Electronic Health Records

The creation and dissemination of electronic health records (EHRs) was inevitable the moment personal computers provided every household with unlimited access to porn. While everyone was enjoying themselves in the presence of nubile cyber nymphs, the Powers-That-Be were preparing for an all-out assault on every last sector of the planet that was operating without a keyboard. Today, as long as you appreciate running water and not shitting in public, you must comply with the internet. Medicine is no exception.

I.

EHRs started to become wide-spread in the medical field sometime in the early to mid-2000s with all the snake-oil promises that one would expect which included: reducing medical errors, making information available in order to reduce test duplication, and improving accuracy and clarity of medical charts. In the same way that Congress has no idea how the internet works (some believing it to be a series of tubes), the medical community and its self-appointed leaders clearly had no idea what they were doing or how to internet. They probably should have asked a Millennial. I’m sure any one of them could have quickly showed them the error of their ways with a simple cat meme. But alas, an expert was not consulted and here we are today, wringing our hands in protest of our new overseers.

For over a decade, physicians have been struggling with accepting the use of EHR. Many have expressed dissatisfaction over the fact that more than half their time is spent “interfacing” with a shiny rectangle instead of intently listening to their patient’s complaints which are likely centered around nebulous fibromyalgia pain. Some of the older physicians are even fantasizing about leaving medicine citing the increased burden of serving as a gloried data-entry monkey instead of a physician which is what they were originally trained to do. Furthermore, the promises of reducing errors have been found to be baseless  in that the alarms and alerts scattered about the EHR do nothing more than produce alarm fatigue with only minor improvements in care processes at best. I don’t care how many pop-ups you place in front of me, the foley is staying in.  Although, to be fair, it appears that prescribing errors have decreased some but only because each order starts with a default dose followed by a range of options which allows the physician to at least have a chance at guessing the right answer; we are only trained to excel with multiple choice exams. And as far as decreasing duplication of records, that has also been found to be a bogus claim. As of 2015, 60% of PCPs were unable to electronically exchange records with other physicians outside of their practice. This is not limited to the outpatient world. Anyone who has spent any time in the inpatient setting trying to obtain records from an outlying facility is usually shit out of luck, except for in larger cities where different institutions may have the same EHR and thus are able to share some limited records. This is less that information sharing is streamlined and more a gradual monopolization of information by a superior EHR system (read: Epic). Trying to get records from an outlying transferring facility that does not have the same EHR? Good luck! I can’t tell you how many records I received either by fax or transferring medic which were still hand-written and illegible. HAND WRITTEN! And that is assuming they even send records of any remote importance. Most transferring facilities seem to believe that nursing notes and skin assessments are all that is needed.

But despite all of these problems, the fact that research has continually debunked the promises of EHRs and that many physicians would prefer to slam their dick in a sliding glass door than interact with their institution’s medical record system, they are still being touted as necessary to patient safety and improved care. Although reality is quickly becoming irrelevant (see: Presidential Election 2016), it is still fascinating and horrifying that despite very clear evidence to the contrary, the zealots of EHR refuse to acknowledge the fact that they were wrong; they were wrong about everything. None of their promises have been fulfilled but I suspect that none of their promises were ever meant to be. Hindsight is 20/20 but realization is a bitch. EHR’s were never meant to improve the lives of patients or physicians; they were meant for control.

II.

Back in the day, during a simpler time in medicine where medications were limited and payment could consist of eggs and a chicken, physician notes were meant for no one but themselves. There was little order to how they were written and legibility was only relevant to the person writing the note. SOAP notes did not exist. Best practices did not exist. Medication reconciliation and a full review of systems did not exist. Often times, a few simply lines would be all that was written as documentation for a full clinic visit. This took a few minutes. It was likely the least consequential part of being a physician. Those lucky bastards.

