"Hindsight is Always 2020. Ask My Dog"

After reading and digesting the article What Will EHRs Look Like in 2020?, my partner Don Kamens, MD had some insight to share- Enjoy!

 

When a physician practicing 15 years from now (2030) looks back one decade (to 2020) will he or she see a quantum leap in usability and functionality from our current time?  Certainly, in the decade 2005 to 2015, the leap has not been quantum, but impaired.  Impaired by such encumbrances as MU (meaningful use) and similar constraints that require caregivers to work with keyboards and mouse, rather than with patients. 

Interestingly MU is also the answer to a famous Zen koan that means "nothing, nothingness, or not at all." It applies in the EHR realm too. In Zen, the question that yields MU, "Does a dog have the essence of Buddha?" contains about as much meaning as meaningful use in the EHR realm. None. Ask my dog, he will tell you. Or he will bark at you.

EHRs bark at physicians too.  Ask the users.  As one punster said, "it's a ruff situation." Indeed, after a particularly trying shift, most ED docs would rather be wresting with the pit bull who bit the patient in room 14, than with the EHR to complete notes, and get home.  Many would choose the dog as an easier path .  

It is also interesting that a section in the JAMIA article is headed Billing Requirements Now Drive Much of Documentation.  Now?  Billing requirements have been driving documentation since well before the advent of EHRs, as they are now known.  Indeed, "justification of evaluation and management codes" has been with us for many, many pre-silicon decades. The difference now is that these justifications are now viewed as electronic data, rather than as marks or notes on paper.  But the information is not substantively different at all; it is identical, just gathered and assembled differently, and more transferable, interoperable. Severing the calcified link between a physician's account of clinical work done and payment received will need  surgical intervention. Many are pushing for outcome-based reimbursement schemes. But few physicians want to see outcome-based payment systems, as those with poor outcomes sometimes require the most work.  

What is missed in this analysis, is that the EHR in 2020, when looked at with 20-20 hindsight, should not repeat the mistakes of the past.  But it will.  It will because the perspective of guidance in this realm is incorrect, and far too quantitatively based.  Medicine has quantitative aspects, but it is far from a quantitative science. It is largely qualitative, and heavily subjective. 

What is the fundamental mistake that has been repeatedly made with EHRs that will perpetuate the sins of the past?  Well, one would hope that in 5 years, approaching the EHR on a case would be greeted with a sigh of relief, rather than with the trepidation of taking the first step from basecamp to climb Everest.   EHR developers should be using the experience of video games, Roku's, automobile driver interfaces, Khan Academy, from (yes) smartphones and cool apps.  It's not happening at the moment.  And it is not happening particularly because of the constraints that MU and related rules put on the system.  

Ask any Zen adept. Emptiness ! MU is nothing. Or ask any ED doc forced to use an EHR that drives him or her nuts.  Or ask my dog.