Thursday, December 13, 2007

EHRs --- The AMC Pacers of the Computing World

Although I am a surgeon, I have enjoyed using computers since I was a teenager. My father worked with computers for IBM, and was so excited to one day open a box and set up a Radio Shack TRS-80 computer on the kitchen table. The "Trash-80" was no favorite of my mother, but despite her desperate attempts, it lived in the kitchen -- on a TV tray -- for quite a while. It was cool -- with a 4 MHz processor and 4K of RAM; today, that kind of blazing speed will maybe be enough to run an old sprinkler system.

Soon thereafter, I took my first computer course as a freshman in high school. As I recall, there was a Univac machine the size of a DeSoto in a corner room of my high school, and we would type up simple programs on keypunch cards to get it to calculate the square root of 42 or other such nonsense --- we were "programmers" in the sense that a guy changing his oil is a mechanic. But, it was fun, and kept me interested in the potential of computers.

Fast forward a few years to 1984, when I was about to enter the best medical school in the country. IBM had introduced the PC, and I just had the overwhelming urge to plunk down a good 5 grand of hard earned money to buy me one -- with two floppy drives, an AST expansion board (fully loaded down with a screaming 384K of RAM), and a color monitor, no less. Smokin'!!

What would that baby do? Well, after booting it up, I could use the good old WordPerfect word process software I had purchased to, well, word process. And word process I did, to the tune of $30 per medical school lecture to help pay for the darn computer (and buy beer) ---- because we had a lecture note taking service, and some folks just really didn't like to type up a lecture for distribution. Not only did I make a few bucks, but I learned the material a bit better by listening and taking notes, and then typing them up while listening to the lecture tape all over again. And, in the process, I learned quite a bit more about computers, with an awareness of how they could become much more functional in medical care in the future. Then came residency. Zoom -- the computer world completely passed me by, as I had no time to take care of bodily functions on a regular basis, much less screw around with bits and bytes.

Why do I write this? To tell you, and remind myself, that I am no technophobe. I bristle when I read in blogs and newspapers that physicians simply are too technophobic to "accept" electronic medical records. I love the functionality of computers, the simplicity of e-mail programs, the elegance of my Microsoft Excel spreadsheets, and yes the word processing prowess of Microsoft Word. I can use HTML --- OK, I'm a real novice --- on this blog and two websites that I have had to maintain. I can navigate my way around most programs and within a few minutes figure them out so that I can be functional.

I'm not a computer dumbass, dammit!

Except, of course, in the narrow minded world of the electronic medical record programmer. The systems that I have seen are so non-intuitive, so counter-productive, and so blinking difficult to navigate that they make other business world programs seem so advanced that they were given to us by time travelers who had spent time with Captain Kirk. Some of them have the feel of a potpourri programs forced to work together but which were written in different programming languages in different decades, and they look as elegant as the interior of an AMC Pacer (why do I know what that looks like? Don't ask, and please don't ask my wife).

Doesn't this thing have drop down menus? Well, yes, but only on certain screens, which you must access by retyping your password, but this time with "caps lock" on (don't forget to turn off "caps lock," though, because otherwise you sometimes get frozen out of the system). Can I just click here to get to the next piece of information? Er, no. Hit F12. F12?? What program for average people still uses the function keys??? Quicken? Nah, didn't think so.

How about this. I need to look at all of my patients' vital signs and ins & outs for the past 24 hours, can I do that? No, because the system hasn't been programmed to recognize anything other than a midnight-to-midnight time frame. We hope that will be patched in the next version --- which might be upgraded to include Pong if we're lucky!!!

How about my 128 character sign-on password that must include capitals, small letters, at least a dozen numbers and the symbol for that guy who used to be called Prince --- do I really need to change it on alternating Tuesdays and every new moon? Oh, yes. And don't forget -- if you leave the computer for 3.7 nanoseconds without any activity, it will shut you out and you need to sign back on. After, of course, you have called the help(less) desk and waited on hold for approximately the length of time Mars has been in phase with Jupiter for the past decade and begged forgiveness.

Why have we gotten here? Why do we have elegant, well-written programs to allow us to do everything from blog to run the books at major corporations, but the medical system has programs that might have been adequate in the 70s? I think there are a few reasons, and since nobody else will listen to me, I feel justified in inflicting my opinion on those 2 people who have gotten this far:
  1. All hospital computer systems were originally written for one purpose -- billing. As a result, the folks that have been the most heavily involved in getting us new programs start with the premise that billing is the most important function of the code that is to be written.
  2. Money, part one --- hospitals decided they needed to act just like other businesses, and adopted one of the corporate world's worst attributes, the constant worrying about this quarter's projected budget and last quarter's revenues against the projection. Not net loss or gain, mind you, but imaginary numbers that must be met, or heads will roll. How are you supposed to outlay a lot of cash for a new computer system if you are worried about this quarter's budget?
  3. Money, part two --- hospitals, and doctors, rightly see that their income is going down, so unless a new computer system can pay for itself over the long haul, why bother? And if CMS says you have to have one, spend the least money for it.
  4. Janet Reno and Bill Clinton --- my pet theory is that Bill Gates and that giant group of smart people in Washington could write a great program that would work for every hospital in the land, make it easy to use, and make it affordable. And they'd make a ton of money doing it. But, of course, the Clinton Justice Department jumped all over them a few years back for creating a "monopoly," which obviously never existed, so why would they bother with creating a potentially real one? So, Mr. Gates took his money overseas to help folks with malaria.
  5. Last, but not least, there are not a whole lot of physicians who write code in their spare time, so getting a program that fits the needs of docs, hospitals, nurses, et al is a tall proposition.

So, what to do? Most nights, I dream of short circuiting the hospital's computers so we can have nurses go back to actually taking care of patients instead of poking on keyboards. Most mornings, I have to restrain myself from hurling hot coffee at the computer screen. And most evenings, I leave the hospital resigned to the fact that there is nothing that I can do, and that really ticks me off. So, again, what to do? I guess have a martini and forget about it.