Welcome to the CJU website » LOG IN

Free Articles


How Many Clicks Does It Take To Get To The Middle Of An EHR?

The electronic health record (EHR) is the current darling of health care reform, the “must have” item for all health care providers. Advertisements boldly announce that the EHR “...allows doctors to spend more face time with patients than on paperwork”.

In the ancient history of the paper chart (circa 2008), I would sit face to face with a patient and scan the chart. Flipping through the chart would remind me of key elements in their history. Today I speak to them indirectly over my shoulder while I stare at the computer screen clicking my way through screen after screen searching for that key page, ultimately spending less face time with the patient.

What seems to be paramount in the new world of the EHR is to collect information. Some of this is to achieve the nirvana of “meaningful use”. According to one EHR web site “...simply collecting information without addressing the human experience creates disconnection instead of connection; often leading to dissatisfaction by both the patient and provider.” I’ll click to that.

HIPAA (Health Insurance Portability and Accountability Act) creates another challenge to the efficiency of the EHR. While the need for security of the system is readily apparent, sites require that the EHR system logs out after a relatively few minutes of inactivity. On a typical 25 visit outpatient day (I admit an embarrassingly low number compared to our primary care colleagues) I have to log back in dozens of times. This repetitive activity sometimes makes me feel like I am developing OCD. A thumb swipe or proximity tag system would do much for the EHR functionality allowing instant “re-access” to the EHR. Somewhere in cyberspace I am convinced that there is some arbitrary “regulation” making this logical efficiency unthinkable. Forcing EHR users to manually type and click into the system seems to have become the de-facto norm.

According to, over 600 different EHR vendors exists with each having its own proprietary methods of maintaining data, making efficient communications across EHR systems a challenge to the goal of improving health care communication. Sadly, there exists a government proven and robust nationwide EHR system that can handle vast amounts of data. The Veterans Administration EHR system has stood the test of time. The lack of billing capability has been cited as a reason for not widely distributing the system.

Government incentives are motivating many to rapidly adopt the EHR. Perhaps too rapidly, before the bugs and inefficiencies in these new systems are worked out and the goal of enhanced productivity, cost reductions and improved patient care and safety can be achieved. The official message is that the government is not “forcing” doctors to adopt the EHR, but if doctors do not implement EHRs in their practices, Medicare will deduct 1% of payments in 2015 with the “penalty” increasing to 5% in 2019. Is there really a choice?

One highly touted feature of the EHR was to reduce prescribing errors. A recent study has demonstrated that we are not there yet with the error rate between written and electronically sent prescriptions identical at about 10%. Considering it takes about a dozen clicks to e-prescribe I can see why this might be.

Once fully implemented, the EHR will hopefully be more than the electronic file cabinet of information that it is today. We still have to rely on volumes of paper charts in storage that frequently need to be retrieved from their secret mountain location and scanned into the EHR, an unrecognized cost of transitioning to an EHR beyond the hardware and software. It will take years to fully transition away from the paper chart and work out all of the bugs in a system of this magnitude and importance. The EHR will ultimately serve the health care needs of the future if we can all survive the challenges of the implementation process.

For Mr. Owl, it took only three licks to get to the center of the Tootsie Pop. I wish I could be so lucky.

Leonard G. Gomella, MD
Thomas Jefferson University, Philadelphia PA

© The Canadian Journal of Urology™; 18(5); October 2011