EHR Blues...Co-authored by Dr. Donald Kamens

Upon reading even just a few of the thousands of review articles on the Electronic Health Record- EHR, it is quite reasonable to conclude that most clinicians would prefer paper.  Why?  The details are many, but the overall impression one gets is that providers do not really see value in performing tasks that are predominately secretarial especially when their already overstretched time could be more effectively spent on actual clinical matters, like communicating with patients and staff, decision making, care consideration, and real-time research.

Unfortunately, though, an unanticipated secondary tier of clerical tasks accompanies most newly deployed EHR modules, and these wind up, of course, in the physician's to do box.  Particularly within modules for order entry (CPOE) and chart documentation, such overhead generates excessive demands on provider attention and effectiveness.

At many institutions, un-navigable interfaces trigger
frustrations and administrators react by throwing more staff at the problem.  Therefore, we now see an increasing number of extra personnel (medical assistants, physician extenders and scribes) carrying laptops, tablets, and smartphones, but not bandages and IV fluids.  Because there is a tendency to sweep EHR deployment shortcomings under the rug, they tend to live beyond conscious recognition, and instead within some hypothetical virtual promise, in a time soon to come.

Thus, while hires may -  on the surface - seem to be made to help provide better overall care, the intrinsic, systemic demands placed on a mouse & keyboard ED staff, by far exceed those placed on a pen & paper staff.  Indeed, logic says that a staff whose workflow and process has improved above that of pre-EHR times, needs correspondingly fewer personnel.  Right?  However, inadequacies in EHR design and performance, and the  necessity of complex workarounds to accomplish simple basic tasks, have instead added to the workload, and have done so beneath the surface, in an almost unconscious plane of operation.

So, since costs tend to reside in an unconscious plane, the ED department will likely not recognize the source of the issues for what they are: generated by the very presence of the EHR, itself.  Moreover, no EHR vendor intends to clue your department in on this.  After a while, one becomes accustomed to extra medical staff, as they become embedded features of the landscape.  Has anyone said that the cost of medical care has gone down since the advent of EHRs?  No Way!  Rather, it is continuous, in the other direction- up, always up.  Hence, a few minutes with pencil and calculator can show that the cost of (staff) adoption to meet EHR practical use will soon exceed the billions in incentives directly paid to physicians for EHRs adoption through meaningful use.  In the end, therefore and sadly, a loss.

This is not to say there is no value in EHRs.  There is indeed some, and there is certainly promise.  Yet, to put the rate of progress directly on the backs of practicing physicians makes no sense whatsoever, especially when the big-picture for the US, includes major systemic health-care overhaul.

 

In areas such as data collection, decision-making, and legibility, a (very) few EHRs hold promise to make things better, in comparison with care currently able to be provided with just pen and paper.  That's a problem, because it trades current quality of health care for future promises that do not have guaranteed benefits.  Doing so isn't necessary.  Yet with quality EHR offerings slim, and pressure to choose high, physicians are correspondingly impaired in their ability to discern what's best for them within what is available.  As a result, most initially attracted by meaningful use monies have found it simply not worth the effort.  Of course, administrators and those who oversee healthcare from a governmental level will think differently.  Nevertheless - and this is a key point - most persons responsible for selecting clinical systems, are themselves not providers, have never directly provided medical care, and never will provide medical care with their own, medically trained, hands.  That's like turning over car design to a group that rides bikes to work every day.

 

Indeed, after all the effort made with meaningful use, and all the billions spent, there is minimal substantive evidence that quality has improved or that efficiencies have been achieved.  Meaningful use activities may look good from a statistician's viewpoint, but very few of the processes that necessarily tag-along with EHR implementation have practical function in the real world.  For example, handing a patient a paper copy of a CCD*, together with 12-pages of discharge instructions, serves little purpose.  Not surprisingly, many clinicians simply do not even know what a CCD even is - nor should they need to know - any more than we need to know the underlying formatted structure of the receipts we sign in restaurants and retail merchants.  Each format is different from the next, and even though the data elements are identical, we commonly just scan for the bottom-line, whether paying at a restaurant, or understanding what actually happened with a patient.  In the case of a patient "represented" by a CCD, chances for successful electronic transmission and succinct presentation of the "bottom-line", are marginal, if at all present.

Over the last few years,, the rush to implement EHRs in time to get meaningful use money has forced hospitals to make decisions based too fully on financial considerations, instead of on finding practical, real, solutions to improve care.  This has led to user (physician) angst and chronic end-user (patient) uncertainty.

 

Institutions have also tried, not-surprisingly, to solve long-term efficiency issues with computer-based solutions that don't address underlying issues.  For example, an electronic bed board may say that room 222 is ready to be cleaned, but if the system cannot assist housekeeping personnel to get there in real-time, the patient destined for that room - once cleaned - is still taking up a bed in the ED.

 

Turning providers into "data jockeys" has created cumbersome workarounds (some quite creative) to offset what was lost from the inherent benefit, simplicity, and efficiency of paper and pen. 

 

But, there is hope.  Perhaps the media will one day say about meaningful use, what Elwood said to Jake in the Blues Brothers (1980), "It wasn't a lie, it was just bulls**t."  With costs increasing and reimbursements under constant scrutiny, there will be in the future a huge push to have an end-user friendly electronic health record with all the fancy artificial intelligence features to save money and eliminate inefficiencies.  Let's hope it really succeeds the next time around.

* The CCD (Continuity of Care Document) is one of several electronic templates proposed by standards organizations to enable interoperability (electronic sharing and reuse) of medical information.  The CCD (as well the CDR, the CDA-R2-CDA, and others) has been constructed to standardize and facilitate rapid transmission of a summary of the patient’s recent course and current condition, readily showing vital signs, family history, plan of care, and so on.  The CCD, however, is not considered the best formulation by everyone. There have been multiple CCD releases over the past decade, all the while trying to establish a standard format into which an EHR can automatically input a summary of the medical history, and output the CCD as an HTML-type document that can be sent to, and read by, other EHRs.  Hence, again in theory, any CCD should be electronically transmissible between differently constructed EHRs, installed by different vendors, and operating cross distances.  Achieving this would be something like building standard fuel pumps for automobiles, so that no matter what the engine happened to be, fuel-pump replacement on a Mercedes would be the identical to that on a Ford. 

Wikipedia says:  “The patient summary contains a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to another practitioner, system, or setting to support the continuity of care. Its primary use case is to provide a snapshot in time containing the pertinent clinical, demographic, and administrative data for a specific patient.^{[1  ]    “}