Tag Archives: EHR

EHR Copy and Paste Considered Harmful

DRY principle – Don’t Repeat Yourself

How bad are Electronic Health Record (EHR) programs? Let me count the ways. Rather, let me not, as I and many other folks have already done so. Even non-tech savvy doctors (of which there are fewer and fewer) realize something is wrong when they compare their experience using an EHR with virtually every other computer program they come across, such as the apps on their phones. As the click counts required to do simple tasks mount up and repetitive stress injury of the hand sets in, even the most sanguine of medical personnel will eventually realize that something is not quite right. And as EHR companies forbid sharing of screenshots of their user interfaces, you’ll just have to take my word for it these UIs are, let us say, quaint. Hey EHRs, the 90s called and want their user interfaces back.

In this post I’ll point out just one of the many problems with EHRs: EHRs violate the DRY principle.  The acronym DRY is familiar to computer programmers, but not to most medical people. DRY stands for “Don’t Repeat Yourself.” In computer programming it means don’t write the same code in two or more different places. Code duplication is what some programmers refer to as a code “smell.” There is no reason to duplicate code in a computer program. A single block of code can be called from multiple procedures.  There is no reason for each procedure to have its own copy of this code block.   Code duplication leads to code bloat and code rot, where two procedures supposed to do the same thing get out of sync with each other because of changes in one copy of the duplicated code and not in the other.

Applying the DRY principle to a database requires that every item of data has a single location in the database. Multiple copies of the same data increase the size of the database and invariably cause confusion. Which copy is the original? Which copy is the true copy when copies disagree?

An EHR program is at root a gigantic database. Ideally Patient Smith’s X-ray report from 1/1/2017 is filed away properly in the database and easily retrieved. Same with his blood work, MRI results, etc., etc.

Enter Copy and Paste.

Copy and Paste is evil. Unlike Cut and Paste, Copy and Paste’s close cousin that moves data around without duplication, Copy and Paste is bad, lazy, and sloppy.  Copy and Paste needlessly duplicates data. Copy and Paste violates DRY.

EHR notes are rife with Copy and Paste. X-ray reports are copied and pasted. Blood work too. Even whole notes can by copied and pasted. It is easy to copy and paste a prior progress note and then make a few changes to make it look like it wasn’t copied and pasted. Everyone does it.

Many EHR progress notes fall just side short of novel length. Whole cath reports, MRI results, other doctor’s notes, kitchen sinks, and other potpourri are thrown in for good measure. Usually with a bit of skillful detective work one can determine the minor fraction of the note that is original. Usually it is last line. Something like: “Continue current plans.” These could be the only words actually typed on the keyboard. Everything else is just copied and pasted.

So you get all the downsides of DRY: bloated notes, duplication of data, possible inaccuracies and synchronization problems. The X-ray report may be revised by the radiologist after it is copied and pasted into the note. Nevertheless the unrevised report persists forever sitting as a big blob of text in the middle of a now inaccurate note. Of course there is some consolation that no one will ever read the whole note anyway, with the possible exception of a malpractice lawyer.

Why is Copy and Paste so prevalent in EHR notes? It isn’t just laziness. Like the pulp fiction writers of the 30s, doctors are effectively paid by the word, so that the longer the note the better. Longer notes reflect higher levels of care, more intricate thought processes, more — wait a minute! No they don’t. Longer notes reflect mastery of Copy and Paste, something that’s not too difficult to master. Even non-tech docs seem to have no trouble with it. Long notes are a way to justify billing for a higher level of care, i.e. more dollars. Since the Powers That Be Who Control All of Medicine (i.e. not doctors) decided that billing would not be based on what doctors do, but on what doctors write in the chart, it doesn’t take a crystal ball to predict that note bloat, electronically enhanced, would be the inevitable outcome of such a stupid policy.

What are the alternatives to Copy and Paste? The best is the use of hyperlinks, something that you might be familiar with if you ever use something called the World Wide Web. If I want to put a YouTube video on my blog, I don’t copy the video and paste it here, I just provide a link. Similarly, if you want to refer to an X-ray report in a progress note it should be possible to just provide a link to it. Something short and sweet.

