I’m an admitted technophile.  I couldn’t tell you a single NBA basketball player or who the in-couple in Hollywood is, but I’d geek out if I met Ryan Block or Peter Rojas on the street.  I can write my own computer programs and I cut my teeth reallocating memory manually on a black and green screen DOS system to get it to play games from 5 1.4 inch floppies when I was 12.  My reputation is for always having the latest tech and having already hacked it to do things it wasn’t designed for.  I’ve been lobbying my EMR company from day 1 to get it compatible with the iPhone so I can look up labs remotely or have critical labs alerted to me remotely.  I love tech and how much it improves our lives when it works well.  I also know it’s not a panacea and can make things worse if used improperly. 

As much as I love tech, the sad truth is that every EMR I’ve used (six) or tested (>20) is practically junk.  (Disclaimer: I have no financial or professional interest in any EMR, software company, Dunder Mifflin etc.  I also haven’t used every EMR such as Hello Health). 

Ever known a doctor to not want the latest and greatest MRI, virtual CT scan, 3^rd generation anti-CCP test, electronic stethoscope etc?  Of course not.  We love advanced tech and our use of it is one of the many reasons that politicians say medicine is so expensive and we do admittedly get over excited and use it too much at times.  So why is it that in this one area of medicine doctors are resistant to new technology?  Because we don’t like change?  Because we love writing in paper charts with our drug rep pens?  Because we’re oblivious to all the problems with the current system?  No, it’s because the product is inadequate (technically, they suck).

The basic problem I think is wrong with most EMRs is that they were not designed around the primary reason for an EMR—documenting the patient/physician encounter.  I’ve heard legions of sales pitches about how easy research will be, how billing will be improved, how future compliance issues will be solved etc. but none of that matters if the primary purpose isn’t l33t (perfect).  If the doctor can’t unobtrusively, quickly and easily document the encounter at the point of care, then the information will not be as accurate or as complete, which means the billing/research/compliance will fail.  Patient safety issues will fail.  The EMR will fail. 

My current (hospital chosen) EMR wants me to step through different sections on different screens to enter the different sections of my note (PMH, meds, SH, FMH etc).  Of course, the encounter doesn’t flow that neatly.  The patient mentions their mom’s RA randomly when I’m asking about her medications.  It’s entirely too slow to flip back and forth.  It’s very easy and quick to type in a blank word document or write on a blank piece of paper (“Mom RA”).  So, after a month of trying to use this EMR, I gave up and either type while the patient talks if they’re relatively clear spoken or use paper if they’re a poor historian and dictate, transcribe or use voice-recognition software later. 

We’ve probably all used EMRs that wanted us to choose items from a list with the mouse.  Again, this is ok if your patient tells you about things only in the exact same order as the list in the EMR but I haven’t met one yet that does (they also don’t seem to read the textbooks either, gosh darn it).  On top of that the notes end up all sounding the same so they don’t jog my memory when I read them later.

Of course, there are many other problems with EMRs.  I’ve used ones that were abysmally slow on top end hardware.  Fail.  I’ve used ones where basic medicine terms were renamed other things. “We want you to call the past medical history the problem list now.”  Fail.  I’ve used them that were just impossible to find basic information.  Fail.  Most have not even followed basic conventions of programming and design layout.  Fail.  Other major problems these days: proprietary systems that don’t use a common base format (PDF, doc, RTF, txt) so that files on my system are not available on other systems (and yet I can view radiology images from any of the 100+ hospitals in my state that send me CDs.  Hm.), don’t work natively with the operating system’s built in calculator, spell checker, email program etc., cannot display multiple types of data on the same screen, (insert your problem here!)

If the EMR performs worse than paper and pen then don’t waste my time.

I’m tired of people saying that doctors are luddites and are resistant to change as an excuse to try to ram crap software down our throats.  The problem is the product not the consumers.  When my current hospital changed their EMR, we had a meeting a month in to discuss problems we were having.  It became clear immediately that it wasn’t a true problem finding meeting and that the hospital admin/software company PR’s position was that “you are just uncomfortable with technology.”  There was a moment of silence and then loud laughing from the doctors in the room.  Over half could write their own computer programs, all were less than 40 and could type faster than they could write, all had smartphones and used them constantly.  We were Gen X and had been looking forward to a great EMR because we love tech, are much more comfortable typing than writing or dictating, but when we tried to point out the obvious problems we were told that we were the problem.  The anachronists in the room were the non-doctors trying to use old arguments on a new generation of physicians.

Consumer electronics companies don’t tell their customers that they’re technophobes, don’t know what they’re talking about and demand the government drag them kicking and screaming into their stores to buy their product, but that is exactly what is happening in medicine. 

The meta-problem as I see it is that politicians, administrators and public policy types are being successful at forcing clinicians to adopt alpha and beta tech.  Beta tech is ok for consumer electronics (maybe) but has no place in medicine.  Just as a new procedure, imaging machine, medicine would have to be tested against the old standard, so should EMRs, and each EMR, have to be tested.  If a CT scan has a bug that leads to patients getting 10 times the normal radiation, that company would be liable.  If a medicine is made in a plant with inadequate sanitation measures and contaminated pills injure patients, that company is liable.  If an EMR leads to patient harm then the company needs to be held liable.  I’ve had the wrong meds ordered, even though on review of the incident the correct order was chosen and the correct medicine was listed in the chart.  My current EMR always orders lab test X when you click on lab test Y.  The company has known about this for 3 months.  No fix yet.

So I’m standing here before you not refusing to change or recalcitrantly resisting giving up my Mont Blanc for an Apple keyboard but begging on my knees for a perfectly designed, exquisitely coded, adequately implemented EMR that saves time and money, provides better patient care and improves patient safety that I can proudly put on my list of “haves” at gdgt.com next to my iPhone, Xbox, and LED TV.

Until then I’ll keep trying (and paying for) transcribing software, flatbed scanners, electronic pens and whatever else the consumer electronic companies invent in an attempt to find the best choice for myself and my patients. 

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