Bad software destroyed my doctor’s memory
Bad software destroyed my doctor’s memory
Design this bad should sicken developers – but it's the rest of us who end up feeling queasy
Physician and Chief Medical Officer here. I started my practice on the tail end of paper records and I have been through, and led, several different renditions of electronic medical records. Like any other software, the technology has evolved and matured over the last 20 years. Electronic Health Records are just about patient information anymore either. They incorporate patient info, clinician orders, billing, and also provide numerous cross checks and safety systems to improve patient care.
The article discusses the issue with digitizing handwritten notes. This is always problematic as they are not searchable, indexed, etc. and can be very difficult to work through. The system where I work has been on the same medical record system for over 10 years. This provides an efficiency that I didn't have when I was working in a paper system. The entire chart is searchable. Medical history sections are filled out and robust.
From a safety perspective, these systems give us so much more than we had. One prime example is bedside scanning. When a nurse administers a medication in a hospital environment the medical record plays a pivotal role. As a physician I enter and order for a medication. If there is an allergy, medication interaction, or a host of other things, the system will alert me to it before the order is signed. Once signed, the order then goes to a pharmacist to review and approve. The patient's nurse will then be notified of the order and be able to pull the medication from an integrated medication storage unit with multiple drawers and compartments to ensure the right medication is taken. Finally, the nurse must use the EHR to scan the patient's armband and the medication barcode. If there is any discrepancy, the medication is not given until the issue is resolved.
From a user perspective, I can now create notes and write orders faster than I could in a paper world, even with dictation. Most docs use a combined template/voice recognition approach which works well. There has been a great deal of work in the Epic world (one of the largest EHR systems) to increase efficiency and improve the user experience.
Are these systems perfect? Far from it. But things are better now, at least where I work, than this article makes it seem.
Side note: I get the impression that medical professionals are the core customers of Dragon.
We use Fluency Direct, but you are correct. Dragon is quite popular too.
Just wanted to add that event digitizing older records these days is better. Some hospitals do make old scanned notes indexed and searchable through OCR now.
This sounds great in a bubble where it works.
Over here there is no standardised way of sharing such info between doctors/hospital/care givers. I have been through multiple GPs because some stopped working, some where to far away after a move and so on. I had to bring my data to them and good luck to me if I hadn’t gotten a copy of something when it happened. I had to stop medical personnel from giving me paracetamol (I have asthma and shouldn’t take any of that or anything like aspirin), the GP of my SO had to basically partly roll back a medication plan he had gotten from the hospital after being in the ER and those are mild cases where nothing did actually go horribly wrong. My SO got two incompatible medications about two years ago because the tool that crosschecks the database did not throw the relevant warning correctly. It messed with his brain chemistry a lot. His GP wrote the programs makers to have them remedy that asap, since it was pretty bad.
I actually use the health app medication reminder/tracking now and have seen that the app can theoretically store data from health professionals about me. It looks like it is completely unused in the country I am in and I can’t manually add in data at all. This would be super helpful in some cases where I could use it to quickly convey key points about my health, especially when I am not as present (high fever, accident or some such).
The issues you bring up are well known and I couldn't agree more. Interoperability needs to be better. See my comment further up.
Really great article on the importance of UX to software development.
Digitization genuinely can be amazing. It means that (with proper practices) nothing critical is ever lost, key information can easily be accessed and communicated without risk of loss or duplication errors, and additional analysis can be quickly and easily done (minimal cost per extra set of data analyzed; it does take appropriate design and investment to design the algorithm), and a variety of other benefits.
But if you don't have a very clear picture of how the data will actually be used in the real world, none of those benefits matter because the whole thing is a pile of shit.
Consumers of the software want one thing. C-Suite doesn't know what they want, but want to be involved in every step dictating terms. Designers are caught in the cross-fire (if they even get a chance to get consumer input). C-Suite pulls the paycheck trump card to get what they want then cry, "Why do they hate our software?"
We need a government-run medical records system, so there is one source of truth, which would be illegal to sell or share with anyone other than a patient's doctors. My hospital has changed records systems twice now and my own doctor didn't have access to key information from ten years ago that I remembered but he didn't. It's 2023, for fuck sake.
Right now US privacy laws aren't compatible with one overarching centralized healthcare record.
Short of that, however, would be an interoperable system. Epic, which is the largest US medical record system, allows for different facilities on the same platform to share information. It is up to the specific facility if a records release is required. Most systems in a given region will have that worked out ahead of time and build it into their general consent for treatment (a form everyone signs). It works quite well. Where I practice, I am able to get all the information I need from across the country, assuming they are on the same platform at the time I am seeing the patient.
For other platforms, it's more mixed. Federal law requires certain interoperability, but it is fairly limited and not real time. Generally it involves a flash drive with the info on it.
As for the comment about changing platforms in a similar system, that is a struggle. Hospitals are required to keep patient information forever. When they first started going up on electronic systems, they only went back so many years as the scanning costs were huge. As time has moved forward, many systems are bringing all the information over to the new system so they don't have to maintain more than one electronic system for archive purposes.
Source: I am a physician and chief medical officer.
That's the case in many places around the world. From your "We need", I'm assuming you're in the USA?
Yeah. Sad face.
which would be illegal to sell or share with anyone other than a patient’s doctors
Assuming you are in the US, this is already the case. HIPAA is incredibly strict.
agreed. as patients we should be able to login and then select hospitals, practices, doctors, etc to allow access.