Of course the example note I referred to above would be reduced in length to just a number of links and the sentence “Continue current plans.” This will hardly satisfy the coders and billing agents and whoever else is snooping around the EHR trying to find ways not to pay anyone (i.e. insurance companies). Nevertheless these shorter notes would be much easier to digest and might even encourage a doctor to elaborate a bit more in his or her own words on the history, physical, diagnosis, and plans. Unlinking billing and documentation would go a long way towards making EHR notes more manageable and informative. No one seems to keen on doing this however. Documentation as a proxy for care  is just one of many broken pillars of the Byzantine edifice known as the American Health Care System.

[note: the title refers to a famous (in computer circles) 1968 letter by Edsger Dijkstra entitled “Goto Statement Considered Harmful.” It has inspired tons of computer articles with similar titles, including this one.]

A Tale of Two Histories

Compare the following two versions of the same medical history:

Version 1

CC: chest pain
Mr. Smith is a 57 y/o white man who comes into the office today for the first time with a complaint of chest pain. He states he has been in generally good health in the past, though he has smoked about 40 pack-years and admits to not exercising much, other than occasional games of golf. He has trouble keeping his weight down. He has been a middle-level manager for many years, but about a month ago changed jobs and took a pay cut. He says this has been quite stressful. He has changed jobs before, but states “I’m getting too old to keep doing this.” About 2 weeks ago he started noting some mild heaviness in his chest, lasting up to 5 or 10 minutes. He attributed this at first to eating heavy meals at dinner, but now thinks it occurred after climbing stairs following meals. He took some Tums, but was not sure if the pain eased from this or just from resting. These episodes of discomfort were localized to his anterior chest, without radiation or other associated symptoms at first. Over the last 2 weeks he thought that they were getting a little more frequent, occurring up to twice a day. Two days before this visit, he had an episode of more intense pain that woke him up from sleep at night. This episode lasted about 15 minutes and was associated with diaphoresis. “My pillow was soaking wet.” He woke up his wife who wanted to call 911, but he refused, though he agreed to make this appointment somewhat reluctantly. He has had no further episodes of chest pain, and feels that he is here just to satisfy his wife at this point. He generally doesn’t like to come to the doctor. He doesn’t know his recent lipid levels, though he says a doctor once told him to watch his cholesterol. His BP has been high occasionally in the past, but he attributes it to white coat syndrome: His BP is always normal when he uses an automatic cuff at the store, he claims. He is on no BP or lipid-lowering meds.  He takes a baby aspirin “most days.”  His parents are deceased: his mother had cancer, but his father died suddenly when his 40s, probably from a heart attack, he thinks.

Version 2
  • Mr. Smith
  • CC: chest pain
  • Age: 57 y/o Sex: M Race: Caucasian
  • Onset: 1 month
  • Frequency: > daily [X] weekly [ ] monthly [ ]
  • Location: Anterior chest [X] Left precordium [ ] Left arm [ ] Other [ ]
  • Radiation: Jaw [ ] Neck [ ] Back [ ] Left arm [ ] Right arm [ ] Other [ ]
  • Pattern: Stable [ ] Unstable [X] Crescendo [X] Rest [X] With exertion [X]
  • Duration: < 15 min [X] 15 min or more [X]
  • Risk factors: Tobacco [X] Family history CAD [X] HTN [?] DM [ ] Hyperlipidemia [?]
  • Relief: Rest [?] Medications [?] Other [ ]
  • Associated symptoms:  N, V [ ] Diaphoresis [X] Dizziness [ ] Other [ ]
Which is better?

Version 1 is an old-fashioned narrative medical history, the only kind of medical history that existed before the onset of Electronic Health Record (EHR) systems.  This particular one is perhaps chattier than average.  It is certainly not great literature or particularly riveting, but it gets the job done.  Version 2 is the kind of history that is available on EHR systems, though usually entry of a Version 1 type history is still possible albeit discouraged.  With an EHR, entering a long narrative history requires either a fast, skilled physician typist, or a transcriptionist — either human (frowned upon due to cost) or artificial, such as Dragon Dictation software.  This latter beast requires careful training and is frustratingly error-fraught, at least in my experience.  The Version 2 example is not completely realistic.  In practice there are more check boxes, more pull-down lists and other data entry fields than can be shown here.  But you get the idea.

