in Europe, a new
standard is being adopted for quality that has a significant usability
section in it. Whether the US adopts this or not, any product sold to
European countries will have to adhere to this standard. Thankfully, my
company is adopting those standards even for US products.

Obviously there are many other items to speak to in this realm, but I'll
hold out my opinions for now. :) At least there's a high level hope that we
can address some of these issues, but it's going to be a long, tough road to
get there.

David

On Sat, Oct 24, 2009 at 11:44 PM, Kim Bieler <kimbieler at gmail.com> wrote:

> There's a fascinating article in the Washington Post this morning
> about the failure of electronic medical records in U.S. hospitals and
> clinical settings: http://bit.ly/2Rb7lG
>
> There are obviously a lot of culprits in this story -- design isn't
> the only issue. But I'd be interested in hearing back from any of
> you who've worked on medical records or devices. Do the issues and
> problems presented here sound familiar? If so, how did you overcome
> them?
>
> You may need an account to read the article, so I'll summarize the
> main points:
>
> - There's a strong incentive to adopt EHRs: Under Obama's stimulus
> program, hospitals and physicians can claim millions of dollars for
> IT purchases, and will be penalized if they do not go digital by
> 2015.
> - While some studies show that electronic records reduce mistakes and
> benefit outcomes, anecdotal evidence suggests major problems.
> - Complaints about existing systems include: Faulty software that
> miscalculated intracranial pressures and mixed up kilograms and
> pounds and a computer system that systematically gave adult doses of
> medications to children.
> - Small, often unwilling, user base: Barely 8 percent of U.S.
> hospitals have even a basic electronic medical system. Only 17
> percent of physicians use electronic records, and many of those are
> uninstalling them.
> - Data entry takes too long: Physicians spent nearly five of every 10
> hours on a computer. "I sit down and log on to a computer 60 times
> every shift. Physician productivity and satisfaction have fallen off
> a cliff."
> - Poor design and usability: "I can't tell from the medical display
> whether a patient is receiving 4mg or 8mg of a certain drug. It took
> us two years to get a back-button on our [EHR] browser."
> - IT-related mishaps are hard to quantify: Electronic medical records
> are not classified as medical devices, so hospitals are not required
> to report problems. Many health IT contracts do not allow hospitals
> to discuss computer flaws.
> - EHR systems are mission-critical: "The system crashed soon after
> it went online. I walked in to find no records on any patients. It
> was like being on the moon without oxygen."
> ________________________________________________________________
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25 Oct 2009 - 7:21pm
Siegy Adler
2009

As a developer of medical practice management applications, I%u2019d
like to add my two cents to the discussion. Electronic medical
records (EMRs) have their pros and cons.

Some pros:
%u2022EMRs facilitate communications between medical professionals
and institutions. For example, a primary care physician can enable a
specialist or hospital to electronically access a patient%u2019s
history.
%u2022EMRs may have built-in logic to prevent errors. For example,
logic can be incorporated to ensure that correct medications are
prescribed, etc.
%u2022EMRs can ensure that patient charts are not misplaced.
%u2022EMRs can be accessed by the physician from anywhere. For
example, a physician on call can access the patient%u2019s record
from their home.

Some cons:
%u2022EMRs can add significant overhead (software, implementation,
maintenance, etc.) to medical practices.
%u2022EMRs may not be secure and can be hacked.
%u2022EMRs can actually lead to more mistakes. For example, a
physician can click the wrong check box, etc.
%u2022EMRs can take longer to update than paper charts.

I believe that EMRs are inevitable %u2013 but they are not the
panacea many make them out to be.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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26 Oct 2009 - 3:23am
Gregor Kiddie
2008

Vested interest time (full disclosure, I'm a developer currently working
on EHR's for the British NHS).

Design is one of the biggest factors involved with writing systems for
GPs and hospitals. Systems need to allow input and retrieval of data
quickly, securely, and safely.

The average GP in the UK has roughly 7.5 minutes with a patient, so the
process of running through a session needs to be snappy above all
things. Selecting and retrieving a patient (the correct patient),
allowing access to their up-to-date demographic and clinical
information, and then recording any data entry in a consistent coded
fashion.

