Sarcasm Will Only Get You So Far

Recently, WBUR posted an article about a parody Twitter account that satirizes one of the biggest electronic health record (EHR) software vendors: Epic. When the reporter reached out to Epic to ask them if they had any response or reaction to the parody account, Epic replied, “We do not.”

Anyone who knows Epic’s culture won’t be surprised by their silence. This is a midwestern software company  which prefers that their customers speak for them and that their products speak for themselves. Luckily for you, kind readers, even though I too am from the Midwest, I am happy to wax poetic about the current state of EHR software and its impact on clinicians. Heck, it’s what I do on a regular basis.

I should begin with some disclosures (most of which are true):

• I am a physician. I practiced primary care pediatrics full-time for eight years, but I don’t see patients nowadays.
• I was an employee at Epic from 2005 – 2011.
• Epic is a privately-held, employee-owned company. When you leave, you leave any stock or stock options on the table. Hence, I have no financial ties to Epic.
• I work for an information technology (IT) consulting company. We have no financial ties to Epic, but we work with a bunch of Epic’s customers.
• I am very tall and very good-looking. I’m often confused with that TV pediatrician from the show ER. What was that guy’s name again? George something.

Let’s begin with a fact: this EPICparodyEMR doctor dude is funny. He’s witty, sarcastic, and can write good copy, and he’s able to weave pop-culture trends into clinical practice scenarios with ease. Add on a touch of “yeah I’ve been there” EHR insanity, and you get comedy gold. It’s funny because much of it is true. Since the good doctor is clearly an Epic user, he focuses his wrath on Epic. I get it. But . . .

While Epic and the other big EHR software vendors can – and must – make better products, I’m here to tell you that a big chunk of the problem is the healthcare “system” in which we practice. Want the software to work better? We need to do a lot of work on regulatory, tort, and payment reform in the United States in parallel with software usability, user-centered design, and user experience improvements.

Let’s talk about some of the decisions that Epic (and Cerner and Allscripts and Athena and other software companies) did not make for their U.S. users:

• If the doctor didn’t document it, the doctor didn’t do it.
• If the doctor didn’t document it, the doctor didn’t think it.
• If the doctor didn’t document it in just the right way, the doctor can’t bill for it.
• If the doctor didn’t document it in just the right way, yet still billed for it, the doctor at best can owe a lot of money to an insurance company and at worst can go to jail.
• If the doctor didn’t order it, and it happened to the patient, someone is to blame.
• Team-based care is encouraged, but it’s best to do it outside the U.S. . . . just to be safe.

I could go on, but it’ll just depress me. So, let’s stop here.

Before I go on to dig into some of EPICparodyEMR’s hilarious and tongue-in-cheek commentary, let me ensure that everyone knows I get it; it’s a parody. The word parody is in the name of the commentator. It’s not meant to be taken seriously. Yet, people are taking it seriously, and many doctors really do believe that the software vendors are to blame for the practice of medicine in this country. I’m sure I’ll be accused of not being in on the joke. People, for the record, I’m in on the joke (see this and that.)

Myth #1: EHR vendors love clicks

We can thank Xerox PARC for inventing the mouse and Steve Jobs for introducing it to the masses. Remember the time before the mouse? It was bad. I used to type things like “dir” and “cd –“ into things called command lines. Compared to a keyboard alone, the mouse is a godsend. EHR vendors use the clicking of a mouse to indicate user choices. The mouse isn’t the only way to enter data into a computer program, but it’s what most people use. Epic allows physicians to quickly enter data via voice recognition and keyboard shortcuts, but precious few doctors are aware of these or work to overcome the small learning curve. Why is this? That’s for another blog post.

Reality: The people who pay for care, evaluate care, and sue over care demand documentation and details that force EHR vendors to offer tools for said documentation and tools. Granted some of the tools are lousy, but don’t blame the software company for their existence.

Myth #2: EHR vendors don’t take patient safety seriously

As a matter of survival, software vendors can’t produce bad software . . . at least not for long. The vendors I know and work with respond immediately (same day) to claims of serious patient safety issues. I’m not saying that there is resolution the same day, but a rapid response with evaluation by developers and clinicians happens, and it happens fast. I don’t always agree with the proposed resolution or non-resolution, but concerns are immediately evaluated.

