Changing Paradigm of Electronic Health Records
By Howard M. Landa, CMIO, Alameda Health System
Electronic Health Records have evolved slowly over the last half century but rapidly accelerated in recent years. The desired outcomes, the available tools, and the experience of professionals, all developed co-dependently; leveraging the assets and liabilities each possessed to bring us to our current state. I believe we are poised to deliver over the next decade on many of the promises medical informatics has made over the years; but we are at a very turbulent point.
The first successful implementation of a Computerized Physician Order Entry system was at El Camino Hospital in Mountain View, California in the early 1970s. The Medical Information System (MIS) was originally developed by a software and hardware team at Lockheed in Sunnyvale, California; which subsequently became Technicon Instruments Corporation. The MIS system used a light pen to allow physicians and nurses to quickly point and click items to be ordered.
Over the subsequent years HIT grew in fits and starts with a few large healthcare organizations implementing electronic records. But HIT really took off when congress passed the “American Recovery and Reinvestment Act of 2009” and slated over $30 Billion to modernize and “electronify” healthcare, requiring the government designated “Meaningful Use” of EHR technology.
"The EHR:Are we the Tools of Our Tools?"
The early years of MU provided significant incentive payments to adopt this kind of HIT modernization and spurred many healthcare providers and organizations past the tipping point to begin EHR implementations. There are significant benefits to providing healthcare with an EHR and few clinicians who use an EHR would go back to paper. The information is more available, more legible, and tools that support clinical decision making can actually be useful. The day-to-day reality, however, is that we have delivered tools that frustrate and aggravate at least as often as facilitate and enhance. The vast majority of clinicians are dissatisfied with their EHR and every year the dissatisfaction grows. How did we go so wrong?
The “legacy” medical chart was a tool we used to document the patient’s condition and progress and communicate the clinician’s plans and thought processes. One of its most useful attributes was the incredibly high signal-to-noise ratio it had, when created and managed by skilled professionals. “Meaningfully Useful” Electronic Health Records have dramatically changed that paradigm. We have allowed an effective documentation and communication tool to expand to require inclusion of ill-defined clinical and billing workflows, ham-fisted decision support and customer service as a proxy for patient engagement. The EHR has become a ravenous beast which consumes all available data, and in the minds of many clinicians gave little back. The critical signal-to-noise ratio has become subservient to regulatory and coding data requirements. In Dr. Patrick Ober’s exposé “The EHR: Are we the Tools of Our Tools?” He posed a simple but prescient question. When did clinicians start serving the patient record instead of the other way around? Many would suggest this happened in 2009, but in reality it has been a gradual evolution, and medical informatics needs to take a look at itself in the mirror and realize, like Pogo, that we have found the enemy and it is us.
It all really started as an incredibly well-intentioned effort to support healthcare organizations and individual practitioners in the use of standardized, evidence-based medicine supported by clinical decision support, and the exchange of EHR information was touted as a cost reduction and patient safety strategy. Unfortunately, we have subverted what was an efficient documentation and communication tool; creating an overarching, over reaching and overly structured system that does not deliver on the intentions.
There are many reasons that medicine is so far behind other industries in their implementation of innovative information technology. In many other areas of research and innovation healthcare manages more ambiguity and takes more risks than most other sciences. Despite the massive delivery system that exists to provide medical care, most decisions are made one-on-one, between a patient and a clinician. The care for a given disease may be able to be standardized, but the care for a single patient with that disease is often unique. This is the paradigm that makes care standardization so difficult, and one of the things that impede the utility of healthcare information technology.
We also must acknowledge that medicine is much more “analog” than many other industries. We don’t have manufacturing statistics, sales goals and revenue reports; but rather the curing of disease, the mitigation of pain-and-suffering and improvements in the quality of life, things that are not expressed well digitally. Despite this, medical informatics has concentrated on the creation of structured digital data from this analog information, but then we are quick to complain that we are drowning in data but parched for information. We need to re-evaluate the balance between the utility of structured data for reporting, decision support, and research (all vital considerations) with the unsurpassed knowledge transferability provided by the contextual awareness inherent in the prose created by a skillful clinician.
Information technology systems need to be more aligned with the way the human brain works. The human brain excels at complex concept integration. We recognize patterns and can manage ambiguity and uncertainty in ways computers find very difficult. We are notoriously poor at multitasking, managing large volumes of discrete data and making decisions when there are a myriad of options. Yet that well describes the user interface of the EHR.
Providers of healthcare obviously need better tools to put the “care” back in healthcare while patients need tools to assist them in their interactions with the healthcare system and help them manage their health. These things and many others are the reactants needed to transform HIT, but the real catalyst that needs to exist to foster this transformation is payment reform. When healthcare is finally reimbursed based on value instead of volume, all the incentives will be properly positioned to truly transform healthcare and the technology to support it.