Fast forward 30-50 years, with the advent and dissemination of the SOAP note, and the landscape has changed. The notes are still paper, as Big Internet had not come into the picture yet, but the format was drastically changed. In some ways, the change was for the better. There was more structure provided, it required at least some relevant information for those that may be exposed to the notes and were not the author, and one could create pre-printed templates to help expedite the process. But more importantly, this change allowed the implementation and utilization of EM codes. Physician’s had to prove their worth by writing down their thoughts as well as important aspects of the patient encounter and then code accordingly based off the complexity of the encounter. This form of note writing did end up taking more time but it was not overly burdensome. Physicians could still enjoy being physicians.

Now bring it to the present, for the last twenty years or so, and the landscape has changed once again. Big Internet kicked down the door, flexed nuts, and opened a portal from Hell to fill the land with endless Best Practice Advisory pop ups, guideline reminders, data element requirements, check boxes, and ICD codes. With the implementation of EHRs throughout the land, the task of billing and note writing which was once considered an inconvenience, has become the tools of our enslavement. What once use to consist of no more than a page in short-hand has now morphed into a 4-7 page, primarily auto-populated and copied forward, irrelevant gargantuan ever evolving to demand more data without providing any useful information. Per usual, the outside influences were far more intelligent than the whole field of physicians. The insurance companies, and specifically Medicare and Medicaid, saw the opportunity that the electronic age provided for demanding more and giving less. They also seemed to understand the cowardice of the physician population and took special notice of the fact that their training made them particularly susceptible to achievement-oriented enslavement. With this knowledge, and the weaponry known as The Affordable Care Act, an all- out assault on the medical field was launched.

Notes were scrutinized with ever more arbitrary elements required to obtain a certain level of billing, the calculation of which was purposefully made difficult in an effort to then fine and demand repayment for the inevitable misbilling of encounters. Requirements regarding obtaining a “full” review of systems, despite the complete lack of evidence this provides any useful information, a family history, social history, and a complete medication list (despite the fact that NO ONE knows what they put into their mouth) were required for every note in every encounter, especially in the outpatient setting. Particular language regarding diagnosis and timing of diagnosis were established, and frequently changed, in order to deny payments for mislabeled diagnoses or for missing diagnoses of questionable importance at the time (IE: Obesity). This assault has been further augmented by the requirement of physicians to register with several different physician review organizations, often requiring renewal of registration every few months, with penalties for those who forget or have better things to do (like finish those God-damn notes). And lastly, as if to add insult to injury, the Powers That Be have felt the need to make sure one cannot successfully navigate through their EHR without suffering through no less than 5 pop ups demanding attention to several, often times inconsequential, elements of a patient’s care. (No, I am not going to order a flu vaccine. It’s May. Fuck off!)

It’s all about control. None of this is for the patient. None of this is for the physicians, in as much as it improves their lives or makes their job easier. It is all to control and bewilder those that have the real power. Keep them focused, keep their heads down, do not let them look up, do not let them get comfortable, change the rules, add more tasks, and never let up. This is their game and it works! Instead of requiring change, instead of saying “No”, instead of fighting back, we slouch down and continue with the grind. Occasionally, we like to use our “science” to make a point, but that never does any good. (Remember all the studies about how patient satisfaction is bullshit?) Science will not change the minds of those with an agenda. The assumption when studies are published is that the minds they are meant to change are ignorant to the fact presented; the fact is we are ignorant to their agenda. We are also ignorant to the fact that when we prove a system is flawed and then do nothing to change it, we are helping our oppressors. We may feel smug in our knowledge that the polices are bullshit, but the overlords already know that and we are still following them. “We got them good! Now I better get back to clicking boxes or Massa gonna be upset!”.

Someday, after alcoholism and suicide has ravaged the medical profession, assuming the world has not ended in nuclear disaster or an Idiocracy-style decay, the medical field will make a change. The oppressor will be identified and de-throned. When that day will come, I have no idea. And what the profession of medicine will look like at that time is unclear. But I can assure you that if the change is not made fast enough, and while enough intelligent people still want to invest their life into it, we will be in trouble.

But in the meantime, those boxes aren’t going to click themselves.

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