healthy4u: RAND

"Doctors' Dissatisfaction With EHRs May Be Early Warning of Deeper Quality Problems" - And Some Common Sense on EHRs and Clinician Distraction and Time-Wasting

The following article was published regarding physician dissatisfaction with EHRs, referencing a RAND study on EHRs commissioned by the American Medical Association: <a href="http://cnsnews.com/news/article/susan-jones/doctors-dissatisfaction-ehrs-may-be-early-warning-deeper-quality-problems-0">http://cnsnews.com/news/article/susan-jones/doctors-dissatisfaction-ehrs-may-be-early-warning-deeper-quality-problems-0</a> <blockquote class="tr_bq">Doctors' Dissatisfaction With EHRs May Be 'Early Warning of Deeper Quality Problems' October 18, 2013 - 10:17 AM By Susan Jones</blockquote><blockquote> Electronic health records (EHRs) are a source of frustration to many physicians, says a new study conducted by the RAND corporation and commissioned by the American Medical Association. Electronic health records are a source of frustration to many physicians, according to a study on physician satisfaction sponsored by the American Medical Association. The findings could serve as an "early warning of deeper quality problems developing in the health care system," the AMA said. The <a href="http://www.rand.org/pubs/research_reports/RR439.html" target="_blank">study</a>, conducted for AMA by the RAND Corporation, found that doctors who perceived themselves or their practices as providing high-quality care reported better professional satisfaction. Electronic health records (EHRs) were a source of both promise and frustration, the Rand study found. Although physicians tend to like the concept of EHRs, those surveyed said that current EHR technology interferes with face-to-face discussions with patients; requires physicians to spend too much time performing clerical work; and degrades the accuracy of medical records by encouraging template-generated doctors' notes.</blockquote> I believe the title should have been "Doctors' Dissatisfaction With EHRs Is A Warning of Deeper Quality Problems".  The academic-style fudge words "may be" and "early" are disposable. <blockquote class="tr_bq">"Physicians [i.e., all of them - ed.] believe in the benefits of electronic health records, and most do not want to go back to paper charts," said Dr. Mark Friedberg, the study's lead author and a RAND scientist. "But at the same time, they report that electronic systems are deeply problematic in several ways. Physicians are frustrated by systems that force them to do clerical work or distract them from paying close attention to their patients." </blockquote> Dr. Friedberg commits a faux pax symptomatic of an amateur scientist (or of a politician).  That is, making a statement that seems to speak for all physicians, and then for "most" physicians.  Clearly he didn't interview "most" physicians.  I know many who see the EHR as bureaucratic invasion of little clinical utility, and would gladly dump the poorly-engineered EHRs foisted on them that "interfere with face-to-face discussions with patients; require physicians to spend too much time performing clerical work; and degrade the accuracy of medical records" for good old-fashioned paper, supplemented perhaps with document imaging systems that make the notes available anywhere, anytime. <blockquote>... Health and Human Services Secretary Kathleen Sebelius has said that EHRs will lead to "more coordination of patient care, reduced medical errors, elimination of duplicate screenings and tests, and greater patient engagement in their own care."</blockquote> Sebelius is parroting others; there is little or no robust evidence supporting such a grandiose assertion (or, typical of today's politicians, she's simply lying; the reader can decide which). For 2014, some commonsense observations and recommendations on EHRs: 1) The pioneers in the 1950's and 1960's developed systems and experimented with their use in an environment far freer of the bureaucratic need for massive amounts of ultra-taxonomized data than today, where visits were not forced to be time-limited for "productivity", and where clinical notes were pithy and terse, as they were for patient care, not bureaucratic satiation.  The pioneers likely could not have conceived of what clinicians are being called on to enter manually, in 2014.  (I was taught Medical Informatics by some of those pioneers.) 2) The pioneers never intended to add uncompensated burdens onto clinicians.  They intended to help clinicians practice medicine more smoothly, not in a time-starved and robotic, slave-to-the-machine fashion. 