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The EHR Has Clothes … At Least Some of Them

Posted on July 10, 2012 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’ve been really falling in love with some of the content that the Health Affairs blog has been putting out there lately. A recent post titled “The EHR Has No Clothes” was no exception. In this incredibly thoughtful post by Barry Saver, he’s not afraid to start a discussion about points that many are afraid to talk about. I like that a lot. Although, I think the post also represents a couple ongoing trends I see in EHR perceptions.

Common EHR Problem 1 – I can’t tell you how many times I ask a doctor how they like their EHR and then they provide me some small facet of the EHR which annoys them. In Barry’s case it’s “Most screens do not show age, date of birth, or medical record number.” While we could delve into the particular feature that Barry mentions, that’s really not the point. The point is that far too often I see users of EMR systems fixating on one particular issue and ignoring the dozens of other items that are better than the paper world. It’s the proverbial throwing out the baby with the bath water.

No doubt I have a little Pollyanna in me. Although, I should be clear that I’m not suggesting that EHR problems shouldn’t be addressed. Please do hold EHR vendors accountable if their software needs changes. I am saying that I see far too many doctors and clinics that get so fixated on one problem that they ignore all the other good things that are possible. There are deal breaking EHR features and their are EHR annoyances that can be fixed. Make sure you know which one you are really dealing with when you see it.

As an interesting sidebar, this same fixation often happens in the EHR selection process. Although, in this case the person selecting the EHR often fixates on some particular feature (valuable or not). For example, they’ll say that they really love the login screen or background color. It’s amazing what little things can have such an influence on our decision making when they shouldn’t matter at all.

Common EHR Problem 2 – I’ll call this problem the mature feature problem. It turns out it’s a fallacy to assume that a mature EHR (ie. one that’s been around for a long time) has had time to fix all the problems. Here’s a short paragraph from the above linked post:

Approving 12 months of refills when I receive an electronic refill request typically takes a combination of 14 mouse movements, clicks, and keystrokes – as opposed to four if it were implemented efficiently. The list of items needlessly making it more difficult to provide efficient and effective care would cover many pages. These might seem like issues that could be present in version 1 of a system and then promptly fixed, but we currently have version 5.6.

I’ll save the discussion of mouse clicks and keystrokes for another post since it’s an important one. Instead, let’s focus on the idea that a mature EHR will have worked out all the issues with certain features. While this can definitely be true in the early development of EHR software, the opposite often comes into play as EHR software matures.

When an EHR begins its development life cycle it’s usually only saddled with a very specific task. In fact, you don’t have time to build all the features so you often have to make it really simple because of time constraints. Assuming this meets your workflow, it’s a great thing and you enjoy a wonderfully simple interface. Over time, features continue to be added to the interface. Plus, they have to start supporting all 50+ medical specialties that all have their own specific needs. Quickly, the beautiful EHR interface gets bloated to the point that it can do everything imaginable, but it does nothing really well.

Certainly, the best EHR software vendors know this and battle against it. Although, it really takes a battle to overcome this challenge.

What I find even more ironic is that Barry suggests Vista as the solution to his issues with EHR. At least he admits to never having used it other than the demo client on the web. Certainly Vista has its place in the EHR world and I love that it’s open source and benefiting from that innovation. Although, I think it’s crazy to think that a small doctor’s office is going to implement Vista. I’d love to see Barry do a write up after he adopts Vista.

Does the EHR have no clothes?
I think many EHR companies do have clothes on. I think the real problem is that we need to just stop shopping at the high end stores by the nude beach.

Can Access to Prior Test Results Reduce Healthcare Costs?

Posted on March 12, 2012 I Written By

Priya Ramachandran is a Maryland based freelance writer. In a former life, she wrote software code and managed Sarbanes Oxley related audits for IT departments. She now enjoys writing about healthcare, science and technology.

Quick True or False question to brighten your day: If you switched doctors and your new doctor had access to your previous x-rays and lab tests, you’d probably not need to re-do your tests again.

If you answered true, great, you’re far more optimistic than what this study in Health Affairs reveals about doctors’ test-ordering propensities. According to the study (which BTW I haven’t fully read yet, having read only the abstract and the write-up about the study in the Health Affairs blog), doctors who had access to prior tests and images – tended to order more tests, not fewer, contrary to what one would expect.

One of the big reasons why EMRs are being so heavily touted from the government downwards is because they’re expected to reduce redundancies and save costs. Except that they might not.

Here’s a rundown of the study, based on what I read in the abstract as well as blog entry:
– The study analyzed 28,741 patient visits to 1,187 doctors offices in 2008.
– Access to computerized imaging results was associated with a 40-70% higher chance of a test being re-ordered. Access to such tests was not necessarily through an EHR.
– The presence of an EHR was not the key factor affecting the results found by the study. Rather it was the access to prior test results which was the determining factor. According to the blog post, “Physicians without such access ordered imaging in 12.9 percent of visits, while physicians with access ordered imaging in 18.0 percent of visits.”
– Also according to the blog, specialists tended to order additional imaging tests compared with primary care physicians. There were also gender differences with women receiving more tests than men.
– It’s not clear why. The blog quotes a researcher as surmising that perhaps if you make something easier to do, people will tend to do them more often, presumably referring to the ease with which a test can viewed, and later ordered from an EHR.

Of course I’m interested in knowing more about what’s going on and more importantly why.

– The finding about specialists might even make sense if the study had delved into how sick the population visiting the specialists was. Specialists typically see patients after they’ve been seen by a PCP, and maybe they’re seeing a sicker population on average.

– I also want to know more about the quality of images and how easily they can be accessed by the physicians across various. If my hospital or practice uses Vendor A’s EMR and I’ve been allowed to view Patient B’s records on Vendor X’s EHR, maybe I will just order a new test to get the same data into my own system.

– I’m also wondering what the insurance company’s take on all this is. I’ve not had much experience with imaging and tests and the like, touch wood, so this is a genuine doubt, no matter how stupid it sounds to you readers. I get a test done today, and a month later a different physician orders the same test, will my insurance company refuse to cough up for my second test?

Interesting study, nevertheless. Go check it out here or here.