UI design is driven by a collaboration between designers and GPs.
Designers come up with the UI and GPs derive any clinical safety issues.
The UK has a slight additional complication thanks the MS CUI
(http://www.mscui.net/) project.

It's am interesting space to work in, as there are three competing
elements which at times have contradictory needs (the NHS, GPs, and
patients themselves). Unfortunately only one of those elements are
paying for the work.

Now just to clear up some of the mis-conceptions in the article.
EHRs are MORE secure than paper records. Yes they can be "hacked", but
paper records are stored in less than secure areas of surgery's (the
drugs are better protected), usually meaning one broken window is all it
takes.

One of the huge benefits of EHRs are the ability to interop,
collaborate, and report on a much wider basis. Without a huge effort, a
surgery would be unable to determine how many patients they had in a
particular age bracket suffering from a particular condition, they
wouldn't be able to easily share this data (EHRs make out-of-hours
service much safer for patients as they have fuller and more up-to-date
information than the patient can usually supply), and they certainly
couldn't be able to tailor wider initiatives to cater to the group
(swine flu vaccinations to vulnerable groups anyone?)

Gregor Kiddie
Senior Developer
INPS

Tel: 01382 564343

Registered address: The Bread Factory, 1a Broughton Street, London SW8
3QJ

Registered Number: 1788577

Registered in the UK

Visit our Internet Web site at www.inps.co.uk

The information in this internet email is confidential and is intended
solely for the addressee. Access, copying or re-use of information in it
by anyone else is not authorised. Any views or opinions presented are
solely those of the author and do not necessarily represent those of
INPS or any of its affiliates. If you are not the intended recipient
please contact is.helpdesk at inps.co.uk

26 Oct 2009 - 8:17am
Mariah Hay
2009

Gregor- thanks for your honest look as EHRs.

Having worked in a state-run American hospital one of our biggest
challenges were simply maintaining the paper records. Doctor
handwriting challenged the quality of care patients received and if a
chart vanished, a whole patient history was lost. At one point we even
started giving our docs recording devices and then having their
recordings transcribed overseas so they could be printed and put in
the file- amazingly backwards, but the state was not willing to spend
the money on the EHR.

In a Country which spends an average of 22% of all healthcare costs
on administration and paperwork, you would think we would realize
that change to EHR is vital to be competitive with the world market,
which averages 4-8%.

I can't help but get the feeling that this nation aversion to change
is also laced with political fear mongering in general.

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26 Oct 2009 - 8:24am
Michele Marut
2005

Hi Kim,
Some of these issues are touched on at the Designing for Care site.
http://designforcare.ning.com/

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26 Oct 2009 - 8:41am
kimbieler
2007

Thanks for the responses. I'm hoping not to turn this into a
political discussion about the lamentable health care system in the
U.S., but that may be inescapable.

I don't work in this space and (luckily) don't interact with the
health care system very often. But I'm amazed at how technologically
backward the industry seems to be. On one occasion, my own GP's
office had to call me to confirm an appointment because they had no
way to look it up by my name. I asked and they informed me they had
no patient database, not even an electronic calendar! Admittedly,
they're a tiny operation, but this seems terribly basic.

I'm all for electronic records if for no other reason than I think
patients should be able to have their own portable copy at all times,
especially those who have to see doctors and specialists frequently.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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26 Oct 2009 - 2:28pm
Adam Lerner
2009

I am currently in the midst of a long-term consulting gig for an EHR
software suite geared specifically for US hospital emergency
departments so I deal with a subset of these issues every day. The
one that has proved most immediate in the emergency department
environment is the issue of time. Specifically, the clinicians lament
the time that electronic documentation takes from their interactions
with patients.

Required fields and poor UI design are certainly responsible for some
of this, but the biggest culprit is simply having to input data into a
machine rather than scribble on a piece of paper (or, in a pinch, a
bedsheet, the clinician's arm, or the wall for later transcription.)