3) The health IT industry and its health IT designers, and the largely medically-incompetent data processing/merchant computing personnel in hospital IT departments, appear to have not cared less about these real-world HIT issues - as evidenced by their products - until the pressure was put on by users, resulting in studies of IT safety by the Institute of Medicine (<a href="http://hcrenewal.blogspot.com/2010/10/cart-before-horse-again-institute-of.html">http://hcrenewal.blogspot.com/2010/10/cart-before-horse-again-institute-of.html</a>) and of IT usability by NIST (<a href="http://hcrenewal.blogspot.com/2010/12/nist-provides-healthcare-it-industry.html">http://hcrenewal.blogspot.com/2010/12/nist-provides-healthcare-it-industry.html</a>) in just the past few years. With these factors in mind: <blockquote class="tr_bq">... AMA noted that some medical practices are experimenting with ways to reduce physician frustration by hiring additional staff members to perform many of the tasks involved in using electronic records, such as data entry. </blockquote> Actually, the use of clinicians as computer data-entry clerks was the real experiment, an experiment whose failure is becoming increasingly apparent.  The "experiments" with hiring of data entry clerks should be made official healthcare policy as follows:  1)  Physicians and nurses should be relieved of the burden of data entry into computer interfaces (as opposed to merely viewing) nearly entirely.  Data entry cannot be done under the real-world conditions of patient care in 2014, for most specialties, without compromising the focus on patient care (let alone clinician morale).   2) Considering the hundreds of millions per organizations spent on theses systems, a pool of data entry clerical staff can well be afforded, hired and trained to transcribe data into computers from clinicians' paper notes, using specialized forms where necessary.   3) Those same paper notes can be rapidly imaged into a document management system (e.g., Documentum, <a href="http://www.emc.com/enterprise-content-management/documentum-platform.htm">http://www.emc.com/enterprise-content-management/documentum-platform.htm</a>; I managed a pharmaceutical department of ~55 people and a $13 million budget using such a system) and made available before transcription.  The note images can also serve as a supplement to data viewing screens in the EHR, which at least in 2014 are themselves poorly engineered from the perspective of optimal presentation of information. 4) The workflows for such arrangement are known to me; I created such an environment in a busy invasive cardiology department, a critical care area performing more than 6000 procedures/year and responsible for 25% of the organization's revenues - fortunately having been able to neutralize and marginalize an IT department seemingly hellbent, perhaps through ignorance, on sabotaging the effort.  See "Essential Value of Medical Informatics Expertise in High-Risk Areas: an Invasive Cardiology Example" at <a href="http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story">http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story</a>.  The offloading of data entry by clinicians into the computer, and the use of special paper forms for the clinicians, worked exceptionally well in allowing the clinicians to focus on what really matters most - patient care. 5) If healthcare organizations insist on direct clinician data entry, then clinicians' time doing so should be fairly compensated.  Lawyers generally earn from $250/hr and up for profession-related clerical work, like creating legal briefs and letters.  I think physicians should do at least as well.  (If readers believe clinicians should take on this considerable burden and not be fairly compensated, I'd like to hear why.) 6) If healthcare organization leaders truly believe the EHR hyper-enthusiasts, the expense of the clericals will be far offset by the "billions and billions" saved by these systems.        a) If they don't believe the EHR hyper-enthusiasts, they should be far more skeptical of implementing such systems and imposing the mission-robbing burdens on their clinicians in the first place. 7) These measures will free industry resources for doing what really matters most in clinical care, namely, health IT robustness (freedom from error, security, etc.) and optimal presentation of information customized for the needs of the many different clinical specialties and subspecialties. -- SS