Version 2 seems to have a higher signal to noise ratio than Version 1.  It’s just Version 1 boiled down to its bare essentials, stripped of unnecessary verbs, conjunctions, prepositions, and other useless syntax.  It contains everything a medical coder, a medical administrator, or a computer algorithm needs to do his, her, or its job.  It has taken the medical history, the patient’s story, and put it into database form.

But Version 1 is not just Version 2 embellished with a bunch of fluff.  Certainly Version 1 is more memorable than Version 2.  There is a chance the physician who wrote Version 1 will remember Mr. Smith when he comes back to the office for a follow-up visit: Mr. Smith, that middle-aged fellow who was stressed out when he took a pay cut while starting a new job and started getting chest pain.  Another physician meeting Mr. Smith for the first time might after reading this history modify his tactics in dealing with Mr. Smith.  One gets the impression that Mr. Smith is skeptical of doctors and a bit of a denier.  Maybe it will be necessary to spend more time with him than average to explain the need for a procedure.  Maybe it would be good to tell his long-suffering wife that she did the right thing insisting that he come in to the doctor.  All this subtlety is lost in Version 2.

There are some cases where Version 2 might be preferable.  In an Emergency Department, where rapidity of diagnosis and treatment is the top priority, a series of check boxes saves time and may be all that is needed to expedite a patient evaluation.  But for doctors who follow patients longitudinally, Version 1 is more useful.  A patient’s history is his story: it is dynamic, organic, personal, individual.  No two patient histories are identical or interchangeable.  Each history has a one-to-one correspondence with a unique person.  A good narrative history is an important mnemonic aid to a physician.   A computer screen full of check boxes is no substitute.

While the Version 2 history was designed for administrators, coders, billers, regulators, insurance agents, and the government, the Version 1 history was designed by doctors for doctors.  We should be wary of abandoning it, despite the technical challenge of its implementation in EHR systems.


Geeky Docs

I remember the disdain some of the EHR trainers had for their trainees back when our hospital system “went live” several years ago. Of course this disdain was tempered by their knowledge that if docs weren’t so computer illiterate, or the user interfaces of the EHR systems weren’t so awful, or if the EHR software wasn’t so bug-ridden, their jobs wouldn’t exist. So they soldiered bravely on, undaunted by grumpy old docs who now had to type their notes despite never learning how to touch type, who had to reconcile medication lists a mile long including meds like cinnamon that they really could care less that the patient was taking but had to be reconciled nevertheless, who had to painstakingly enter orders using an interface designed by an engineer who knew as much about medicine as — an engineer, and who were angry and resentful that this newfangled computer system was being shoved down their throats under threat of loss of government medicare reimbursement. Given the tensions and personalities involved, it still amazes me that the EHR transition was accomplished without loss of life or limb.

Maybe the classes helped. Long before the go-live date, we went to EHR school. This consisted of several days of classes, during which the world of health care delivery was supposed to stop (it didn’t) while all medical personnel sat around drinking coffee and listening to talks about how the EHR was supposed to work. Even though this was a useful education into what the life of a hospital administrator must be like, the real world of patients and disease tended to encroach on the world of mouse clicks and meaningful use butttons to the point that I skipped the last afternoon of classes and the final exam. Unfortunately my truancy was detected and, under penalty of garnishment of wages, I was forced to do a make-up class. Despite the rigorous training, the number of months that elapsed between EHR school and going live ensured that I and my colleagues pretty much forgot everything we learned — hence the need for the EHR trainers.