There are many benefits to be had. Many. But the clinicians I speak
with say that EHRs have put a further layer between clinician and
patient. To make matters worse, many of these EHRs have UIs that were
created by programmers with the data needs of the system in mind --
not the workflow of the user. The frustration with those systems has
created a real and legitimate backlash among many in the medical
field against EHRs, making the push for adoption a more difficult
one.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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27 Oct 2009 - 4:50am
Gregor Kiddie
2008

" Required fields and poor UI design are certainly responsible for some
of this, but the biggest culprit is simply having to input data into a
machine rather than scribble on a piece of paper (or, in a pinch, a
bedsheet, the clinician's arm, or the wall for later transcription.)"

You've actually hit upon the biggest problem with paper records, and one
of the biggest reasons EHRs are useful (at a more abstracted level than
the clinician).

A scribble on a piece of paper, bedsheet or wall isn't a record. The
piece of paper can be lost, the handwriting mis-interpreted (is that 30
or 50 mg? A pretty important question when dealing with prescribing!),
and there is no effective record of who made what decision when (vital
for finding out what went wrong when things do).

I agree that a hard to use system takes clinicians away from their
secondary task, dealing with patients face-to-face (I put their primary
task as actually making them better), and nobody likes paper work, but
this is the task for designers, creating a system that is not only
accurate and safe, but also removes a lot of burden from the user.

Transcription is useful when it comes to sending letters as these are
frequently not time-essential tasks, it is not useful where a delay in
getting data into the system may result in insufficient, or incorrect
care being given.

If I can be slightly snarky at the US system for a moment (and given the
recent attacks on the NHS from the US, I feel I am justified), it feels
like the system for care in the US is completely driven by money.
Insurance costs, billing systems, etc seem to take pre-eminence over the
actual care the patient receives. Until that sea shift is made, I cannot
see EHR systems in the US being any more than advanced billing systems
with some healthcare tagged on.

Gk.

Gregor Kiddie
Senior Developer
INPS

Tel: 01382 564343

Registered address: The Bread Factory, 1a Broughton Street, London SW8
3QJ

Registered Number: 1788577

Registered in the UK

Visit our Internet Web site at www.inps.co.uk

The information in this internet email is confidential and is intended
solely for the addressee. Access, copying or re-use of information in it
by anyone else is not authorised. Any views or opinions presented are
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INPS or any of its affiliates. If you are not the intended recipient
please contact is.helpdesk at inps.co.uk

27 Oct 2009 - 5:35am
Adam Lerner
2009

Gregor - I am certainly not going to defend the hodge-podge corporate
patchwork we call an insurance industry in the US, but I think that is
really not the culprit for the issues we are discussing. (There are
other EHR issues for which it bears a lot of responsibility -- such
as charge coding ridiculousness, for example.)

Something you said struck me as a little off, though. Making a
patient well is not a task. It's a goal. It should be (and usually
is) underlying the decisions the clinicians make in the emergency
department, leading to various tasks that must often be performed at
speed to save lives. In emergency medicine the EHR's biggest
challenge is being able to adjust to the realities of
rapidly-changing workflow but also has a feeling of being cohesive,
consistent and useful.

Paper records can be a nightmare. Agreed. BUT, and this is not an
insignificant but from the part of the patient or the clinician, you
can chart at them at the bedside without looking at them. That fact
alone leads to increased feelings of engagement between doctor and
patient. And more time for the doctor to actually learn what he or
she needs to in order to make the patient well. As of yet, tablets
and COWs don't work very well in real-world ED settings.

I agree that EHRs are necessary for all the reasons you delineate,
but they also represent a pretty big step backward in terms of
doctor-patient interaction in the Emergency Dept. We're making
progress but EHRs have a long way to go catch up to paper forms in
this (important) way.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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27 Oct 2009 - 7:05am
Gregor Kiddie
2008

" I agree that EHRs are necessary for all the reasons you delineate,
but they also represent a pretty big step backward in terms of
doctor-patient interaction in the Emergency Dept."

Totally accepted. My particular PoV is of that of a GP rather than the
emergency dept, and I agree that they have differing needs.

Reporting is less of an immediate need, and a well written and
maintained paper record almost certainly outperforms electronic records
in that setting. Other care settings however, the reverse is probably
true, where reporting is more important, and correctly coded records are
an important part of continuing care.