"Doctors' Dissatisfaction With EHRs May Be Early Warning of Deeper Quality Problems" - And Some Common Sense on EHRs and Clinician Distraction and Time-Wasting

The following article was published regarding physician dissatisfaction with EHRs, referencing a RAND study on EHRs commissioned by the Amer...

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Comments by Dr. Reed Gelzer on RAND Health IT Report and Op-Ed in Pittsburgh Post Gazette

<div class="ajy">A 2005 RAND Corporation report predicted that health IT could save the U.S. healthcare system $81 billion a year. Since then, however, annual health spending has increased by almost a trillion dollars, and quality and efficiency have not budged much, even with an increase in health IT adoption, according to researchers Arthur L. Kellerman and Spencer S. Jones in a Jan. 2013 <a href="http://content.healthaffairs.org/content/32/1/63.abstract?sid=1667406b-f4db-408e-8226-b472f25c225c">RAND study</a> published in Health Affairs.  Kellermann is chair in policy analysis, and Spencer Jones is an information scientist..</div> A new Op-Ed by Kellerman and Jones entitled "<a href="http://www.post-gazette.com/stories/opinion/perspectives/it-in-health-care-is-mia-677680/" target="_blank">IT in health care is MIA</a>" appeared on Mar. 3, 2013 in the Pittsburgh Post-Gazette. They wrote: <blockquote class="tr_bq">Because information technology has so quickly transformed people's daily lives, we tend to forget how much things have changed from the not-so-distant past. Today, millions of people around the world regularly shop online; download entire movies, books and other media onto wireless devices; bank at ATMs wherever they choose; and self-book travel while checking themselves in at airports electronically. But there is one sector of our lives where adoption of information technology has lagged conspicuously: health care. Some parts of the world are doing better than others in this respect. Researchers from the Commonwealth Fund recently reported that some high-income countries, including the United Kingdom, Australia and New Zealand, have made great strides in the use of electronic medical records among primary-care physicians. Indeed, in those countries, the practice is now nearly universal. Yet some other high-income countries, such as the United States and Canada, are not keeping up.</blockquote> Of course, the U.K. recently suffered a rather severe blow, <a href="http://hcrenewal.blogspot.com/2011/09/npfit-programme-going-pffft.html" target="_blank">on the order of 13 billion Pounds' worth</a>, to its National Programme for Health IT in the NHS (NPfIT).  Australia is not exactly an "Emerald City" in terms of health IT, either, as can be seen from numerous links at the blog of Sydneysider Dr. David More, <a href="http://aushealthit.blogspot.com/" target="_blank">Australian Health Information Technology</a>. The RAND authors throw in some boilerplate grandiose predictions of certainty about health IT, which seems to have become a common phenomenon in newspapers and even scientific publications of late: <blockquote class="tr_bq"> ... The U.S. government is trying to help. In 2009, Congress passed the Health Information Technology for Economic and Clinical Health Act. HITECH has undeniably accelerated IT adoption, yet the problems of usability and interoperability persist. ... The sky is the limit when it comes to potential gains from health IT ... The payoff will be worth it. Indeed, as with the adoption of IT elsewhere, we may soon wonder how health care could have been delivered any other way.</blockquote> Read the whole Op-Ed at the Gazette. (My mother, an unwitting expert with significant experience on health IT adverse effects, is unavailable for comment, as she is dead due to a HIT-related accident.) However, another expert is available: Reed D. Gelzer, MD, MPH is an EHR/HIT systems and policy analyst for private and Federal agency clients, primarily in program integrity and clinical quality support.  In clinical practice for 11 years before transitioning into health IT, he also co-chairs the HL7 Records Management and Evidentiary Support (RMES) Workgroup.  He served US Navy Medicine’s Data Quality Office, various private insurers, as well as three years on CCHIT workgroups.  He was the Prevention Workgroup Chair for the 2007 ONC study on mitigation of EHR mediated waste fraud and abuse. I find his opinions posted at the Gazette comment board of interest.  