Abraham Verghese: 'We Are Responsible' for EHR Dysfunction

; Abraham Verghese, MD; Michael S. Blum, MD; Jessica Mega, MD, MPH


August 22, 2017

Medscape held a Medicine 3.0 town hall event on Technology, Patients, and the Art of Medicine on July 20, 2017. Following are excerpts from the panel discussion.

Eric J. Topol, MD: I wanted to get to this problem we have today of the disillusioned physician. As all of us here know, the rate of suicide among physicians is the highest ever recorded; [rates of] depression, burnout, and overall disenchantment are incredibly high . I'd like to get the panelists' sense: First, why have we hit this meter? Second, do you see things on the horizon that can titrate this?

Abraham Verghese, MD: My sense, and I do not have data to point to this, is that a lot of the dysfunction stems from that little piece of technology, the electronic medical record, given that [medicine] is a human-to-human interaction and we have someone who cannot do what they want to do because they are forced to answer a lot of inbox queries and so on. There is a very famous study by Christine Sinsky, MD,[1] showing that for every hour that you spend with the patient cumulatively, you spend 2 hours on the computer and 1 more hour of your personal time, and that is just too much.

We have not taken into account what Arlie Hochschild, a wonderful sociologist, calls emotional labor. There is a kind of work that is involved in dealing with critically ill patients and their families. It is costly. It is costly to the psyche. It is costly to the system. The notion that we can just shorten that time and fill it with somewhat meaningless electronic medical record time—first of all, it does not pay enough homage to the importance of that kind of emotional labor, and second, you are being forced to replace it with something that we view as largely meaningless.

My sense is that the current dysphoria in medicine revolves a great deal around the electronic medical record, but not solely. I think the other piece is that everything is moving much faster—so many more patients and so much more information per patient. The human organism is just stressed trying to make sure it digests all of that. We tend to be very driven people. People in medicine, by their nature, are very driven. They do not like to leave any box unchecked. That is the cumulative effect of what we are seeing: a dysphoria that has to do with technology, compulsion, and a tremendously staggering trend in the volume of things we have to handle.

Jessica Mega, MD, MPH: Three things come to mind, one we already talked about: the tsunami of electronic paperwork. That's not why anyone got into medicine. If you were to ask me, as I was filling out my medical school applications, "What is your mission?" My mission is to treat patients and change the world—not to fill out a lot of boxes.

The second thing is anything that keeps us away from that human interaction, as you noted.

The third one is that a lot of the tasks that we end up doing are not actually the optimal use of our time. One example that comes to mind is reading ECGs. I actually love reading ECGs. During my training fellowship, my advisor was Peter Yurchak, MD, who really had a long history of training generations of individuals to read ECGs.

When you come home after a full day's work, getting home around 6- or 7 o'clock, and then you have a stack [to read]... I remember I had a stack of ECGs and they were all paper. And to then sit down... I had a young child. I would spend some time with him. Luckily, he was at that age when kids like black and white, so I remember holding out a reading of the ECGs and signing off on them.

Then an interesting technology came into place that used algorithms to read some of the ECGs. Now everything was electronic. You could sort by normal and abnormal. These kinds of fixes that end up addressing real people who have to have a life both in the hospital and out of the hospital are things that are going to start to get us back to where we want to be, and that is caring for people and taking care of one another.

We have got to start putting the user in the center as we create these new technologies and get rid of a lot of the overhead.

Michael S. Blum, MD: The other thing I would add is that the difficulties and the change in physicians' lives predated EHR implementation. This is 3-5 years ago that there was this dramatic push to EHRs. Physician suicide is not a problem that started 3 years ago and burnout did not start 3 years ago.

I would trace [burnout] back 10-15 years when there was increased regulation and evaluation and management coding.

I would trace it back another 10, maybe 15, years to when there was increased regulation and evaluation and management coding; all of a sudden, the way you wrote a note was a billing document. It was no longer a brief description of how your patient was doing or what you did for your patient. It became the thing that you billed from and the thing that was going to keep you out of trouble when someone came to look at what you were doing. That was a fundamental change in how we, as physicians, took care of patients and went through our lives.