Marrying up that dichotomy? I've not good a good answer. Give me a wodge
of cash and a length of time and I'll do my best though ;)

Edit : At some point I'll remember to hit reply all... Sorry Adam!

Gk.

Gregor Kiddie
Senior Developer
INPS

Tel: 01382 564343

Registered address: The Bread Factory, 1a Broughton Street, London SW8
3QJ

Registered Number: 1788577

Registered in the UK

Visit our Internet Web site at www.inps.co.uk

The information in this internet email is confidential and is intended
solely for the addressee. Access, copying or re-use of information in it
by anyone else is not authorised. Any views or opinions presented are
solely those of the author and do not necessarily represent those of
INPS or any of its affiliates. If you are not the intended recipient
please contact is.helpdesk at inps.co.uk

27 Oct 2009 - 7:56am
Adam Lerner
2009

All right, Gregor. Now all we need is a financial backer and together
we'll get this whole healthcare mess straightened out. We can write
up a casestudy about how UX can save the world and offer
profit-sharing to the entire IxDA membership for their love and
support. ;)

I'm certain that GP practices are very different. Actually, even
within the ecosystem of the ED we have a lot of different user
constituencies ranging from nurses who usually check boxes and
free-text very little to physicians who need the flexibility to
create a record with maximum flexibility to document care to lab
systems and specialists who "graze" on select data.

Then you add in complications such as the entire of the triage
process needing to be completed within 3-5 minutes (!) often with
uncooperative or non-communicative patients...well, you get it.

Oh, and everybody wants to see every piece of data on the screen at
all times to support on-the-spot decision-making.

I would love to learn more about systems that support private
practice and non-warzone-like medical environments.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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27 Oct 2009 - 12:51pm
fritzism
2009

Thanks Kim for broaching this subject, it's such an extremely
important issue.

The things I think about the most is access & workflow. As it stands
we have ZERO access (at least conveniently) to the medical of
children, or family or ourselves. Also regarding workflow (or work
modeling) this is one of the biggest reasons (seemingly) why EMR is
so challenging, they seem hellbent on bending (healthcare) staff
around the software.
Also the workflow of hospitals with large staffs & resources is one
thing but what about your dentist, private doctor, pediatrician,
neighborhood clinic, chiropractor/PT etc. all of these healthcare
professionals have their own processes, ways of working & preferences
as it pertains to data input (not to mention how their current records
get converted).

Again this is a major area of concern and an area where I see UX &
Interaction designers literally being able to save lives based on the
work done. Much of the EMR software pkgs that I've been researching
look straight out of the 90's (or earlier), to take a page from Mr.
Cooper's canonical work, the Inmates are truly Running the Asylum...
but luckily at least this time we know & hopefully can change work to
change it.

Kudos to those of you fighting the good fight in this area, you're
needed. I hope to one day to join your ranks. - Fritz

P.S. - Btw, here are two good resources on the EMR/EHR topic:

1) CBS News' & David Pogue video report on EHR/EMR (about 9min):
http://j.mp/4n3yIu

2) Fast Company & the good folks at frog design (who clearly see this
opportunity) just recently published a bit of good reading on the
subject here:
http://www.fastcompany.com/future-of-health-care

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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27 Oct 2009 - 12:52pm
fritzism
2009

The CBS/Pogue video link got screwed up it's: http://j.mp/4n3yIu

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27 Oct 2009 - 1:44pm
Marc Resnick
2006

I usually hate to join a conversation after dozens of replies have
already been offered, but I have to jump in here because it seems a
big culprit is being missed (unless I skimmed the many replies too
fast).

I have done a decent bit of consulting in this space and I have found
that there is often a lack of understanding of the complex processes
that underlie hospital activities and the EHRs miss something that
medical personnel can hack into their paper records but not the EHR.
The multi-disciplinary teams (nurses, doctors, technicians) all have
different expertise, knowledge, and task needs. There are handoff
issues when shifts change, especially for nurses. There are changes
in diagnosis and treatment protocols (i.e. for H1N1) that can't be
captured if the EHR is not flexible enough.