Some of the themes are very familiar. His comments are reproduced here with just a few comments of mine interjected: <blockquote class="tr_bq">Good afternoon Mr. Kellerman and Mr. Jones, Thank you for the recitation of the arguments for HIT. I am particularly pleased that you note that a principle block to advancing HIT in the US is the fact that systems are not standardized. One of the reasons many of our Industrialized Nation peers are far ahead of us is that they, in effect, standardized their systems by having one customer, a government entity operating health care. I assume you are not proposing that. If not then what, in the absence of regulation, will achieve your proper objective of standardizing HIT? Well, we could simply let the market decide among the current non-standardized, non-regulated systems by accepting the accompanying burdens of cost, patient harms, and highly variable to unreliable data, and so on, in a nationwide experiment using the citizens of the U.S. as the test subjects [without informed consent or opt-out provisions, I might add - ed.] . A free market though would necessitate an absence of market-corrupting subsidies and transparency on comparing products, so that we can all equally hear when systems don't work as expected or cause problems for users, clinics, hospitals, and patients. No subsidies, no advantage to legacy vendors, and publicly available information about system problems, defects, and harms for a free market in HIT seems as unlikely as a single payer, government run system in the U.S., so what other options do we have? We could say, we as a country want to improve this faulty and expensive industry, and so that is what we will hold providers responsible for. Doctors, hospitals, nurses, clinics, everybody -You have a duty to achieve better.  IT is a means, not the end. Purchase and apply the tools you decide you need to fix the problems you see. If you find you cannot do it, then close your doors and go to work for someone who can. In support of this, as we do with drugs, we do not expect doctors, hospitals, nurses, clinics to independently research what is safe, what is usable in medications, in lab and imaging equipment and medical devices. We make sure that the tools available are safe, reliable, and do what they are intended to do. We do not de-regulate pharmaceuticals to speed innovation [due to the common claim by HIT hyper-enthusiasts that regulation would harm IT innovation, one might surmise they presumably would support pharma deregulation as well - ed.], we regulate minimum requirements of safety and efficacy so that such tools of medicine can be delivered to the bedside without the clinicians having to spend hours worrying about whether they're even fit for use. Improving the safety, value, and effectiveness of patient care is not dependent on HIT.  Fit HIT is an indispensable enabler of KNOWING that we are doing our best and KNOWING where we are falling short and where improvements can best be directed. Meanwhile, there can be no doubt that we will increasingly regulate HIT simply because it is the only way we can ever have non-anecdotal and systematic reporting on what HIT actually does (or doesn't do) for benefiting patients. Otherwise we will continue to be stuck where we are now: between a defective government policy that has bought the vision and promise (and there's a "no return" policy) without evidence, and the accumulating evidence of the difficulty, complexity, costs, and harms rendered by the current national experiment. [This evidence is often ignored or denied by the hyper-enthusiasts - ed.] Again, thank you for reiterating the necessity of standardization. This should progressively elevate the attention to the vast library of HIT standards existent (and still evolving) that remain unused by vendors. Not just vendors, though. Standards also remain unused by doctors, nurses, hospitals, and clinics (and their organizational advocates) who still, amazingly do little, if any due diligence on the fitness of HIT to their use as patient care tools and records thereof.  [This is known as "negligence" and perhaps "gross negligence" - ed.]  Given that Meaningful Use has lowered the Certification bar so much lower than it was in 2009 and since subsidies have made it a Sellers market (and a race to avoid penalties) it is hard to imagine how the geometric progression of risk of non-standardized [systems] untested for safety, usability, or fitness will not assure pain and suffering of many kinds for years to come. I look to you RAND to project your dynamic model for how Standardization will be achieved. In the meantime, of course this means that, among other things, they are not standardized for fitness in use for patient care. RDGelzer, MD, MPH.</blockquote> These are good thoughts. I repeat my warnings that until sanity and caution is restored to the health IT sector (or started, as it may never have  existed) it is not likely that "we may soon wonder how health care could have been delivered any other way." -- SS

