The Revenge Effects of Electronic Medical Records
Alison Reiheld

In 1996, historian of science Edward Tenner published his influential book Why Things Bite Back: Technology and the Revenge of Unintended ConsequencesIt is an extended consideration of how technology comes to demand much of us even as it frees us from demands. In it, Tenner introduces a concept that has come to be important in philosophy of technology: the revenge effect. Revenge effects are in play when a technology designed to alleviate a particular burden in fact imposes that burden. As Tenner puts it, “when a safety system encourages enough additional risk-taking that it helps cause accidents, that is a revenge effect.” This is an apt description of some of the consequences of Electronic Medical Records (EMR), also sometimes referred to as Electronic Health Records (EHR).

Tenner’s examples of revenge effects include the way that increasing computerization was intended to lead to a paperless office. Instead, at least during the 80’s and 90’s, it documentably led to even more printing because of the ease of producing printed versions with each revision. As Tenner makes clear, a significant factor leading to revenge effects is humans: when “we try to take advantage of some new technology, we may discover that it induces behavior which appears to cancel out the very reason for using it.”  Now, this is simply a “may.” Tenner is by no means arguing that all technology will have such revenge effects. However, he makes compelling case that it often does.

This conceptual framework has helped me to think through an issue highlighted by those of my medical ethics students with decades of experience in medicine, nurses and others who have practiced through the transition from paper to electronic medical records. This transition was mandated in the United States by the American Recovery and Reinvestment Act, to take place no later than January 1, 2014; not all systems talk to each other and not all are created equal, nor do all institutions incorporate them into care in exactly the same way. In a recent discussion by some of my students, several nurses with such experience noted that they seem to spend as much time maintaining the medical record as they do with patients, and that they perceive the EMR as taking them away from their patients.

One might reply, but documenting within the EMR helps your colleagues better serve the patients later on, and helps to preserve detail the mind might forget. Indeed, the merits of EMRs as described by include just such issues:

  • Providing accurate, up-to-date, and complete information about patients at the point of care
  • Enabling quick access to patient records for more coordinated, efficient care
  • Securely sharing electronic information with patients and other clinicians
  • Helping providers more effectively diagnose patients, reduce medical errors, and provide safer care
  • Improving patient and provider interaction and communication, as well as health care convenience
  • Enabling safer, more reliable prescribing
  • Helping promote legible, complete documentation and accurate, streamlined coding and billing
  • Enhancing privacy and security of patient data
  • Helping providers improve productivity and work-life balance
  • Enabling providers to improve efficiency and meet their business goals
  • Reducing costs through decreased paperwork, improved safety, reduced duplication of testing, and improved health.
  • Providing accurate, up-to-date, and complete information about patients at the point of care

Yet to hear the experienced practitioners with whom I relate tell it, the EMR has a kind of revenge effect: while it may in some ways help improve patient care, it also reduces the amount of time that providers spend with patients and changes how they listen to patients and how they ask questions of patients (one needs to ask the questions that will provide data to fill in the fields; if the fields are not well-designed for providing health care, this becomes a serious problem).

I think that part of what is happening is that the version of the patient in the EMR becomes the one that must be maintained, distracting from the actual patient. Tenner hints that such things can happen when he points out that technologies generate special classes of persons dedicated to servicing the technology and that, when these persons forget what the purpose of the technology is, the technology becomes their purpose. The nurses in my courses are reporting something very like this: they feel the pull and indeed the institutional incentives to service the EMR instead of serving the patient.

Now, let’s take this together with a recent article in WBUR’s CommonHealth series, “Death By A Thousand Clicks: Leading Boston Doctors Decry Electronic Medical Records.” The article begins:

It happens every day, in exam rooms across the country, something that would have been unthinkable 20 years ago: Doctors and nurses turn away from their patients and focus their attention elsewhere — on their computer screens.

By the time the doctor can finally turn back to her patient, she will have spent close to half of the appointment serving not the needs of her patient, but of the electronic medical record.

Electronic medical records, or EMRs, were supposed to improve the quality, safety and efficiency of health care, and provide instant access to vital patient information.

Instead, EMRs have become the bane of doctors and nurses everywhere. They are the medical equivalent of texting while driving, sucking the soul out of the practice of medicine while failing to improve care.

This framing of the issue fits the revenge effect most well, and the fit becomes more precise as the article goes on.

Instead of making this easier, most EMRs create extra work. A lot of extra work, thanks to endless prompts with multiple choice answers that hardly ever fit the facts and that demand click after click to get anything done.

Want to order a simple test? That requires getting through multiple prompts. Need to write a prescription — an exercise that used to take less than 15 seconds? Another set of clicks.

Typing, filing, mailing results and placing referrals all used to be done by assistants. Now, EMRs put that burden on clinicians, and we must do it during office visits, or “encounters,” as EMRs call them. And when the wrong button is clicked, the wrong test or drug is ordered, or it does not go through at all, delaying medical care.

It’s death by a thousand clicks, and it happens every day.

We are frustrated by EMRs because they pull us away from our patients. We are driven mad by the fact that EMRs in different locations do not talk to each other. And we think it’s just wrong that much of the EMR’s busywork is about optimizing billing for the hospital.

Are we doomed to live with this revenge effect, to suffer through ill health with it?  Tenner’s own work isn’t just a diagnosis of a problem of technology, but also carries with it a kind of treatment recommendation: “If we learn from revenge effects we will not be led to renounce technology, but we will instead refine it: watching for unforeseen problems, managing what we know are limited strengths, applying no less but also no more than is really needed.”

EMRs that drive health care providers to serve the EMR instead of the patient are not well-designed for the primary goal of health care. EMRs that drive health care providers to serve institutional imperatives such as maximizing billing over and above patient care compound the problems of a system that already embeds health care providers within sometimes-conflicting priorities from different stakeholders. What is in the best interests of the hospital’s bottom line, and of the insurers who pay the bills, is not always what is in the best interests of the patient. And yet patients cannot get care if hospitals cannot get reimbursed for services sufficiently to keep the lights on, repair and replace equipment, and pay staff. The ethical question, it seems to me, is this: which imperatives are given priority in the design of technological solutions? And to borrow Tenner’s language, how can we refine EMRs, manage their limited strengths, and apply no less but no more than is really needed?


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The Revenge Effects of Electronic Medical Records — 2 Comments

  1. I just had an experience typical of what you are describing. Having called my pediatrician during off hours and talked with the referral nurse at a nearby excellent children’s hospital about half an hour away, I followed her recommendation and took my feverish headachy teen to the emergency room. Initially service was great, and the nurses were kind, personable, and encouraging. But once the doc came in and asked a few questions, she turned to the computer and typed, typed, typed, maybe for 10-15 whole minutes, no longer speaking to us. The one suggestion I made, about a particular blood test that relative who was a pediatrician had suggested, was apparently forgotten in the flurry of typing. I had to ask three times to get the doc to pay attention. In the end, the illness didn’t seem to require all that much typing, either. How much can you say about a headache and a fever that was initially unresponsive to ibuprofen, but came down with a combination of that drug and acetominophen? In the end we went home with no prescription, no diagnosis, and a simple common-sense, routine set of recommendations, but the computer file was probably three pages longer, and the doc had spent a lot of time that could have been spent on patients.

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