• Opinion

    An Epic Struggle Looms: What’s Wrong With the Big EHRs?

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    Richard P. Mills, MD, MPH

    By Richard P. Mills, MD, MPH, Chief Medical Editor, EyeNet


    If you have been living in a cave, EHR as the acronym for electronic health record might have escaped you. But, I suspect, if you’ve been confronted with the daily clinical hassles associated with current EHRs, a cave is where you wish you had been. Or you want to crawl into one now. The best analogy I’ve come up with is that experiencing today’s EHR marketplace is a lot like living with teenagers. Having grown too fast over the last few years, they are awkward, surly, uncoordinated, picky, spendthrift, and immature. And they have plenty of zits. Despite their many different personalities, they all strive to emulate each other. They have great potential, yet most of it is unrealized.

    Spurred on by the expiring bonuses for early adoption of EHRs, ophthalmologists, like lemmings, have taken the plunge. As physicians in an almost purely outpatient specialty, requiring a lot of image manipulation, private practice ophthalmologists have tended to prefer smaller EHR vendors whose products can be easily adapted to their particular needs. But ophthalmologists practicing in academic medical centers and large multispecialty group practices are forced to use the EHR system chosen by their institution. Half of the institutional market uses one of the three big systems that expanded their market share in 2013: Epic, Cerner, and Meditech. The other half is scattered among CPSI, McKesson, Healthland, Siemens, HealthCare Management Systems, Allscripts, and NextGen. The big ones will be getting bigger, as hospitals buy practices. Guess what? The absorbed practice is required to use the hospital’s EHR.

    Ask any administrator of a large hospital system, and you will hear nary a discouraging word about their EHR. They simply paid too much for it to fail. Installing Epic, for example, reputedly cost Duke $700 million and Kaiser Permanente $4 billion. Starting over with a different system is unthinkable. So most of the grousing about large EHR systems comes from the clinicians who actually see patients. What do they grouse about? Inefficiency: Check boxes and pull-down menus take time and invite shortcuts like checking boxes for an exam that wasn’t done or choosing a close, but not-quite-right, diagnosis. Loss of patient rapport: There’s a puppy in the exam room that diverts the doctor and the patient from the key work of nonverbal communication. Computer proficiency: Some colleagues just write the findings in longhand on paper, and the scribe enters it in the record later. Late dinners: “When will you be home, honey?” “As soon as I finish up a few charts.”

    So how responsive are the large systems to the needs of clinicians? Not so much, especially for a small player like ophthalmology. The Academy’s IRIS (Intelligent Research in Sight Registry) has successfully installed software integrators to extract data seamlessly overnight from the systems of 27 different EHR vendors, but not Cerner or Epic, although we are in discussions with them. And what about interoperability? Hardly at all. Interoperability is the term that refers to sharing of medical records between systems. In fact, some of Epic’s installations cannot talk to each other, even if they both have an Epic system. Cerner can’t talk to Meditech, and neither can talk to McKesson.

    I sure hope our teenaged EHRs grow up, as the AAO and AMA have urged. A future world with our current EHRs is pretty scary.