Comments by Dr. Reed Gelzer on RAND Health IT Report and Op-Ed in Pittsburgh Post Gazette

A 2005 RAND Corporation report predicted that health IT could save the U.S. healthcare system $81 billion a year. Since then, however, ann...

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Study highlights 'lurking question' of measuring EHR effectiveness: The science in Medical Informatics is dead

<div dir="ltr" style="font-family:arial;"> </div> <div dir="ltr" style="font-family:arial;"> </div> <div dir="ltr" style="font-family:arial;">The science in Medical Informatics is dead. I'm not going to even use academic fabric softener in my assertion, e.g., "may be", "appears to be", or "is it?" (as a question) dead. It's dead. When HIT experts recommend changing the study goalposts when existing studies don't give results they'd like to see, rather than first and foremost critically and rigorously examining why we're seeing unexpected results, science is dead.<a href="https://exchangeweb.drexel.edu/owa/redir.aspx?C=213cd2a382634858bbe315d958ccc5a4&URL=http%3a%2f%2fwww.healthcareitnews.com%2fnews%2fstudy-highlights-lurking-question-measuring-ehr-effectiveness" target="_blank"> </a> </div> <blockquote style="margin-right: 0px;font-family:arial;" dir="ltr"> <div dir="ltr"> </div> <div dir="ltr"> </div> <div dir="ltr"> <a href="http://www.healthcareitnews.com/news/study-highlights-lurking-question-measuring-ehr-effectiveness"> </a><a href="http://www.healthcareitnews.com/news/study-highlights-lurking-question-measuring-ehr-effectiveness"></a><a target="_blank"></a><a href="http://www.healthcareitnews.com/news/study-highlights-lurking-question-measuring-ehr-effectiveness">Study highlights 'lurking question' of measuring EHR effectiveness</a> December 22, 2010 | Molly Merrill, Associate Editor WASHINGTON – Hospitals' use of electronic health records has had just a limited effect on improving the quality of medical care nationwide, according to a study by the nonprofit RAND Corporation. The study, published online by the American Journal of Managed Care, is part of a growing body of evidence suggesting that new methods should be developed to measure the impact of health information technology on the quality of hospital care. [In other words, we're not getting the results we thought and hoped we'd get with "Clinical IT 1.0", so let's alter the study methodologies and endpoints --- rather than using the results we have to identify the causes and improve the technology to see if we can do better with "Clinical IT 2.0." Further, it's not as if there's no other data on why health IT might not <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=2009">work as hoped</a> - ed.] Most of the current knowledge about the relationship between health IT and quality comes from a few hospitals that may not be representative, such as large teaching hospitals or medical centers that were among the first to adopt electronic health records. [This implies "other" "representative" hospitals are either not doing it right, or the technology is ill suited for them and may never work. Which is it? We really need to know before we proceed with hundreds of billions more in this "Grand Experiment" - ed.] The RAND study is one of the first to look at a broad set of hospitals to examine the impact that adopting electronic health records has had on the quality of care. The research included 2,021 hospitals – about half the non-federal acute care hospitals nationally. Researchers determined whether each hospital had EHRs and then examined performance across 17 measures of quality for three common illnesses – heart failure, heart attack and pneumonia. The period studied spanned from 2003 to 2007. The number of hospitals using either a basic or advanced electronic health records rose sharply during the period, from 24 percent in 2003 to nearly 38 percent in 2006. [How many billions of dollars diverted from patient care needs does that represent? - ed.] Researchers found that the quality of care provided for the three illnesses generally improved among all types of hospitals studied from 2004 to 2007. The largest increase in quality was seen among patients treated for heart failure at hospitals that maintained basic electronic health records throughout the study period. However, quality scores improved no faster at hospitals that had newly adopted a basic electronic health record than in hospitals that did not adopt the technology. [In other words, the improvements or lack thereof had little to do with electronic vs. paper record keeping - ed.] In addition, at hospitals with newly adopted advanced electronic health records, quality scores for heart attack and heart failure improved significantly less than at hospitals that did not have electronic health records. [In other words, the clinical IT was probably impairing doctors compared to simpler paper methods and good HIM personnel - ed.] EHRs had no impact on the quality of care for patients treated for pneumonia. Researchers say the mixed results may be attributable to the complex nature of healthcare. [That is likely true, but maybe the mixed results are also -- and even more likely in major part -- due to poorly designed and/or poorly implemented IT - ed.] Focusing attention on adopting EHRs may divert staff from focusing on other quality improvement efforts. [That speaks to poor EHR overkill, poor usability, unfitness for purpose, and other issues that may or may not be remediable in short or even long term - ed.] In addition, performance on existing hospital quality measures may be reaching a ceiling where further improvements in quality are