Two Dirty Little Secrets About Electronic Health Records

By Larry Husten for Forbes

Here are two dirty little secrets about electronic health records (EHR). Just about everyone in the field already knows these secrets, and many are quietly horrified, but few want to discuss them since there are no obvious or easy solutions.

EHRs Are a Threat to Freedom of Speech and Academic Freedom

Epic Systems, a privately-held company, is the largest provider of EHRs. Most of the big medical centers, including all of the top 10 academic medical centers in the US, use Epic. Like many other EHR companies, Epic requires hospitals and physicians to sign a non-dispargement agreement, or “gag” clause. In fact, Epic doesn’t even allow its hospitals and physicians to publish screen shots of its software in use.Think about that for a second: Epic users– including a large percentage of the leading physicians in the country– are legally forbidden to criticize their EHR or even share images of how it works.

Bob Wachter, a leading doctor at UCSF, recently wrote about a case in which a young patient nearly died after receiving a massive overdose of an antibiotic. The incident was caused in large part by the poor design and interface of the Epic system. Wachter  needed to obtain permission from the CEO of Epic to reproduce screenshots to tell the story. Wachter, who was recently named Modern Healthcare’s most influential physician in 2015, would not have been able to fully tell this important story without the permission of Epic.

My question: how is it even possible that the top hospitals and medical schools in the country agreed to this severe restriction on academic freedom and freedom of speech? How is it that one company can limit the ability of doctors to write about their cases? Imagine for a moment if a pharmaceutical company insisted that hospitals and doctors could only use its drugs if they agreed not to say bad things about those drugs. I understand that there may be some legitimate issues involving proprietary information, but this limitation goes way beyond any possible legitimate interpretation.

Electronic Health Records Are Not Even Electronic Health Records

Here’s the second secret: EHRs are not really EHRs. That is to say, electronic health records were not designed with the primary goal of helping physicians and other healthcare workers provide the best possible healthcare to their patients. Instead, the primary goal of EHRs is to make sure that healthcare providers receive maximum reimbursement and to provide data to executives to help them “manage” their workers and their systems. EHRs have not been designed by doctors and nurses and patients for the use of doctors and nurses and patients. Instead, these systems have been designed for healthcare executives to manage their enormously and increasingly unwieldy and complex systems.

EHRs and the Future

I don’t want to give the wrong impression: I’m not against EHRs. The future of medicine and our healthcare system depends on their success. Let me just briefly mention two important reasons. One, it is clear that the significant advances promised from “Big Data” or “Precision Medicine” will require an efficient and trustworthy EHR. Two, EHRs are absolutely required if we are going to have randomized registry trials, which may well be the best single way to bring a solid base of evidence to the vast amount of medical care for which no evidence base exists.

But we are not going to be able to achieve those goals if we have proprietary, closed systems, immune from criticism and scrutiny, designed for bureaucrats and not healthcare providers.

This story has been updated to reflect the fact that Dr. Wachter did not seek permission from Epic to tell the story of the overdose. He did seek and receive permission from Epic to reproduce screenshots that help explain the story.

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  1. UCSF decided not to set such limits when they bought and built Epic to their specifications. You cannot blame the computer when it’s programmed based on their instructions of how they want it to work. The doctor should have caught it – I did immediately – the pharmacist should have seen this – I did as it’s pretty obvious at the bottom of the section and the nurse should have asked why so many pills. 3 health care professionals did not do their job of double checking their med administration.

  2. This appears to me to be a rather one-sided view from an evidently prejudiced person (user or otherwise). I totally disagree that EHRs were built specifically for executives rather than clinical providers. The EHR was built to support a one-world healthcare data exchange which was a key component of Mr. O’Bama’s HITECT ACT update in 2009. Whether you are dealing with EPIC or Meditech, or any other of a half dozen EHR providers, none of them work to the greatest benefit of the patient or the clinician because medicine and treatment protocols are not always “cookbook”, and I am sorry to say but non-medical or non-clinical people haven’t a clue what is relevant in documentation or how it should flow or how quickly such and such should talk to such and such. Healthcare does not work like a department store or even the IRS. There are too many “unknowns” until proven or validated by diagnostic testing results? At any rate, don’t beat up just on EPIC – put the blast where due – i.e., the Federal Governments continued interference into healthcare. Creating laws and regulations with unintended consequences and then making the healthcare providers pay for the mistakes they created.

    I am against the continued push toward EHRs. Although automation is very helpful when it works correctly, it is the most irritating and frustrating thing when it does not provide what is needed to do one’s job. As a co-worker commented to me just yesterday, “I have learned to be an expert in the “work around” game”! What he meant is that those of us in healthcare have had to create work arounds for our missing links in the EHR – things we have to have or do that these systems cannot deliver. Physicians and hospitals should be encouraged to continue to move toward the development of a “real” electronically generated health record, but it should not be driven and forced upon anyone to the extent that healthcare providers are forced to use inadequate tools or pay a penalty for not doing so. The whole thing is someone money-making fantasy at the moment. I opt out, myself!

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