Turning and turning in the widening gyre
The falcon cannot hear the falconer;
Things fall apart; the centre cannot hold;
Mere anarchy is loosed upon the world.
–William Butler Yeats, The Second Coming
The end of this year was dizzying. As we sat and watched the ball drop on TV, announcing the New Year, we thought about the past year in practice. The year 2014 ended with a unsatisfying bang, with the new year ringing in the news that almost half of all doctors eligible for Meaningful Use bonuses on meeting Stage 2 criteria did not meet the government’s standard for the program, so instead of bonuses these physicians will have penalties. It is estimated that over 250,000 physicians will receive penalties of a 1% reduction in Medicare payment. Many physicians left the year feeling like the government had played a fancy game of three card Monte with them, getting them to pay hard-earned money for expensive EHR systems, initially letting them win a little bit, then through some slight of hand, having them lose significant amounts of cash.
Dr. Chris Notte and Dr. Neil Skolnik
While we are champions of EHRs and clearly believe that their benefits outweigh the problems they bring, we continue to empathize with our colleagues and recognize that to use the EHR efficiently and effectively requires an incredible amount of work. While we will continue to go over EHR issues large and small, as well as specific strategies for success, we thought that it would be appropriate to start the year by letting the voices of some of our readers who have taken the time to email us their thoughts express the concerns of many from whom we have heard.
Dr. Sanjay Raina, an internist from Slidell, La., wrote: “In my opinion, EHRs are still not ready for prime time. I have practiced for 18 years as a primary care physician. I was not raised in the computer/electronic gaming era nor did I type very much growing up. EHRs have many benefits, but they are cumbersome. It seems that transmission of datasets and data mining is the main use of present EHRs and that information is used to determine payments and perform reporting of quality measures.
“The main problem I have is the lack of efficiency of the systems. I have heard people say that notes take a few minutes longer now to complete. In my opinion, to claim a chart note, which would take 1-2 minutes now takes 3-5 minutes per patient, as Dr. Depietro said in a previous column, is wishful. It is also more difficult to navigate through past records in electronic charts, compared with flipping pages in a paper chart.
“The EHR seems to have made communication more difficult. Reading through consultant notes that have been generated with an EHR is cumbersome, and the main point of the consultation is often hidden. I miss the days of typed consultations mailed on professional paper that addressed the patient’s problems and made clear recommendations.
“Younger-generation physicians, if they can maintain eye contact with the patient while touch typing, will do well. Those not so familiar with touch typing have to concentrate on putting in information and will be distracted from the patient.”
Dr. Raina’s comments are reflective of many we heard – a disappointment that the EHR has not realized its potential and neither improves quality nor saves time. Another common theme is that the EHR takes more time, that it makes it difficult to find the important information in consultant notes, increases practice expenses, and makes it more difficult to connect with patients.
Dr. Melvin Monroe, a family physician in Lima, Ohio, wrote: “I recently retired after 50 years in practice, and the computer was part of the reason why. The most important negative was losing face time with the patient. To minimize the effect on patient interactions, I would write in a note pad while seeing the patient then go to the computer to do my documentation. This approach greatly reduced my productivity.”
Clearly, the sentiment expressed by our colleagues is that EHRs have not been a net positive for doctors or patients. The year ended on a frustrating note, with over 250,000 smart, capable, caring physicians – people who work hard to do the right thing – being told that they would receive government penalties for not meeting stringent criteria that they do not see as helping either them, their practices, or their patients. That is both insulting and costly, and we are not sure which feels worse. The second stanza of Yeat’s poem quoted at the beginning of this column starts off with the phrase, “Surely some revelation is at hand.” That is what we can all wish for this coming year.