Vertical Integration of the Electronic Health Record

After reading multiple articles on the pros and cons of the Electronic Health Record (EHR), it is crystal clear there are multiple competing forces on the utility of the EHR.  These can be divided into five-factions with their independent, but often conflicting needs.

Governmental
Their needs and desires are #1-10; the pursuit of data.  This data will be used to create health policy that will theoretically control costs.  The key to controlling costs will be behavior modification.  the most expensive item in medicine used to be the pen, but it is now the mouse click where multiple clicks can easily spend large amounts of money.  Behavior modification comes through the endless "carrot and stick" approach.  Meaningful use monies (a huge driver in the rush to adopt EHR systems with the fear of claw backs are classic tools of situational bribery.  The move to ICD-10 and ePrescribing are more attempts to capture more data.  The positive side may be the development of the ACO's (accountable care organizations) that will pay on performance.  How this will occur in reality remains to be seen.

Hospital
Their need is based on getting "paid" under the ever increasing burdens of unpaid government mandates.  The institution need records that obtain the meaningful use money, core value reimbursement data, and sophisticated billing strategies to obtain any and all available funding.  The hospital's bottom-line drives the purchase of the EHR and mandates that the employees and providers conform to the EHR work-flow paradigms rather the more logical reverse.  This puts more demand on providers and staff without the positive team approach feedback.  The end result is chronic dissatisfaction, reluctance to embrace the "future", and decreased productivity.  The hospital attempts to use the EHR to control behavior and outcomes are not working to well.  Computer driven paradigms can assist, but cannot control the complex interactivity between multiple providers and staff.  The hospital also has not taken into account the "cost of clicks" and by making the provider the de-facto ward secretary has led to poor productivity.

Third-party payers
Insurers have a keen interest in the out-workings of the EHR.  Not only will their data - see government- be therein contained, but also their actuarial statistics that allow determination of premiums, profits, and thus survivability.  All three of the other parts of the pyramid are balanced on the payer, and these entities are in the very middle of the mix.  Every one of the other factions relies on the payers to keep the balance.  It is an uneasy reliance at that.

End-User
The clinician wants a program that works for them.  This means the program must be developed from the user's point of view not the computer programmer or organizational views.  This means that the needs of the operating room are different than the Emergency Department.  A program with a strong central backbone that integrates with various products designed specifically for that area is desirable.  The user wants walk-up usability (no need for endless training and retraining), easy navigation, crisp interfaces, and easy access to nursing notes, old records, and ancillary service records.  The user wants a cost-benefit analysis of the elimination of the "classic" ward secretary leaving the providers to fend for themselves with minimal support.  The providers should be supported rather than given more "data entry" tasks.  When overall productivity go down and meaningful use money disappears; making the provider more efficient will make the organization more money.  The user wants clinical decision support (Artificial Intelligence), but with a "soft touch" not a hammer.  This will help with malpractice, billing, and ACO support.

Patient
The patient, or should it be said "and then there is the patient..."  Usually the most forgotten in the mix, but also the most important, the bottom line, the raison d'etre for all the others.  Why is the hospital erected, the provider well-studied, the government interested, or the insurance company calculating, if not the this central, key entity...the patient.  More and more, EHRs are actually allowing patients within a system to have certain forms of access to see results, and report status back to the clinicians.  Keep in mind though, if the patient's are not happy...think: long waits, errors, incomprehensible documents...it ain't gonna work.

Bottom-line is the needs of all groups are important, but by enlisting the player who is really the quarterback (the end-user clinician, physician) as a champion, calling the plays calling the shots, one has the best organizational team for success.  By vertically integrating the Electronic Health Record and providing the needs of all five silos, with one quarterback, the EHR will be gladly accepted and not create so much angst.