The response to our request for readers to share their experiences with electronic health records continues to be intense, with comments that generally recognize the advantages of EHRs but emphasize the challenges they have presented for workflow and patient interactions. Some responses are downright negative, and reflect a level of frustration and disappointment in a system that they feel is no longer working for them or their patients.
Mark Goldberg is a family doctor in Alpharetta, Ga. He has practiced in a variety of settings over the last 29 years, and recently moved to urgent care from traditional primary care medicine in large part because of EHR implementation in his office practice.
His practice, part of a large health system, was located in a rural, underserved county. He had been a part of that practice for 16 years, and worked in an office with four other physicians. He describes their practice as serving the community in all capacities, including walk-in, same-day appointments. As he says it, "If our patients needed us, we saw them." Their average appointment load per doctor was about 25-30 patients per day. Their practice used paper charts, which where often dictated. Dr. Goldberg, on making the transition to an EHR:
At large cost, the owners of the clinic implemented an EHR, and initial users were dissatisfied with both the difficulty of using the system and the way it slowed workflow. Training was intensive. Nonetheless, dissatisfaction was high.
The handwriting was on the wall, and I left the practice coincident with the implementation of the EHR. Sadly, my fears were realized for my ex-partners and my patients. Productivity dropped dramatically, and stays low to this day. The practice no longer sees walk-ins. The physicians barely see 20-22 patients per day, down about 20% from the number of patients seen before the EHR. The physicians are often there 2-4 hours after the office closes to finish typing their notes, whereas we used to leave within a half-hour of closing. One physician told me that he would only allow his patients to tell him one complaint per visit, because he didn’t feel he had time to document more. He also felt his notes in the EHR were much less complete than his dictated notes in the paper chart. Physician quality of life and family time has been dramatically impacted. Patients are angry and frustrated. Two other physicians ultimately left our practice as well and have been very hard to replace.
In my opinion, implementing EHR destroyed a healthy and happy practice that served its patients well, and filled a huge need in an underserved county. Three out of five physicians left the practice, leaving primary care for good. I do not feel that this was due to "poor implementation," as everyone in the practice had extensive training prior to going live. I see it more as a failure of the EHR vender to understand the workflow needs of physicians in a busy office setting.
Dr. Goldberg voices a point of view that, unfortunately, we’ve heard before – that EHRs change the way a practice runs, decrease productivity, and distance physicians from patients. The experience in his practice serves as a warning to others to be careful both with their expectations for their EHR, the selection of which EHR to purchase, and how to implement its use in their office.
Dr. Mel Chandler, a 66-year-old family physician from Edmonds, Wash., shared insights informed by seeing many changes to the practice of medicine over his long career:
I have had many experiences over the years including an elderly practice partner in my first 3 years who managed to keep all of his records on 3-by-5 cards in his desk. In the left-hand top drawer were his patient notes on these cards and in the right-top drawer, his 3-by-5 cards with records of the loans he made to his patients, often at no interest. It worked well for him, but not so well for those of us needing information when on call. For our records, we dictated a SOAP [subjective, objective, assessment, and plan] note. This worked well enough for years.
I believe the EHR may help with record keeping in a very limited fashion. The programs I have seen are complex, use templates, and make it difficult to enter information. I have resisted the use of templates previously so that I could freely think rather than have my thinking directed by a prescribed format. Over the last decade, I have changed my practice to focus purely on those who have severe mental illness. It is important for me to maintain eye contact or at minimum watch my clients at all times while they are in my presence. In my state of residence it is illegal to text and drive an automobile. This is because of the disastrous effects of the distraction of typing. Is my interaction with my patients no less important to perform with full attention than driving? We meet with patients/clients to have a person-to-person interaction to problem solve, teach, and often console.