I was a little disappointed that I wasn’t selected to be a “superuser.” A superuser is a user who is technically savvy and enthusiastic about using the EHR — a true believer who could help other users who were having problems, even after the EHR trainer cadre had long since departed to initiate other hospital systems into the EHR religion. I suppose I failed to qualify on my lack of zealotry. I also kept my technical savvy under the radar. So I became merely a user. I found that, unlike my experience with other forms of technology, the EHR was making my life worse. Simple tasks became complex. My work slowed down. More mistakes were made. I was stunned. I could not think of any other example where a computer program was less efficient than the technology it was designed to replace. But it appeared that EHR systems were a counterexample to this.

So I decided to write a few blogs about how bad our EHR was, but the EHR company, who employs people whose sole purpose is to scour the internet looking for screenshots or bad-mouthing of their precious software, caught wind of this and reported it to the administrators of the health care chain I worked for. After some angst, I agreed to shut up for a while, though now that I am retired, I don’t feel bound by any non-disclosure agreements the hospital system signed with the EHR company.

EHR advocates have sometimes commented that once all the old, non-technological, non-touch typing doctors die off, then everyone will be pleased as punch with their EHRs. The new generation of doctors, raised on technology, able from infancy to handle a Playstation controller with aplomb, will have no problem using EHRs. There is some truth to this, but this criticism misses the point of my and others’ criticisms of current EHR software. There are plenty of technologically sophisticated doctors of all ages who are uncomfortable with the state of EHR systems today. I have written computer software and most would consider me one of these “geeky docs.” Most of the critiques of EHRs that I have read have been from tech-savvy doctors, not from the technological dinosaurs that the EHR pushers believe make up the majority of doctors today. None of us wants to go back to a pen and paper chart system. All of us want to see EHR systems improve in usability and interconnectivity. We all use computer software in our daily lives and know that EHR programs don’t measure up to standards that other computer programs meet. We don’t like the secrecy of the EHR companies or the astronomical cost of the software. But mostly we just want the software to get better. This won’t happen unless the software designers start listening to users. Tech-savvy docs need to be on the forefront of this. We need to push for change and not allow the EHR companies to keep falling back on their old excuse: if you docs only knew how to type, you’d love our system.

I’m a Better Computer Than Any Doctor

[Ed note: I couldn’t resist writing the following after reading this post on KevinMD.com by Dr. Keith Pochick. Please read it first. Apologies in advance.]

I’m a Better Computer Than Any Doctor

“I love you,” she said as she was leaving the room.

“I, I um…”

“Not you. Your computer.” She cast my computer, still warm and glowing with its brilliantly colored logout screen, a glance of longing and desire, and left the exam room.

“Oh, I thought…”

The slamming of the exam room door clipped off whatever the end of that sentence might have been.

I sat down and rolled my chair over to the computer. I stared at the mutely glowing screen. It stared back at me, mockingly perhaps, daring me to click the OK button and log out. Which is what I should have done. She had been my last patient of the afternoon. Not that my day was over. I had to go back to the hospital to see a couple of consults that had come in during office hours. And I was on call tonight. I was tired, but that didn’t matter.

Yet here was this stupid machine in front of me, getting all the credit when I was doing all the work.

I was in a sour and contrary mood. I cancelled the logout. The busy EHR screen reappeared — my patient’s data, all fields filled, all checkboxes checked, and all meaningful use buttons pushed. Yet somehow, despite fulfilling all my data entry duties, I didn’t feel satisfied. Who was the doctor here anyway? Me or the blasted computer?

I scanned my patient’s history. Female. Black. 45 years old. Diabetes. Abscess. The boxes were all ticked, but somehow the list of characteristics failed to capture the essence of my patient. Where were the checkboxes for sweet, smart, chatty, charming, or stoic? How was I going to, five minutes from now, distinguish her from every other “female-black-middle-aged-diabetic-with-abscess” patient? Of course the computer wouldn’t have any problem figuring out who she was. Birthdate, social security number, telephone number, or patient ID number — all those meaningless (to me) numbers were easy for the computer to remember. I had to make due with trying to remember her name, and her story — a story that had been diluted down and filtered out of any meaningful human content by the wretched EHR program.

