Our Hospital’s New Software Frets About My ‘Deficiencies’

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We had been waiting for this day for years — the day our hospital in San Francisco would shed its antiquated electronic health records system in favor of a more modern alternative called Epic, which has been, or will soon be, adopted by many of the nation’s top medical centers.

Our hospital was full of strangers in turquoise T-shirts, called Epic Superusers, who provided “at the elbow support” for the staff, there to usher in the “death of the legacy system” (as the administrators’ emails put it) and the birth of a new, well, epoch.

But on a recent Monday morning when I logged into so-called Epic Hyperspace for the first time, I was greeted with a pop-up box and an urgent message: “You currently have deficiencies that are either delinquent or will become delinquent within one week. Please complete at your earliest convenience.”

I blinked. The words on my monitor were thick and black on a background of rich mustard yellow. On the left side of the message was an exclamation point inside a circle. Today was my first day using Epic. Had I already done something wrong?

I looked around. There were no turquoise people in sight — our workroom was cloistered in an older building, a long walk from the Superusers.

“You currently have deficiencies.” The words seemed harsh and punitive, and brought me back to middle school: The student dean, reading my name aloud at assembly from a list of students “in trouble” — in my case, for having hidden my crush’s backpack behind a wall in an ill-conceived attempt at flirting.

My English teacher, giving me detention — the only one of my life — when the hem of my shirt inched above my waistband as I reached for a high shelf. My mother, glaring at me in the car when I realized I had left my Samsung flip phone under my seat at the theater.

As a child, I wanted to be good. I wanted to be safe. I wanted to be loved. As an adult, this message was making me feel bad.

I have friends who work at Facebook, writing prompts, reminders, buttons. They talk about voice; they want Facebook to make its users feel a certain way. I understand this. Facebook’s voice, at times, can make me feel cared for, with joyful birthday reminders, old photos resurrected with messages of nostalgia, and words of condolences when a Friend has died.

The breezy, casual voice of JetBlue (“Feeling fly today?”) calms my nerves at 35,000 feet. The fun, cheerful voice of Rent the Runway (“Inspiration for your next shipment!”) makes me feel as if I’m sipping wine at a women’s clothing swap.

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My hospital’s “legacy” electronic health record system was too disjointed to have a singular personality. Throughout the day, one had to operate many software programs at a time, toggling between screens and tolerating maddening lags. Using it felt less like having a conversation with a helpful colleague and more like standing in a hellish echo chamber of dissonant voices. From the ’80s.

Hence the hospital’s decision to switch to Epic, commonly viewed as the least imperfect of several imperfect electronic health record systems on the market.

As of 2018, all 20 of U.S. News’s “top rated hospitals” were using Epic or had signed contracts to do so. It’s a single, centralized system, and its ubiquitousness makes it easier for doctors to see health care data from other institutions. Its graphics feel modern. It’s customizable.

But Epic has downsides. Many physicians have written about its overwhelming complexity, with a dashboard — encrusted with scores of buttons, switches, lights and levers — that feels like the cockpit of an airplane.

There are the unintelligible medical notes, filled with ragged vines of superfluous, robot-generated text. And Epic makes abrupt requests, mid-documentation, to “assign” patients diagnoses from a list of highly specific options. “Walked into lamppost, subsequent encounter.” “Headache associated with sexual activity, initial encounter.”

It’s an ask that can feel premature, granular and intrusive, especially when symptoms are evolving and clinical reasoning is in flux.

But few have written about the product’s voice. Spot an incorrect diagnosis on a patient’s list of medical problems? Good luck deleting it. Much easier to “resolve” it — a word choice that suggests an expectation of unmitigated success, as if Epic were your helicopter parent.

Checking in on a beloved patient who was hospitalized? Enter his chart and an accusatory pop-up may appear: “Deceased Patient Warning: You are entering the medical record of a deceased patient. Are you sure you want to proceed?” This can be a jarring way to hear the news. But Epic offers no condolences, no empathy, no acknowledgment that doctors, too, have beating hearts.

Who is Epic? I try to imagine. Perhaps a clean-shaven man who wears square-toed shoes and ill-fitting business suits. He follows the stock market. He uses a PC. He watches crime dramas. He never bends the rules. He lives in a condominium and serves on the board of directors. He rolls his shirts into tubes and arranges them by color in his drawers.

When you bring cookies to work, he politely declines because he is on a keto diet. He sails.

And he doesn’t know his audience.

Medicine, with its academic hurdles and rigid professional hierarchy, tends to attract people like me, motivated by compassion and a love of medical science, but also a desire for external validation. Doctors love ivory towers, honor societies and prestigious awards. But we’re also cruel to ourselves and feel a deep sense of anguish — even failure — when we make mistakes or are admonished by superiors.

Some have asked why doctors haven’t organized, why we haven’t raged against the system that has left us underslept, overstretched, chained to our computers — pushed to the edge of sanity in a frenetic system that values throughput and profit over physician well-being and authentic human connection.

Here is one answer: We have no idea how. We are about as rebellious as a church group.

Instead, we turn our anger inward. Medicine’s culture of perfectionism can sometimes border on self-flagellation, self-sacrifice, even martyrdom. It’s widely known that doctors suffer from disproportionately high rates of burnout, depression and suicide.

But Epic’s voice seems not to have been designed with this in mind. Instead, we are met with relentless reminders of tasks we haven’t completed, supplications to correct our documentation for billers, and daily, jaundiced reminders. “You are currently deficient.”

Perhaps Epic doesn’t care. As some astute physician-colleagues pointed out to me, Epic’s goal — unlike that of JetBlue — is not to make its users feel good. It’s to maximize productivity, to keep us checking boxes and churning through patients as fast as we can.

A more humane version of Epic would take a different tone. In the absence of a true emergency, its colors and symbols would be neutral, even tranquil. Deceased-patient warnings would recognize the emotional impact of a life lost.

Deficiencies and delinquencies would become incomplete tasks, and pop-ups would float into view as small islands of empathy, like the system’s periodic emails. (“Thank you for all of your hard work.”)

But until then, the voice of the program itself — urgent, intimidating and tinged with allegation — will continue to contribute to the profession’s growing sense of despair.

On my fifth day with Epic, I “jumped” to my in-basket and found a longer message. It said: “Our records indicate that you still have 0 total delinquent deficiencies. Please note that any deficiency that has been declined will appear on this letter until it has been investigated and reassigned to the correct provider.”

I spent a good few minutes trying to figure out what on earth this message could mean. Then my pager went off. An older man with cancer had vomited again, and needed my care.

I summoned a spark of defiance and deleted the message.

Emily Silverman (@ESilvermanMD) is an internal medicine doctor at the Zuckerberg San Francisco General Hospital and the host of the live show and podcast “The Nocturnists.”