Everybody hates their EHR

Recently, I was at a meeting of behavioral health executives when someone casually remarked, “Well, everybody hates their EHR.” There were a few grins and snickers, and some head nodding, but no real effort to refute the sentiment.

I suppose that it is certainly true that everybody dislikes at least some aspects of their electronic health record (EHR) system, but perhaps hate is too strong a word.

Personally I’ve been very disappointed with the industry as a whole. I was convinced that by this late date, such systems would be tremendously more functional and reliable than they are. I seriously thought that by now, we would be closer to the “Star Trek” level of performance, where I could converse with my computer about my next patient, whom it would already know intimately from scanning all of the available private records and public documents.

It would not only know the complete physical, medical and legal histories, it would also analyze how depressed patients seemed to be based on their latest Facebook posts and Google searches. It would provide me with some helpful evidence-based suggestions for the upcoming session, as it automatically and seamlessly handled prior authorizations. Simultaneously, it would electronically generate and transmit an appropriate treatment plan and service code to the patient’s insurance company, guaranteed to maximize my reimbursement. 

I’m also surprised that the competition continues to grow, with new IT vendors appearing constantly. I assumed there would be a massive consolidation of the industry with only a handful of surviving vendors. Of course, the Affordable Care Act, parity and Meaningful Use inducements, as well as penalties, have caused venture capitalists to salivate over the prospect of hitting the EHR jackpot.

Latecomers to the EHR trend

Acquiring and implementing an EHR can mirror the courtship process. Like confirmed bachelors, behavioral health organizations and psychiatry were latecomers to the EHR dance. But everyone else had made a commitment, and the clock seemed to be ticking. Suddenly there were a number of suitors on the scene for behavioral health organizations to consider, and the demo process was like going on a blind date. Everyone was on their best behavior, good qualities were emphasized and potential problems were glossed over and minimized.

Once a selection was made, the decision was reinforced by a honeymoon period, when things looked too good to be true. When the honeymoon was finally over and it was apparent that real life differs significantly from the demo, the difficulties began in earnest.

In most cases, organizations and vendors put in a lot of effort to try to make the relationship work. Even if it is soon apparent that the relationship is doomed, many organizations get stuck in denial and continue to flounder in order to avoid admitting that a mistake had been made.

Final breakup

I’ve wondered what factors lead to a final breakup. John Gottman, professor emeritus of psychology at the University of Washington, and renowned authority on human relationships, theorized in 1994 that there are four destructive emotional reactions that are the best predictors of divorce:

1. Constant criticism;
2. Defensiveness;
3. Stonewalling; and
4. Contempt.

Of these, Gottman considers contempt to be the most important predictor. Whether or not this applies to the EHR vendor relationship is arguable, but when both parties start blaming each other, the vendor stops being responsive, and all communication is tinged with contempt, can a parting of the ways be far behind?

EHRs have been around long enough now that many organizations are already on their second or third EHR relationship. While most of these end amicably, some wind up in messy court proceedings and result in various kinds of settlements and non-disclosure agreements.

If only you could really know what you’re getting into in advance. Recently I have been looking at sites where people can leave comments about various EHR vendors and their software products—a sort of “TripAdvisor” for EHRs. Like most rating sites, you have to weed through the comments with a grain of salt, especially for the extreme ratings at either end of the spectrum. Typical of the comments I read was one entitled “Terrible [EHR].” It said:

“I’ve heard people say that no likes their [EHR]. Not true. I’ve worked in many systems with decent [EHRs] that I grew to love. My loathing for [this product] increases every day. It is slow. The server is slow. It takes many, many clicks to do basic functions.”

I believe that satisfaction with specific EHR software has a lot to with perceived needs, flexibility in workarounds, and ultimately the nature of the relationship with the vendor. I’ve known three provider organizations that were using exactly the same software product, but it seemed to function differently in each environment. One organization loved it, one hated it, and the third was in the middle. I suppose EHRs can be a lot like a Rorschach inkblot; people tend to project what they want into them.