My patient hadn’t had to interact directly with the computer like I did. All she saw was me looking up information, me typing in information, me staring at the screen. All she saw during most of the visit was my back. From her point of view I was just a conduit between her and the computer — the real doctor in the room. I was just a glorified data entry clerk. It was the computer that made sure that I was compliant with standard medical practice, that the drugs I ordered did not conflict with the other drugs I had ordered, and that I didn’t otherwise screw up her care. I shouldn’t have been surprised that her last remark had been addressed to the computer and not me.

“Well, screw this,” I remarked to no one in particular. Suddenly angry, I reached down and yanked the powercord of the computer from its electrical socket.

There was a brief flash on the screen. But it didn’t go dark. Instead a dialog box appeared accompanied by an ominous looking red explanation point icon.

“Warning,” it read. “External power loss. Backup battery in use. To protect against data loss, please shut down the computer using the Power Down button. Never turn off power to computer while it is running.”

The condescending tone of this message only made me angrier. I looked at the base of the stand that the computer sat on. Sure enough there was a big black block with a glowing red LED. Must be the backup battery. A thick power cable connected the battery to the computer box.

I grabbed the power cable and wrenched it loose from the backup battery.

Sitting back up I expected to finally see a nice dark screen. Data-loss be damned!

The screen was still on. The EHR program was still on. Another dialog box had replaced the first. The red exclamation point had been replaced by a black skull-and-crossbones icon.

“Critical Error!” it read. “All external power lost. Internal backup power now in use to preserve critical patient data. Local data will be backed up to main server, after which this unit will shut down in an orderly fashion. DO NOT ATTEMPT TO INTERFERE WITH THIS PROCESS AS IT WILL RESULT IN THE INEVITABLE LOSS OF CRITICAL PATIENT DATA!!”

At that moment the gauntlet had been thrown down. I knew what I had to do. Let the dogs of war be unleashed!

In the moment before I acted I imagined the reaction of the software engineers at the company that created our EHR program. “I knew we couldn’t trust doctors with our software. We give them a simple job to do. Just enter the data into the system, print out the generated instruction sheets, and send the patients on their way with a merry ‘have a nice day.’ I knew we should have programmed the stupid doctors out of the loop.”

Too late for that, I thought. My chair crashed down on the computer, smashed the monitor to pieces, and caved in the aluminum siding of the computer case. Sparks flew and the air filled with the smell of smoke and ozone. Suddenly the exam room went dark. The circuit breakers must have tripped when I short-circuited the computer.

The room was not completely dark. There was a glowing rectangle on my desk. My heart skipped a beat, then I realized it was just my phone. I had left it on the desk. Why was it glowing? Probably a text or email or something.

I picked up the phone. It was the mobile app version of our EHR program. A dialog box filled the screen. The icon was a round black bomb with an animated burning fuse GIF.

“FATAL ERROR!,” it read. “You are responsible for the IRRETRIEVABLE LOSS of CRITICAL PATIENT DATA. In doing so you have violated the unbreakable bond of trust between the PATIENT and the COMPUTER. This is a breach of the EHR contract made between you, your hospital system, and our company, as well as a breach of the EULA for this software. As such, you will be terminated.”

Strange use of words, I thought. Also strange that the bomb GIF animation seemed to show the fuse burning down…


Hospital Board Meeting — One Week Later

Hospital CTO: “So it appears that Dr. Stanton, in a fit of anger at our EHR system, took it upon himself to smash his computer. The cause of the resultant explosion that killed him is, certainly, still somewhat unclear.”

Hospital CEO: “Unclear?”

Hosital CFO: “I hate to interrupt, but I didn’t think there was anything in a computer that could blow up, no matter how much you smash it up. Am I wrong?”

Hospital CTO: “Well ordinarily, yes that’s true.”

Hospital CEO: “Ordinarily?”

Hospital COO: “Let’s be clear. Dr. Stanton certainly violated our contract with the ____ EHR Corporation.”

Hospital CEO: “Violated?”

Hospital CBO: “It’s clearly stated on page 197 of the contract that any attempt to reverse engineer or otherwise try to, uh, figure out how the EHR program works is a violation of the contract.”

