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Computers & Software Medicine

Why Electronic Health Records Will Not Get Better

Today I read an article in Politico entitled “Doctors barred from discussing safety glitches in U.S.-funded software.”  The article states that, despite massive public funding of Electronic Health Records (EHR), the EHR corporations (including Epic Systems, Cerner, Siemens, Allscripts, eClinicalWorks and Meditech) routinely attach gag clauses to contracts with the hospitals and medical groups who purchase their systems. We are talking about gag clauses that prevent criticism by health care workers of EHR software, gag clauses that prevent disclosure of technical flaws or software bugs that could be potentially lethal to patients, and even gag clauses that prevent posting of EHR software screenshots. All this is under the guise of protection of intellectual property — as if the public has no right to information about systems that were largely publicly funded, either via taxpayers through the stimulus package, or through payment of hospital bills or insurance premiums. This is outrageous!

But it’s also old news to those of us who have had to deal with the byzantine software behemoths that these companies produce. A couple of years ago I got beaten up by Epic and my hospital administration for publishing a tongue-in-cheek satirical review of the Epic EHR as a video game, complete with screenshots. Epic didn’t like the screenshots and ordered them removed. As it turns out, Epic has a squad of workers (some have referred to them as the “Epic Police”) whose sole job is to scour the internet, looking for Epic screenshots, and then bullying the poster until they are removed. The whole sordid tale is told here.  I am not the only one who has had this experience. Several of my colleagues have had run-ins with the Epic Police, with similar results.

A lega Epic EHR screenshot
A legal Epic EHR screenshot?

Those of us who are critical of the lack of transparency of EHR software are not trying to embarass the EHR companies by publishing flaws in their systems. This is a public health issue. Dr. Bob Wachther published a case in which a flaw in EHR software resulted in a patient getting a massive overdose of the drug Septra. Tellingly, the reaction of the EHR company (Epic again — not to pick on them, but they are the largest EHR company and thus may be disproportionately represented in these stories) was not horror that their software may have led to a life-threatening medical error, but rather that Dr. Wachter had dared to publish screenshots that showed how the error occurred. Again, this is simply outrageous.

Doctors have been accused of failing to police themselves, but in truth there is a long history of transparency in Medicine. In Grand Rounds, Cath Conference, or Morning Report, doctors show cases to their peers that do not always present themselves in the best light. Complications are presented to a critical but sympathetic audience, for we have all been there and want to improve. Constructive criticism is offered and accepted. This transparency extends beyond one’s own group of colleagues. Case reports of complications are routinely published in the medical literature, with the hope that the lessons learned can be passed on to other doctors who can then avoid the same mistakes.

This kind of transparency only works if every component of a case is open for discussion and review. This is not compatible with the gag clauses in current EHR contracts. Having such gag clauses is comparable to having a manufacturer of electrocardiography machines state that the electrocardiograms produced by their machines can’t be posted on the internet. It is equivalent to a drug company refusing to disclose the mechanism of action of a new drug even though they know how it works. It is equivalent to publishing the results of a research study, but refusing to publish the methodology, claiming that information is “proprietary.”

Current EHR systems are not state-of-the-art software. They basically consist of a backend database on a server, and a client user interface that provides data entry. There has been little to no effort made to interface between different EHR systems or provide for a standardized data format. There is very little artificial intelligence built into these systems, other than attempts to force compliance with clinical guidelines and billing criteria.  The user interface is bloated and clumsy. It does not conform to a doctor’s workflow. Instead doctors have had to adjust their workflows to accomodate the EHR systems. I believe major advances could be made in the usability of these systems if, as is the case with most of the non-medical software we use, bugs and other flaws could be openly reported without fear of reprisal from the EHR companies.

Until that happens, EHR systems will continue to suck.

By mannd

I am a retired cardiac electrophysiologist who has worked both in private practice in Louisville, Kentucky and as a Professor of Medicine at the University of Colorado in Denver. I am interested not only in medicine, but also in computer programming, music, science fiction, fantasy, 30s pulp literature, and a whole lot more.

6 replies on “Why Electronic Health Records Will Not Get Better”

You are right, as usual. Unfortunately the large companies have more money to buy legislators than we do. Until “organized” medicine (an oxymoron if there ever was one) rears up on it’s hind legs and says not “just no” but “hell no” to the further intrusion of these f—ing systems that degrade patient care and make our lives miserable, nothing will change.

By the way, “GIGO” (garbage in-garbage out) is particularly applicable to these systems. Physician users are often trapped in a data field that demands an answer before being able to continue but the accurate answer is not available on the list of possible choices. So some people (not me of course) just pick the best choice available, even if it’s not exactly right, to be able to move on and continue trying to deliver healthcare (i.e jump through the next hoop). So all the aggregated data that the geniuses running healthcare will be using to determine how to direct limited resources will be based on data that’s kinda accurate.

These systems are also responsible for helping to drive thousands of experienced and talented physicians to retire before they would have under better circumstances. While that might not be a tragedy for the physician, it means a continuing exodus of experienced and talented physicians. That is not good for healthcare in general.

I am going to go sit down now with a large bourbon now and read something pleasant like some good fiction. Anyone who wants to start a “Stop the madness” campaign, send me an email.

If a patient is injured by errors related to a given EHR, could the EHR company be successfully sued?

Does ‘copy & paste’ without an accurate audit trail promote plagarism? If so, can the ‘copier & paster’ cause errors in patient care? If so, and the ‘copier & paster’ can be identified, are they subject to malpractice suits? If an EHR company permits ‘audit-less’
‘copying & pasting,’ could they then be sued for Medical Malpractice?

I know a former critical care physician who looked at patients ‘from the doorway,’ read nursing and other physicians’ notes, copied them into his note (he viewed labs, chest x-rays, and read all radiograph reports). I don’t know how this physician coded ICU ‘visits.’

All that is needed is for a medical malpractice attorney, with the help of either a physician/coder or just a former EHR programmer to follow the money, then sue all the deep pockets(especially the EHR company)! Perhaps then, quality of EHR programs would improve!!

I agree with you that it might take litigation to bring them around. However my understanding is that the EHR companies usually put in their contracts that they are not liable for medical errors due to their software. Whether such a clause would hold up in court, I’m not sure. Perhaps others who know more about the legal end of EHRs could comment.

Let me add to my comment that the feeding frenzy of EHR companies was predictable from the lure of CMS incentive payments. CMS would have spent a fraction of the amount they actually spent, if they had offered incentives to groups offering open-source EHRs. We would also have EHRs that interact and function far better, etc.

I had a home-made EHR based on Word prior to trying for a certified EHR. I have yet to find a proprietary EHR that is as serviceable from the medical standpoint as my personal EHR was. That is because it was designed by a physician and not an IT person. Of course, the true advantage of EHRs is in the area of billing. I certainly could not match that.

I still have the dream of helping to develop a truly outstanding open-source EHR. If anyone knows of someone who also has this goal, please let me know.

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