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ED Physician Executive Slams EHRs

 |  By smace@healthleadersmedia.com  
   January 28, 2014

Electronic health records "are not effective communications tools—not effective at all," says a self-avowed technology optimist who holds a dim view of current EHR capabilities, but has hopes for better systems to come.



Prentice Tom, MD
CMO, CEP America

Prentice Tom, MD, doled out some bitter medicine to a room full of healthcare IT vendors—and, I think, government regulators at the Northern California HIMSS Innovation and Technology Summit this month.

Tom, the lead speaker at the Silicon Valley event and a self-avowed technology optimist, shared his unvarnished assessment of current electronic medical records. They "are not effective communications tools—not effective at all."

I first encountered Tom about two years ago when he rose at a conference to challenge an HHS official about the inefficiency that electronic medical records were creating in his organization, CEP America. One of the largest emergency medicine groups in the country, CEP supplies emergency physicians to hospitals from California to Maryland.

Tom believes that EHRs "are not at all structured how physicians think." He says all such software is built "on a medical student learning platform" and that for the most part, clinical documentation is unnecessary.

"People believe that we have to have this enormous amount of documentation to do what we need to do, and that's not true," Tom told the HIMSS conference attendees. He cited an often-quoted study stating that the average physician waits 18 seconds before interrupting a patient.

"People often say, what can we do to get physicians to listen to their patients for longer? Actually, the question is, why does the average physician interrupt his patient after only 18 seconds? Because most of the information they're providing is not necessary."

Medical Record Documentation 'Primarily for Billing'
In his work with 2,000 emergency physicians, Tom has observed that the emergency physician looking at a patient's chief complaint knows 95 percent of the time, within 5 to 10 seconds, "what he is going to do with that patient. The rest of the time is going back and putting in place the documentation and studies that are required for him to do what he actually knew he wanted to do in the first ten seconds."

According to Tom, "medical record documentation is primarily for billing and to have a record in the rare event that there's a risk case." Doctors didn't insist on all this documentation, he says. "We didn't put them in place. The federal government did, and every insurance company copies them."

Fear of litigation is the real driver for all this documentation, Tom insists. But for an emergency physician, the chances of being sued are one in 25,000 cases, he says. "You might not be so willing to spend the time that it takes [documenting] for something that's a pretty rare event," he continued.

Tom even cites a January 2014 study that 40 percent of healthcare dollars spent do nothing to improve patient lives. "Why do people do these types of things? Well, because we're risk-averse, it's a rare event, costs are transferable to the patient, so we practice for the exception. We do a bunch of unnecessary testing. [And] there's a lot of unnecessary documentation that goes along with it."

Yet, particularly in the ED, even if doctors have medical records in front of them, they are not going to pore through them when they can just query the patient and get what they need much more quickly, Tom says.

Billable Hours is Not the Model
He contrasts physicians, who get paid more if they see more patients, to attorneys, who bill for the time they spend in any kind of documentation. The more they document the more they can bill. "It's just the opposite for us," he said. "The more time we spend documenting, the less we get paid."

For a significant majority of patients, physicians have no need to spend any significant amounts of time in the medical record. Only relatively few complex patients require such scrutiny, Tom says.

In Tom's ideal world, medical records would be completely mobile and have significant voice recognition capabilities. In a hypothetical scenario, a patient presenting with chest pains would prompt the emergency physician to request a standard chest pain macro, enter appropriate variations, be notified of EKG results, and send those results to the on-call cardiologist.

"That would be it," Tom says. "Now people have developed a system that greatly improves my lifestyle, still has all the documentation, actually improves my ability to communicate with everyone else, and actually allows me to spend more time with patients or seeing more patients or doing the things I need to do, versus going to some fixed station where I have to put in a lot of unnecessary data, except for the fact that I have to bill out."

Too Busy to Innovate
CEP America already uses scribes to try to improve physician productivity. The company bills hospitals for its physicians' services, but must eat the cost of the scribes itself, Tom said. "If we can develop systems that allow us to somehow circumvent our need to put in place all this documentation, that's the type of systems that we're looking for," he said.

I did say Tom is a self-avowed optimist. "I don't mean to sound pessimistic," he told the HIMSS chapter. "What I mean to do is provide you with some understanding of why things have taken the length of time that they've taken in the healthcare industry… every physician, every person, every citizen, is in favor of us being able to extract information [in a short period of time]."

As Tom points out, the changes brought about by healthcare information technology can be threatening. Vendors with little knowledge of what physicians actually do can bring ill-advised solutions to healthcare. Busy clinicians simply may be too busy, or too set in their ways, to explore innovation.

One solution Tom offers, for vendors to pay 100 percent of the costs of implementing a pilot technology at a healthcare system, may appeal to too-busy or the too-habituated health systems, and probably plays well to an AMA-type crowd.

But here's where Tom and I part ways. Again and again, I see health systems willing to risk investing time and money in some iffy technology. It may be that the emergency department, with its immediate demands, would naturally be risk-averse. But for the risk-takers, there are payoffs—although not guaranteed ones.

But that isn't stopping innovators within the healthcare system from taking risks, even as the physicians of CEP America go about the business of saving lives. Healthcare technology is multi-faceted, and to simply expect change to be underwritten by Silicon Valley or other tech companies is as unrealistic as expecting Silicon Valley to send every health IT product developer to medical school.

There will be, and are, middle ways of innovating. I hope the next two years of health IT innovation give Tom a reason to have a less scathing assessment by 2016.

Scott Mace is the former senior technology editor for HealthLeaders Media. He is now the senior editor, custom content at H3.Group.

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