unlikely. [That speaks to a low ROI or even negative for the hundreds of billions of dollars being diverted to the IT sector - ed.] "The lurking question has been whether we are examining the right measures to truly test the effectiveness of health information technology," said Spencer S. Jones, the study's lead author and an information scientist at RAND. "Our existing tools are probably not the ones we need going forward to adequately track the nation's investment in health information technology." ["Probably" not the ones we need? How can the authors know this? This is not science, it is speculation. Further, I'd say the scientific imperative before we design "the right measures" to "truly" test the effectiveness of HIT is to understand why the measures we're using now are not showing the desired results, because perhaps they are perfectly adequate and are revealing crucial flaws, overestimations and false assumptions that need to be dealt with, now, not after another round of billions is spent - ed.] New performance measures that focus on areas where EHRs are expected to improve care should be developed and tested, according to researchers. [In pharma clinical trials, this is akin to what is known as "changing the study methodologies and endpoints" - a form of manipulating clinical research, usually with the true ultimate endpoint of money - ed.] For example, EHRs are expected to lower the risk of adverse drug interactions, but existing quality measures do not examine the issue. [I believe the studies that have been done of CPOE have not been consistently supportive, and in fact show CPOE might create new med errors - ed.] "With the federal government making such a large investment in this technology, we need to develop a new set of quality measures that can be used to establish the impact of electronic health records on quality," Jones said. [This is truly putting the cart before the horse <a href="http://hcrenewal.blogspot.com/2010/10/cart-before-horse-again-institute-of.html">as I wrote here</a>. The studies showing the benefit should have long preceded the "large investments" that were decided upon - ed.] Support for the study was provided by RAND COMPARE (Comprehensive Assessment of Reform Efforts). RAND developed COMPARE to provide objective facts and analysis to inform the dialogue about health policy options. COMPARE is funded by a consortium of individuals, corporations, corporate foundations, private foundations and health system stakeholders. Other authors of the study are John L. Adams, Eric C. Schneider, Jeanne S. Ringel and Elizabeth A. McGlynn.</div></blockquote> <blockquote style="margin-right: 0px;font-family:arial;" dir="ltr"> <div dir="ltr"> </div> <div dir="ltr"> </div> <div dir="ltr"> </div> <div dir="ltr"> </div> <div dir="ltr"> </div> <div dir="ltr"> </div> <div dir="ltr"> </div> <div dir="ltr"> </div> <div dir="ltr"> </div> <div dir="ltr"> </div> <div dir="ltr"> </div> <div dir="ltr"> </div> <div dir="ltr"> </div> <div dir="ltr"> </div> </blockquote> <div dir="ltr" style="font-family:arial;"> </div> <div dir="ltr" style="font-family:arial;"> </div> <div dir="ltr" style="font-family:arial;"> The overarching assumption is that the metrics are wrong, not the quality and fitness for purpose of the technology, the 'wrongness' of which is painfully obvious from the aforementioned other literature, e.g., <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/">link</a>, <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=2009">link</a>, <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=other">link</a>, and the many posts at this blog referring to other literature. Are the authors unaware, one might ask? I know they are not. (Or - blinded? That is, could there be external pressures affecting the thought processes? The arguments might not unreasonably be construed to be skewed from that perspective.) Recognizing the atrocious user experience and mission hostile nature of the technology (<a href="http://www.tinyurl.com/hostileuserexper">link</a>), how disruptive it is (<a href="http://hcrenewal.blogspot.com/2005/03/upenn-not-what-doctor-ordered.html">link</a>, <a href="http://hcrenewal.blogspot.com/2010/01/honest-physician-survey-on-ehrs.html">link</a>), how <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=clinical%20computing%20problems%20in%20ICU">poorly implemented it is often by domain amateurs</a> to support <a href="http://hcrenewal.blogspot.com/2010/12/inpatient-or-outpatient-battle-to.html">financial battles of the payers</a>, not <a href="http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12572">cognitive processes of clinicians</a>, I am amazed there's any signs of improvement at all, not outright deterioration. (That there is not outright deterioration of care displays if anything the results of the hard mental labor and ingenuity of clinicians to work around the technology's deficits.) I note that the last time RAND looked at such matters there were problems with pro-health IT bias, among other issues (see my Feb. 2009 post "<a href="http://hcrenewal.blogspot.com/2009/02/heartland-institute-research-commentary.html">Heartland Institute Research & Commentary: Health Information Technology</a>"). Carl Sagan wrote that science is a candle in the dark in a demon haunted world. It seems the demons are winning. -- SS </div>

Study highlights 'lurking question' of measuring EHR effectiveness: The science in Medical Informatics is dead

The science in Medical Informatics is dead. I'm not going to even use academic fabric softener in my assertion, e.g., "may...

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