Many people trained with that and that is the only thing they know. Then, you threw the EHR on top of that. That just took a bad situation and made it horribly worse, because you had a paper process that really did not serve anyone other than the government and the billers, and then you made it not really electronic, but you put a bad system on top of it. I think that is where we have ended up.

Dr Verghese: That is true, although I think that people who have never experienced the electronic medical record before somehow managed. This is really imposed on us by federal fiat. It changed the nature of medicine. Many small practices were forced to close. They really could not afford the cost. They were forced to merge. They gave up the sort of very personal transactional nature of their practice to join a bigger corporation.

I think you're right. It's not entirely the electronic medical record, but I think it was actually a very profound stimulus. I had a moving email from a young resident who wrote to me saying, you know, I just read something you wrote about the art of medicine. I am really moved by this, but the reality is I am sitting at a computer writing to you, and I will be at this computer for the next few hours. The entirety of my work is going to be right here.

I must say that I felt a great sadness when I read that because, in a sense, we are responsible. We allowed this to happen on our watch...

How did we let this happen? Part of it is that medicine is not really all about medicine. When you spend 17% of the GDP, or whatever the figure is now, on healthcare, we're not the only ones at the table.

The reason that we have made this mistake of epic proportions with the electronic medical records is because it does one thing very well: It bills great.

Somebody in the top suite likes it, and it is just that we do not have much of a voice at the table, because it has become bigger than us. There was a time when perhaps we might have had a voice in medicine, but medicine, I think, for too long was much more concerned about its self-interest. The American Medical Association, many years ago, pioneered the first successful smear campaign to torpedo socialized medicine in the Truman era. The first successful smear campaign was a medical invention, in that sense.

I think that when we start to talk about our needs, we may have lost credibility along the way. That's my theory as to why we don't have the reins the way we probably should.

Dr Blum: I would add another piece to that. I agree, but I think that the other thing is societal change and that expectations around medicine changed dramatically over this period.

There was an interesting article 25 years ago in the New England Journal of Medicine that looked at medication errors and at combinations of medications and how many bad outcomes were coming out of that. There were a couple hundred drugs when this paper was written. It described case after case after case of bad outcomes, because of medication interactions. The end of the story in this paper was, they said, "It's amazing how few bad things happened, how infrequently they happened, and how wonderful everything is."

Fast-forward 25 years. A whole series of papers starts to come out around medication interactions and how disastrous they are. The incidence and the rates were lower than in the paper 25 years previously, but now it's a national tragedy.

Society's expectations have dramatically changed around the expectation of safety in the hospital. Medicine told society that no matter what you have, we will fix it. We will keep you alive. We will make you better, pretty much regardless of what you have. The expectation became that this would be done perfectly safely.

Then you start to see the stories about medicine killing more people than a 747 crashing every day and all of these horrible things, because we had promised what we weren't able to deliver, and the expectation became that we better deliver what we're promising. That's a lot of what drove the EHR, because the EHR was about safety. It's about billing and it's about all of those other things.

The real driver behind physicians allowing it to happen was because we were sold [EHRs] believing that there's better safety in using this technology than not using it. All of the other parts that came along with it aren't working so well.

Dr Verghese: As I sound so dismissive of the electronic medical record, I want to make sure that I acknowledge how much it's done to help us with medication errors and retrieving data, and putting [information] together, to not have to go hunt for the chart in some dusty basement somewhere.

I think that that alone won't fix it. There's a hunger and a need for a relationship that isn't going to be satisfied by more and more technology. I think what will fix healthcare will be a kind of healthcare reform that no one yet has the appetite for. The GDP keeps crawling up and I keep waiting for it to hit the magic number where it becomes unsustainable for the country to spend that much. Then, perhaps, we'll finally come to our senses.

Dr Topol: You could say we're already there, right? All the debate about Obamacare and Trumpcare—the real lesion is this, right? The financial?

Dr Verghese: I thought so years ago. It just seems like every year it's not quite there yet. The pain isn't quite harsh enough, but I'm hoping we're getting there.


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