Designers need to go beyond IXDA and even comprehensive usability
analysis. They need to do some deep ethnography and really get to
know the workflows, culture of care, and politics of the hospital
system to design an effective EHR system. It has to be a system, not
just a standalone set of file formats.

Marc Resnick
Usability Solutions
resnickm at fiu.edu
305 443-3765.

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27 Oct 2009 - 2:26pm
david.shaw6@gma...
2004

Hi Marc,

Agreed with your analysis here. One thing that's unique with the company I
am at is that we actually have a number of ethnographers on staff for
researching workflows, etc. One thing I find however is that many of the
medical facilities are hesitant to let them in unless it's something that
will benefit them directly. So while the research is being done, the whole
system is so fragmented (like you also state) that it's hard to get a
complete picture. There's a ton of opportunity to really do something right
in this space.

David

On Tue, Oct 27, 2009 at 4:44 AM, marc resnick <resnickm at fiu.edu> wrote:

> I usually hate to join a conversation after dozens of replies have
> already been offered, but I have to jump in here because it seems a
> big culprit is being missed (unless I skimmed the many replies too
> fast).
>
> I have done a decent bit of consulting in this space and I have found
> that there is often a lack of understanding of the complex processes
> that underlie hospital activities and the EHRs miss something that
> medical personnel can hack into their paper records but not the EHR.
> The multi-disciplinary teams (nurses, doctors, technicians) all have
> different expertise, knowledge, and task needs. There are handoff
> issues when shifts change, especially for nurses. There are changes
> in diagnosis and treatment protocols (i.e. for H1N1) that can't be
> captured if the EHR is not flexible enough.
>
> Designers need to go beyond IXDA and even comprehensive usability
> analysis. They need to do some deep ethnography and really get to
> know the workflows, culture of care, and politics of the hospital
> system to design an effective EHR system. It has to be a system, not
> just a standalone set of file formats.
>
> Marc Resnick
> Usability Solutions
> resnickm at fiu.edu
> 305 443-3765.
>
>
> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
> Posted from the new ixda.org
> http://www.ixda.org/discuss?post=47008
>
>
> ________________________________________________________________
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27 Oct 2009 - 2:56pm
Alain D. M. G. ...
2003

The NY Times has published several articles focusing on GP use of EHRs.

Here are a few:

http://www.nytimes.com/2008/06/19/technology/19patient.html

http://www.nytimes.com/2009/03/01/business/01unbox.html

http://www.nytimes.com/2008/12/30/nyregion/30records.html

You could also look at the prototype "Innovation Clinic"
Cook Children’s hospital in Texas, which targets small practices of two to three physicians and also the North Shore-Long Island Jewish Health System which is setting up a program to offer GPs (and 7,000 other affiliated doctors) subsidies to adopt digital patient records.

Alain

--- En date de : Mar, 27.10.09, Adam Lerner <vocable at gmail.com> a écrit :

> De: Adam Lerner <vocable at gmail.com>
> Objet: Re: [IxDA Discuss] DISCUSS: Electronic medical records: bad, ugly, and dangerous?
> À: discuss at ixda.org
> Date: mardi 27 Octobre 2009, 1 h 56
> All right, Gregor. Now all we need is
> a financial backer and together
> we'll get this whole healthcare mess straightened out. We
> can write
> up a casestudy about how UX can save the world and offer
> profit-sharing to the entire IxDA membership for their love
> and
> support. ;)
>
> I'm certain that GP practices are very different. Actually,
> even
> within the ecosystem of the ED we have a lot of different
> user
> constituencies ranging from nurses who usually check boxes
> and
> free-text very little to physicians who need the
> flexibility to
> create a record with maximum flexibility to document care
> to lab
> systems and specialists who "graze" on select data.
>
> Then you add in complications such as the entire of the
> triage
> process needing to be completed within 3-5 minutes (!)
> often with
> uncooperative or non-communicative patients...well, you get
> it.
>
> Oh, and everybody wants to see every piece of data on the
> screen at
> all times to support on-the-spot decision-making.
>
> I would love to learn more about systems that support
> private
> practice and non-warzone-like medical environments.
>
>
> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
> . . . .
> Posted from the new ixda.org
> http://www.ixda.org/discuss?post=47008
>
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