Hospital CEO: “Smashing the computer was an attempt to reverse engineer the program?”

Hospital CTO: “I think that we would be on shaky legal grounds to argue otherwise.”

Hospital CEO (nodding to the elderly doctor seated at the other end of the table): “What’s your opinion, Frank?”

Medical Board President: “Well, as the only physician representative here, I’ve become more and more concerned that our EHR system is subsuming more and more of the traditional role of the physician.”

Hospital CXO: “Oh come on!”

Hospital CSO: “Same old story from the docs every time!”

Hospital CCO: “Broken record, I’d say.”

Hospital CEO: “Gentlemen, and Ms. Jones, enough already. This has been an unfortunate accident, and at this point our major concern has to be that there is no adverse publicity that could harm us in our battle against the ______ Hospital System, our sworn and bitter rivals. Accidents happen. The party line is that we are all upset that we lost Dr. Stanton, one of the best EHR data entry operators we had. OK? Meeting adjourned.”

Hospital CEO (Privately to hospital CTO as the meeting breaks up): “George, when are they updating that damn software. You know, that stuff we saw at the Las Vegas EHR convention last month. Where we can finally get rid of these damn meddling doctors who are constantly screwing up our EHR.”

Hospital CTO: “Bob, believe me, it can’t come soon enough. Not soon enough.”


Can Writing About Medicine Change Medicine?

I’m getting to the point where I think it might be time to stop or at least decelerate the pace of my writing on medicine. When I retired from medical practice almost a year ago there were a lot of pent up experiences that I felt a need write about. But now I have already written about almost everything that I wanted to and, as I am no longer a practicing physician, I lack the ongoing experiences and frustrations of day-to-day medical practice to replenish the store. Moreover I am having a growing sense of futility when writing about medicine.  Can writing about medicine change medicine for the better?  Is anyone listening to physicians’ voices?  Or are we all just grumbling to each other?

How many posts bashing electronic health record (EHR) systems does one need to read (or write)? I’m certainly not the only one writing on this topic.  Criticism of EHR systems is very popular amongst physician bloggers nowadays.  I hope someday the shear quantity (and quality) of these posts reaches a critical mass that results in the EHR companies paying attention and making some changes to their products — but I’m not holding my breath. Similarly a large number of physicians rail against the current Maintenance of Certification (MOC) process, yet I see no indications that anyone who can change MOC is listening. The negative effect of the Great Hospital Buy-Out of Physicians of the last decade is also a favorite topic, as are increasing regulations, the hegemony of insurance companies, and countless other annoyances, but what is the use of grousing about all this if no one is listening but our fellow physicians?

Despite voicing our concerns online, we physicians don’t seem to have a voice where it counts — politically.  We don’t have effective representation. Societies that are supposed to represent physicians such as the Heart Rhythm Society, the American Heart Association or the American Medical Association are beholden to groups other than physicians, i.e. drug and device companies — the same drugs and devices that they publish supposedly objective guidelines about. These medical societies also are in bed with the American Board of Internal Medicine, the progenitors of endless board recertification and MOC, and indeed have a nice side-business going on providing expensive board-review courses to prepare for these tests.  Corporate funding of these societies ranges from 20 to 50% of their total revenue (see here, here and here). Go to any big national meeting of these societies and wander through the acres of exhibits. Some of the exhibit booths are bigger than the home in Philadelphia that I spent my first years in. These glittery exhibit halls reek of money. Every time the pharmaceutical companies complain that they have to charge so much for their drugs because of the cost of R & D, I  recall these lavish exhibits as well as the constant TV commercials for erectile dysfunction products and drugs for quasi-diseases like short eyelashes.  It makes me sick! (Ah! New syndrome: TV drug commercialosis!) Money is power in politics, and physicians, despite being perceived as rich and even overpaid by the general public, are low down on the money totem pole compared to other facets of the health care system.

