Thursday, June 04, 2015

Krauthammer: "Why Doctors Quit"
Hint: EMR's have something to do with it...

I'm a fan of conservative commentator Charles Krauthammer. If you read his column in the Washington Post, you might know that he is a physician by training, although he hasn't practiced in quite a while.

Krauthammer's recent column discusses some of the factors that have driven physicians away from actually practicing medicine. It should come as no surprise that EMR's are near the top of the list of troubles.
In general, my classmates felt fulfilled by family, friends and the considerable achievements of their professional lives. But there was an undercurrent of deep disappointment, almost demoralization, with what medical practice had become.

The complaint was not financial but vocational — an incessant interference with their work, a deep erosion of their autonomy and authority, a transformation from physician to “provider.”

As one of them wrote, “My colleagues who have already left practice all say they still love patient care, being a doctor. They just couldn’t stand everything else.” By which he meant “a never-ending attack on the profession from government, insurance companies, and lawyers . . . progressively intrusive and usually unproductive rules and regulations,” topped by an electronic health records (EHR) mandate that produces nothing more than “billing and legal documents” — and degraded medicine.

How did this happen? I've personally advocated for EHR, RHIO's, Universal ID's, etc., since the early days of this blog. What went wrong?

Krauthammer continues:
And for what? The newly elected Barack Obama told the nation in 2009 that “it just won’t save billions of dollars” — $77 billion a year, promised the administration — “and thousands of jobs, it will save lives.” He then threw a cool $27 billion at going paperless by 2015.

It’s 2015 and what have we achieved? The $27 billion is gone, of course. The $77 billion in savings became a joke. Indeed, reported the Health and Human Services inspector general in 2014, “EHR technology can make it easier to commit fraud,” as in Medicare fraud, the copy-and-paste function allowing the instant filling of vast data fields, facilitating billing inflation.

That’s just the beginning of the losses. Consider the myriad small practices that, facing ruinous transition costs in equipment, software, training and time, have closed shop, gone bankrupt or been swallowed by some larger entity . . . Then there is the toll on doctors’ time and patient care. One study in the American Journal of Emergency Medicine found that emergency-room doctors spend 43 percent of their time entering electronic records information, 28 percent with patients. Another study found that family-practice physicians spend on average 48 minutes a day just entering clinical data.
The devil is in the details, in this case the implementation of the details. EMR should have been a boon to physicians and patients alike. No more duplicated tests or doubly-irradiating patients for a repeat CT. No matter where you go, your information should be easily retrieved, yes? Sadly, no. And all because of good intentions, well, we hope the intentions were good, gone bad:
The geniuses who rammed this through undoubtedly thought they were rationalizing health care. After all, banking went electronic. Why not medicine?

Because banks deal with nothing but data. They don’t listen to your heart or examine your groin. Clicking boxes on an endless electronic form turns the patient into a data machine and cancels out the subtlety of a doctor’s unique feel and judgment.
Yes, I'm from the government and I'm here to help you . . . So why is the federal effort a failure?
Because liberals in a hurry refuse to trust the self-interested wisdom of individual practitioners, who were already adopting EHR on their own, but gradually, organically, as the technology became ripe and the costs tolerable. Instead, Washington picked a date out of a hat and decreed: Digital by 2015.
And so, here we are today:
As with other such arbitrary arrogance, the results are not pretty. EHR is health care’s Solyndra. Many, no doubt, feasted nicely on the $27 billion, but the rest is waste: money squandered, patients neglected, good physicians demoralized.

Like my old classmates who signed up for patient care — which they still love — and now do data entry.
Although I have supported the concept of EMR, and particularly image sharing (ala lifeIMAGE), I have also said at least once a week for the past 10 years on this blog that poor software design is an impediment to actually enacting and using these things, EMR, PACS, RIS, etc. We are reminded on a daily, really an hourly, basis that these programs don't work as they should. They have NEVER worked as they should.

We radiologists tolerated the imperfect software because even a VERY imperfect viewer was a huge advance over film. As the late, great Douglas Adams said of the products of the fictional Sirius Cybernetics Corporation in the Hitchhiker's Guide series:
It is very easy to be blinded to the essential uselessness of them by the sense of achievement you get from getting them to work at all. . .In other words - and this is the rock solid principle on which the whole of the Corporation's Galaxy-wide success is founded - their fundamental design flaws are completely hidden by their superficial design flaws.
I'm sure Mr. Adams wasn't thinking of any Epically LarGE companies when he wrote that piece. But this is where we are. We physicians, radiologists particularly, have accepted utterly unusable software in the name of progress. Programs and equipment that should make our job of promoting the health of our patients easier instead get in the way of doing so. EHR's that should streamline the day-to-day practice of medicine do anything but.




In no small part, it is because the software is spec'ed, designed, created, bought and sold primarily by IT folks. And now, of course, the government is stepping in to "help". Those who actually USE the damn things are left out in the cold. And then these same wretches are blamed when patient care is negatively impacted.

This paradigm has to change. But it won't in my working lifetime. Or that of the hundreds and thousands of physicians who are bailing out.

Progress. Forward. Hope and Change. Just keep saying that to yourself when you have intractable pain and there aren't any doctors left to help you.


Unknown said...

Great post Dr. Dalai. The last time I went to my GP I think the doctor barely looked up from her laptop, feverishly taking notes and going through the checklist(s) one after the other. That would be ok if you actually had sufficient time with the doc, but with a avg visit time of 10 min, you barely get to see the whites of the eyes of the physician. Recently I went to the dermatologist, and their practice has one of the techs act as a digital records assistant, so the doc can actually focus on the patient visit instead of documenting the visit. I asked them if they archive their derm photos, she said "archive?". They store them to the hard drive, and don't have access when they are at the hospital....if SIIM has anything to do with it, one day she WILL have her images at the hospital.

As for viewers, I've advocated for years that the viewer needs to be the best possible technology for the reading radiologist. It has to be incredibly performant, and as fast as possible, with the best available tools. Why? Because the viewer is to a radiologist, as a scalpel is to a surgeon. Lesser viewers need not apply. Sadly, the majority of radiologists are using viewers that were developed last century, tackling today's datasets. Better than film? Absolutely. Up to the task(s) of today, and prepared for what's next? Absolutely not. The good news is that the EMR IS spurring change in Imaging in a big way, particularly at the largest institutions. With Enterprise Imaging, and the EMR, many IT departments are kicking dated PACS viewers to the curb, replacing them with the best viewers, and only looking forward....

stacey said...

Just to play devil's advocate... I'm curious... did docs look up more when handling a paper chart? Where did they write their notes? How?

Unknown said...

We used to dictate our notes which took a fraction of the time. And they were much more accurate. Clerks used to put in our orders, now I have to put an order in The computer for every little thing that needs to be done. I see a patient for two minutes, then I spent five minutes putting data and orders into the computer. Food, drinks, warm blankets, vital signs, you name it, nothing gets done unless I log into a computer and search for one of 1 million orders. I have to put an order in the computer for a patient in the ER to go to the bathroom! Sounds ridiculous, but I assure you it's true. I quit!

Unknown said...

We used to dictate our notes which took a fraction of the time and were much more accurate. Clerks used to put in our orders, but now if anything needs to be done in the ER I have to log into a computer and search for one of 1 million orders and put it in. I see a patient for two minutes, then I spend 5 minutes entering data. nurses and techs will not do anything unless I put an order in the computer, food, drinks, warm blankets, I even have to write an order in the computer for an ER patient to go to the bathroom! This sounds ridiculous but I assure you it is true. I quit!