Guest post: EHR would work better if we just got rid of the doctors

I am pleased to share a guest blog by Sue Kozlowski, the Manager of Performance Improvement at Henry Ford Hospital in Detroit, Michigan. She’s a featured blogger at, writing on lean process improvement and change management.  Sue and I were speaking about some of the issues surrounding EHR.  She had an interesting and new perspective, and I asked her to share it with you.  One of my physicians shard something similar with me about the value of the data in their EHR, “The data is great if you are a patient or payer who wants to sue us.”

Thanks Sue.  The rest is hers.

The EHR’s New Clothes

Paul and I were talking the other day about Electronic Health Record systems, and he made an interesting comment. It seems that some hospitals and systems implement their EHR expecting great things, and then they’re somewhat startled to see a big drop in productivity – sometimes on the order of 10 – 30%.

I have a hypothesis about this, related to the way healthcare experts work and the way EHRs are designed. To become a physician, you go through years of school. You learn to develop an intuitive thought process that puts together the patient’s current state, his or her desired future condition, and medical pathway to get there. You were trained to document on a paper chart and when you write assessments or orders, you write them in the chart, sign/date/time it, and then leave the chart for a clerk to transcribe orders and follow through on them.

Now let’s look at this process with an EHR which has a feature called CPOE, Computerized Physician Order Entry. Let’s write a prescription, shall we? (By the way, this scenario is not based on any one system but may be considered a possible experience.)
1. Go to the meds tab
2. Start typing into the field “Tyl”
3. See the drop-down list bring up Tylenol, pick Tylenol
4. Click on the dose field to bring up the drop-down list
5. Scroll down and select 200 mg
6. Click on the route field to bring up the drop-down list
7. Scroll down and look for “oral;” settle for “by mouth”
8. Click on the frequency field to bring up the drop-down list
9. Scroll down and look for PRN; have to select “every 4 hours as needed”
10. Click on the Start Date field to bring up the calendar (can’t just type it in)
11. Select the start date
12. Go to “Electronic Signature” field and type in first three letters of last name
13. Find name in drop-down box
14. Click “Enter”
15. Get warning message, “Medication Alert;” click on alert button to see details
16. Read that Tylenol may have a reaction with another medication the patient is taking; click “Continue”
17. Scroll back down to click on “Enter”

And that’s just for one medication order!

So my point to Paul in this discussion was that so far, we have developed electronic documentation and billing systems that are wonderful for capturing standard documentation information; this is very useful for data-mining and for coding and billing. Features like cross-checking drug interactions, or pre-loading patient care pathways, can also enhance patient safety. These are all good things.

But, it doesn’t do so much for fast-thinking, highly trained, busy caregivers. The cost is in the productivity of the people who are entering the data. From a computer standpoint, everything is codified and the programmers have been careful to provide every possible alternative available in drop-down and radio-button format. We’ve turned the process from a 30-second note (granted, sometimes illegible) into a 3-minute process that is safer, great for reporting, and maximizes appropriate revenue.

And drops your productivity about 20%.

Lest you consider me a Luddite, I’m actually an early adopter of most new technologies and I love the prospect of safer patient care that an electronic medical record can bring. As a process improver, I’m ecstatic about the data mining opportunities. But let’s be realistic when we make these decisions: there is a cost, in addition to money, that must be paid to use these systems in their current state. I hope that in the future, programming can mimic the physician’s thought process and approach. In today’s world, it feels like we are asking our clinicians to meet the needs of the capability of the application, rather than building systems that maximize the value of the clinician’s time.

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