I’m not trying to be pessimistic, just realistic.  Yet if writing is the only weapon we have, what choice do we have but to continue to use it, blunt instrument though it may be?  The growing multitude of physician-bloggers and physician-commenters will continue to write, will continue to fight for changes in EHR systems, recertification requirements, and health care policies. Maybe we’ll get lucky and someone holding the purse strings will be swayed and do something to make the lives of physicians better. Possibly the decision-makers will come to realize that if our lives are better, our patients’ lives will be too. That’s important because everyone, whether politician, hospital administrator or EHR corporation CEO, will sooner or later be a patient in need of a good doctor.

Lost in EPIC Land

One of the many unanswered questions about the handling of the first Ebola case in the United States is the role of the Electronic Health Record (EHR).  Initial reports put at least some of the blame for the patient’s being sent home from the hospital despite a high risk travel history on a failure of communication between the triage nurse and the emergency room doctor, aided and abetted by the EHR system.  Very quickly this story was altered.  On October 2 Texas Health officials were blaming the EHR, stating that “[a]s designed, the travel history would not automatically appear in the physician’s standard workflow.”  The next day, the same officials changed their tune, stating “[t]here was no flaw in the EHR in the way the physician and nursing portions interacted related to this event.” Texas Health Presbyterian Hospital in Dallas uses the EPIC EHR system.  Texas Health officials and EPIC deny that the reversal was related to any “gag order” in the hospital contract with EPIC.  It is not clear (to me at least) if these statements imply that there actually is no gag order in the contract, or the gag order is there but was not a factor in the changed story.  It should be noted that such gag orders are apparently common in contracts with EHR systems.  It should also be noted that EHR systems are very powerful companies.  EPIC’s CEO’s net worth in 2012 was estimated by Forbes to be $1.7 billion.  EPIC has benefited immensely from government largesse in the form of the taxpayer subsidies and mandates requiring physicians and hospitals to purchase EHR systems or risk losing Medicare dollars.  Politicians (especially Democrats) have also benefited from EPIC, with hundreds of thousands of dollars donated to political campaigns.  EPIC is in the running for a huge government contract to provide EHR services to the Department of Defense.  They certainly wouldn’t want the Texas Ebola snafu to sidetrack this.

Could the EHR have played a role in the confusion in the Dallas emergency room the day Thomas Eric Duncan was sent home with some oral antibiotics?  Perhaps we could understand better how communication failures between nurses and doctors using the EPIC EHR might arise if we could look at relevant screenshots.  When a nurse enters a travel history into EPIC, what then appears on the doctor’s screen?  How easy is it to see?  How easy could it be to miss?  Where does it appear on the screen?  How big is the font?  Does it even show up on the screens the emergency room doctor is usually looking at?

One can argue that it shouldn’t matter.  The nurse should have verbally communicated with the doctor the travel history, or the doctor should have taken his own travel history.  This is all true, but remember, EHR systems were supposed to make medicine better.  They were supposed to make sure everything was documented and nothing would fall between the cracks.  So it would be useful to see some screenshots to understand why something entered by the nurse into EPIC was not seen by the doctor.

Don’t hold your breath waiting for the screenshots.  Whether or not EPIC has gag orders in their contracts, they definitely do not allow posting of screenshots.  I found this out personally when I tried to post some EPIC screenshots in the past.  EPIC has a group of people whose job is to be on the lookout for EPIC screenshots on the internet.  When they find them, they contact the offending party and demand their removal.  I had prepared a screenshot with annotations to show how confusing the EPIC user interface is, and how easily one simple fact (Travel History: recent travel to Liberia) could be lost in the morass of toolbars, sidebars, tabs, and menus that is the EPIC user interface, but I can’t chance having the EPIC SWAT Team descend on my house.  So I have attached a blurred redacted screenshot.  If a news agency wants to take on EPIC, I would be happy to provide an unblurred screenshot.  I’m not willing to take the chance, but somebody should.


The EPIC UI, hopefully blurred sufficiently for the EPIC Screenshot Police (click to enlarge)
The EPIC UI, hopefully blurred sufficiently for the EPIC Screenshot Police (click to enlarge)