Reality: Major EHR vendors have teams to evaluate and mitigate safety concerns.

Myth #3: Some software companies have gag clauses that prevent meaningful sharing of usability and safety concerns outside of current customers

Nope. Sorry. This isn’t a myth. I get wanting to protect intellectual property but sharing of screen shots in a thoughtful and productive way must be allowed. We need to make this easier, while at the same time, not putting EHR vendors out of business or stifling innovation. If I had a simplistic answer as to how to do this, you’d read it here. This is complicated and is going to take industry and government to figure out a middle ground.

Myth #4: EHR vendors don’t have clinicians or usability experts as employees or reviewers

Yeah, they do. For reals. I was one of them. These doctors, nurses, therapists, and others work hard to represent their colleagues and produce an EHR that helps them do their jobs. They don’t always get the decisions or priorities that they want, but they have a voice on the inside. I wish this criticism would just stop.

When I was on the vendor side, we didn’t have a formal usability team, or at least we didn’t call it that. Now, modern usability theories and practice are weaved into development at all levels. I know it’s happening, because I see it at the vendor meetings and read about it in release notes.

Reality: Clinicians and usability experts weigh in on development. They sometimes lose out to other dev priorities or company-wide initiatives, but they are there, and they are helping.

Myth #5: The EHR vendor controls every aspect of the way the EHR works at my hospital

This is actually hilarious for those of us in healthcare IT. I like to say that “Once you’ve seen one Epic EHR, you’ve seen one Epic EHR.” Ok, I’m likely not the first to say it, but I still like to say it because it’s true. Most – but not all – modern EHRs allow a ton of configuration. I’m not even talking about a hospital hiring software programmers to write code; I’m referencing switches in the software to turn on and off functionality or control how things work.

This configuration is done by IT analysts at the local level who principally respond to clinicians and other subject matter experts (SMEs). Hence, many features and lots of functionality that doctors crave and have demanded may be sitting turned off in your EHR, and you’ll never be the wiser. Sometimes this is due to the SME who is loudest or shows up to the IT meetings; sometimes it’s due to compliance and legal folks who make decisions that they feel are best but might be detrimental to the physician experience. I think local SMEs are great, but they are experts in practicing medicine or collecting fees from insurance companies; they are not software usability experts (see my commentary here).

Reality: Often, your hospital or medical center has made decisions about how the software looks and functions. Getting involved on IT committees or reaching out your IT physician leaders may be an eye-opening experience and may lead to a better understanding of why things are the way they are.

Myth #6: The EHR vendor controls the clinical decision support that we all love to hate

Drug interaction checking: I’m talking about you. Believe it or not, most drug databases (and the interactions associated with them) don’t come from your EHR vendor. Drug databases typically come from a third party that spends a lot of time keeping up with the current state of medications in the country. So, you should blame those database vendors!

OK, don’t necessarily blame the database vendors. Generally, they’re simply reporting what the package insert says. Have you read a package insert lately? It’s not a fun experience. If it seems like the EHR is telling you that every med interacts with every other med, it’s because . . . they do. And if your patient is allergic to penicillin, woe to you if you want to prescribe an antibiotic.

The good news is that many EHRs allow the hospital or clinic to overrule the third-party alerts so that certain alerts don’t show as often, or at all. If you were a compliance or legal representative at your hospital, would you be in favor of overruling the third-party expert’s recommendations? Maybe not. Yet, physicians who are involved with health IT at the local level may be able to improve the physician experience by their very involvement.

You seeing a trend here? Clinicians at the local hospital and clinic level can make a difference by becoming involved with IT governance. A peek under the hood of your EHR might change things for the better!

Reality: Third-party sources of data often govern the way the EHR operates. This happens by design and is a good thing, yet clinician involvement can help moderate alerting so it’s more likely to hit the sweet spot.

Phew! I feel better now. I hope those not in the IT trenches can appreciate some of the vagaries of EHR care and feeding a bit more than before. If you have the time and inclination, reach out to your friendly physician IT leader (maybe a CMIO or CHIO) and offer to help make your EHR better!

Now, let the hate tweeting begin!