'Why I Hate My EHR'

September 15, 2016
KrisEmily McCrory, MD

A better EHR might seem to be the solution to many physicians' frustrations, but in reality, oppressive quality markers are at the heart of the problem.

I don't really hate my EHR. I appreciate the ability to read office notes that would otherwise be illegible. I can find old orders, past lab results, and every phone message I have responded to. There is no longer a crowded chart room where I cannot find a misplaced chart that may or may not have actually had the information I needed because it was incorrectly filed. No more loose papers or Post-it notes. Having been a teenager in the 90s, I am not daunted by the technology and am not nostalgic for the "better" world of paper charts. Having been gone to medical school and trained in institutions during their transitions from messy paper charts to electronic records, I have not struggled to accept the inevitability of an EHR. I can see so much promise in going digital.

What I actually hate is the chaos and disaster that will be forever linked to the government requirement to use the oft-despised EHR. What we need are systems that work together in a way to permit a secure but accessible flow of information. As the medical world and ultimately patient care becomes more and more fragmented, what we are missing is interoperability and communication. However, instead of improving on the often disorganized paper charts, the forced use of the EHR system has created multiple, disconnected silos of systems that cannot talk to each other. Patient information cannot easily be transferred, leaving items to be printed, faxed, and scanned. In larger offices, especially with higher staff turnover, those scanned items may or may be easy to find within the patient's chart. We have been forced into a hybrid world that cannot fully let go of the old because the new doesn't function well. The failed promise of efficiency of the EHR is no better than the illegible charts it replaced.

Mostly, however, I am frustrated by the insistent linking of EHRs to questionable metrics, payer-imposed check boxes, and barriers to good patient care. The EHR, which could have been a tool for health IT systems to communicate, did not have to lead to complete depersonalization in the exam room - but that is precisely what happened. Between Patient-Centered Medical Homes, Meaningful Use, Accountable Care Organizations, and a variety of other triple-aim organizations, there are so many pieces of data to document one can easily forget there is an actual patient sitting in front of you.

We all want quality healthcare, but medicine is not cooking. You cannot create a recipe for a population of diverse individuals and expect it to be appropriate for each person who walks into the exam room. Approaching medicine as if we know all the answers to patient care is absurd and dangerous. Guidelines should not be rolled into EHR decision trees and treated as solid truths. Even in my short medical career, I have seen significant changes in how many medical conditions are managed as our knowledge grows. EHRs and the so-called quality groups they provide data to, cannot keep up with pace of these changes.

I was asked to join my institution's Primary Care IT workgroup, whose tasks entail finding ways to streamline EHR function to improve physician use. During my first meeting I learned that breast cancer screening is a metric our institution will be measured on for one of several groups we currently report to. One physician asked if the EHR was able to identify the correct screening recommendation by age and described what he used as a recommendation, which happened to be a different guideline from what I use. When I asked which of the several breast screening guidelines the EHR was utilizing and was presumably the requirement for the metric, no one could provide an answer. Herein of course is the problem. Which guidelines? Which recommendations? Which data? And what do I, as a physician, do when I disagree? Writing lengthy documentation on why the guideline does not apply to the individual in front of me is useless when all that is reviewed is the boxes I check.

We learn early on in medical school and throughout training that patients do not read the textbooks and do not always behave as we would expect. I have learned in my career that they do not know the assigned check boxes either. As a conscientious physician solely responsible for my medical license, liability, and ability to sleep at night, I struggle against hard and fast rules that can hurt my patients. Patients will not sue the creators of the check boxes, they will sue me. It is difficult to see a court siding with a defense that I was just following the metrics. Which of course they shouldn't.

Physicians have been educated and trained to care for patients. The increasing loss of autonomy in the face of economic pressures disguised as quality measures needs to stop. These bogus check boxes that fail to account for the often specific nature of illness and health in individual patients may be linked to the EHR, but in reality they exist independently of it. Even if we went to back to paper charts tomorrow, the pressures to meet those infuriating quality markers would persist. Physicians need to rise up and work together to take back our patient care from administrators and payers looking at bottom lines. The problem is so much bigger than an EHR. We need to stop focusing on finding the better EHR and instead push to remove the oppressive quality markers that are at the heart of the problem.