Exactly.
We kind of have this where I am, insofar as we sign a consent for one doctor to take charge of it (it's ours and we can have copies) and then we can sign in online to see notes and test results, etc. But when I see someone else I have to get copies of their notes sent to my doctor's surgery for them to link to my file. I can't add to it myself, only make requests.
It's true, electronic medical records range from garbage to totally broken in terms of usability for healthcare workers. Then you realize the actual customer is the hospital system, and all the design decisions start to make sense. Because the real purpose of the software is efficient billing, not patient care.
Finally something I'm actually qualified to weigh in on! I'm the lead UI developer for an EHR software (not saying which one or getting into details--it'd be pretty easy to figure out my identity).
First, to be fair, it's possible that the software they're using is genuinely terrible. They don't say which EHR. I've heard this kind of thing from providers before, though, and it's usually that they don't know how to use the software. From the way the article describes the provider, it sounds like they're stuck in paper and don't want to learn a new way of doing things. On the one hand, fair enough--patient care should be their primary concern. On the other hand, patient care is so much easier, faster, and more accurate in an EHR.
In my EHR you select a patient and can get a full visit summary on any visit the patient has ever had with a couple of mouse clicks. Immunizations, clinical notes, radiology, goals, problems, vitals, education--everything that happened during the visit. There are built-in tools for reminders that automatically notify you of things that are important for the visit based on previous visits, contraindication checks for medications, tracking of fluid balance, integrated documentation for clinical reference and distributing to patients, etc, etc.
That's not even to mention things like compliance for clinical quality measure reporting, integrating with state immunization registries, easy export of data to external facilities (eg, CCDA), using digital signatures for non-repudiation of controlled substance prescriptions, automagically pinging requests and data around to the different departments, etc. So many things that used to rely on a human squinting at a paper now just happen, with a built-in audit trail.
As for billing: we (developers, testers, and project/product managers) HATE billing. It's a necessary evil, but we package it off as a separate plugin. It can pull procedure codes and the like from the database to do its job, but to suggest that billing is the only reason to use an electronic health record is astoundingly ignorant. Patient care is the primary concern of everyone who actually has hands on the application. Most of us are former providers who just happen to be alright at coding.
Thank you for chiming in on the slightly spurious billing claim. Yes, billing and charge codes are woven throughout EHR systems but that’s just because everything we do in health care costs time/money. It’s as much about cost tracking as cost recovery.
We measure what we treasure however and if you look at the structure of any EHR, they are steadfastly patient-centric. Billing is ubiquitous but it is more like tinsel on a Christmas tree, sort of draped lightly over and connecting everything. Pick off the tinsel and the core patient care features are unaffected.
It will take years to see the effects in large scale but I like the features that allow patients to see their test results the minute they are released. As a patient myself, it gives me a feeling of having a bit more ownership of my own healthcare.
I was intrigued to learn recently that better EHR use a patients highest education level to tailor the way genomic test results are presented in the patient-viewable chart. The same results are reported to anyone but apparently patients with higher education levels will take positive actions when provided with sufficient depth of background information. Conversely, too much background info can be off-putting for others and reduces proactive behavior changes.
I get it, it’s really easy to be cynical about health care especially in the USA where it is kinda bad in many ways for no good reason. But at least pick the right things to complain about.
I see a lot of people talking about how this is an issue of capitalism through the eyes of who purchases (c-suite) the electronic health record or EHR. This isn't really applicable when it comes to healthcare delivery systems. Every system has c-suite representation from the clinical side. CMO, CNO, CMIO, CNIO, etc. In addition physicians have strong lobbying power within the orgs to ensure that they are listened to.
Ultimately trade-offs need to be made somewhere, and the real issue is that these pieces of software are incredibly complicated. Have you ever stopped to consider how much information might be in your medical chart, for a single doctors visit? Prior to the visit they need to have or collect a bunch of customer data on you - name, date of birth, insurance info, etc. They need to schedule an appointment for you at a location with a specific doctor which means they need a calendaring and scheduling system and all the data that comes along with that. They may need to collect and scan documents about you, or get information from other medical systems. Then when you show up, you interact with more people than just your doctor - you get checked in, they collect a form of payment or the actual payment itself (meaning they need to interface with insurance to understand what to bill), then a nurse or medical assistant takes you back. A bunch of vitals get recorded - height, weight, blood pressure, pulse oximetry. Some of these come from devices which are hooked up to their system. Then the doctor comes in and does any number of things to you- there's a lot of narrative that needs to be collected, pieces of information about why you are there, your history, and so on. They may collect some kind of material from you for which the system needs to at the very least record that it was collected and what a result is (realistically it's interfaced and sometimes the interface includes media such as images). I could keep going on, but I think you get the idea - the amount that needs to go into a system to make it useful to all the various staff at a place of service means that the product is very expensive and difficult to create.
The real issue with capitalism comes in here - it's an issue of very few companies providing good products. It's very difficult to create a competing product in the EHR world because the established giants have been developing for 30+ years. They've poured billions of dollars and man hours into creating software that can manage the extreme complexity of medical care. Even among these giants which do hire clinical professionals to help shape the front end so it's as user friendly as possible, medicine is huge and there are people of all walks practicing - some are great at tech and others not so much. Being able to appease everyone means you need a flexible UX which also means... more money and more man hours. This problem unfortunately can't really fix itself until it's possible to create a complicated system with less resources, which I don't foresee happening anytime soon.