Skeptical, yet Hopeful for Healthcare IT
*** yes this is an echo chamber and I realize it, but it’s also my own web site and blog so deal with it ***
So one of the original reasons why I started this website and blogis a way for me to document the things that I have learned throughout my time here at university, and primarily with understanding information technology as well as medicine. It’s why I gave myself the moniker of a “technology adept premed” as a way to try and illustrate that both of these fields are something I hope to further integrate myself in and as my older posts can show, I’ve been interested in healthcare IT for the longest time but more specifically about the pitiful state of the electronic health record software (EHR). Despite being available for decades now, my experience with them has been anachronistic as I feel like I should be back in the 90’s based off of the user interface and graphical design. Granted, strides have been made in the overall look of the EHR, but the implementation of clickboxes and textboxes has me typing and cliking more than actually thinking about the patient’s information and problem. Now that a new year has come around, I wanted to take another look at healthcare IT and specifically EHR and how it can be improved, if it will be improved.
When you buy shoes, you find the shoes that fit your feet. You don’t undergo foot surgery to make sure you fit into that shoe. The fact that EHRs are clunky for the clinician end user isn’t a problem with the end user either. The software system should be designed for the clinician, but unfortunately, until we can change the idea that the EHRs are meant for billables and data purposes, I don’t see that changing much. If someone can’t sit down and figure out how the system works in a period of time, it’s the system having poor user experience. Engineering isn’t for the object, it’s for the humans trying to make something simpler and more efficient.
Though I am still a university student, I’ve had the fortunate opportunities to work with a handful of different EHRs for various reasons, but they’ve been the larger vendors with most of the market share with Epic, Cerner, Allscripts, Practice Fusion and Athena Health and despite its pros and cons, they’re still very lacking in most basic functionalities and focus on specific end-user groups. It’s been suboptimal, clunky and cumbersome despite the nice looking images and user interface, the user experience is still wanting. Shadowing physicians in different specialties in different locations of Chicago has illuminated one vital point in their resistance and frustration, and that is the poor state of healthcare information technology and how its demoted patient-oriented physicians into overcertified, glorified data entry grunts. Sure there are administrative and medical assistants that can do that, but at the end of the day, everything requires the physician’s approval and that means still having to go through everything to ensure that everything is in tip top condition with all the boxes checked and everything written down. However, despite it all, I’m still hopeful that improvements can be to this exponentially growing crossroad of medicine and information technology, but there are a couple of reasons that I am skeptical about the improvement.
- Marketshare and Market Economics. Despite there being hundreds of viable options, it’s a case of early bird gets the worm when the top 10 companies were able to push out their EHR software early in the game of HITECH. Despite their poor reputation of usability, because they were able to promote themselves at the start, they’ve earned a large cult (I use cult liberally) following not because they truly believe in its capabilities, but because it cost so darn much money to use them that many find it financially stupid to try and switch to something else now. With the amount of packages that these companies release for all different roles and specialties, many healthcare organizations are unable to switch to what may be a potentially better EHR but with also less functionality. Especially once all the money has been spent on a specific EHR vendor and when they’ve gained such a large portion of the market, they have everybody under their thumbs so there is simply no need to “improve” and get better because of the old saying, “if it ain’t broke, don’t fix it”.
- The end-user. Who really is the end user for EHR? You’d think that for patient information and care, it should be the healthcare clinicians, but surprisingly it is not! The physicians are not the primary end user, it’s hospital administration and healthcare insurance organizations. It’s the suit-wearing administration that has no reasonable idea of how healthcare and medicine actually works on a patient-care perspective. You’d think that the advent of technology should be focused on saving time and improving efficiency of the end user, and it is, but that’s not the case in healthcare IT. From my experience and understanding, it’s not the clinicians that EHR is billed for, it’s for the administrators and healthcare insurance people to gather metrics and data regarding reimbursements, billables, financials and once again, data. Unfortunately, I’m not sure how to transition this technology to actually to work for the clinicians and actually improve the ability to care instead of being subverted for data mining and analytics as well as micromanagement. Someone once told me, “we’re data grunts with medical training background, and the people are the widgets”, and the more I’m seeing it from different perspectives, the more I can only nod in truth.
It does get better! It’s not that people don’t want to comply and want to shun technology away, everybody sees the potential benefits of technology and recognize that it is the future in all aspects of their lives, it’s just that there needs to be technology that is efficient, productive, and conducive to a clinician’s workflow, not make it worse or draw the attention away to the software instead of the patient themselves. There needs to be a movement that ensures that the medical profession remains a social and personable profession instead of being “type-and-click bots”. Once people recognized that the current technology was garbage and needed reform, it’s important to understand where the reform should take place. For me it’s unreasonable to try and force the end-users to adapt to a new software, instead I believe it should be important that the goals are aligned to ensure that the clinicians are able to transition smoothly into a software system that grants them improvements in patient care, cosider the patient care instead of data voyeurs.
However, that doesn’t mean it’s completely pointless, those were just a few points of skpeticism that have me bitterly grumbling about how technology will be when I hit the medical workforce (hopefully, fingers crossed!). However, I have seen improvements in the two years that I was submerged in the healthcare IT industry and I have found some improving points that I would like to share.
- The technology itself. It’s not seamless, it’s not efficient and by hell it’s not user-friendly. Unfortunately, due to non-disclosures and the fright of having these companies send me some threatening letter suing, I’m not going to post any pictures of screenshots of the worst of the worst. Just try and google image it and you may see what I mean. Overall, I feel like simple design fixes regarding screen interfaces, menu options and patient care data input formats could really help make it a lot easier and user-friendly. It’d help if healthcare organizations would actually focus on end-user groups to provide honest feedback on the system instead of being “here, take it, it’s yours now”. Fortunately, more and more EHR vendors are now pushing towards mobile solutions, and that’s both a good and bad thing. In a sense, it’s another vulnerable device ripe with cybersecurity vulnerabilities waiting to be hacked and stolen, but it’s also a great way to access a patient portal or a patient’s chart easily and quickly. In a sense, I think it’s a good ideal but requires a lot of research and implementation of technical, physical, and logical controls to make it safe and widely available.
- Communication and interoperability. It’s getting there but there are market forces that resist the change. A framework for secure interoperability and data exchange has been formed and is available for use with HL7 and FHIR, it’s just now the time to persuade the large EHR vendors to adopt it. It’s difficult because these vendors used to be able to charge extra to allow for connection between systems but if there is now a data exchange standard for interoperability and coding framework to allow that, there goes some gross revenue out the window! Even within the same healthcare system, not all systems are able to access each other’s records, which makes referrals to different clinics difficult as well. In fact, the problem also lies within the EHR vendors’ release of different applications and packages, and the fact that not all departments will be using the same one hence there isn’t a need to purchase select applications which also leads to incongruity that can be solved. Something to consider though is that in the process for interoperability, there also needs to be a push for informed consent with the patients so that they have a good understanding of where and what their PHI will be used for.
- Relationship with Health IT. I believe that it is of vital importance to understand and create a relationship with Health IT. It’s a way of aligning goals and ensuring that the scope of the EHR is met and understood by both parties. Clinicians pursued medicine to deal with human beings in their most vulnerable states and time of their lives. Information technology despite its ever increasing role in medicine should be a minimal, yet effective part of a clinician’s workflow. As I mentioned, medicine is a colliseum where emotions and logic often battle out within the human psyche, it’s about the clinician-patient relationship that allows for understanding and empathy to flow, especially when facing powerful emotions of varying types. Healthcare is not supposed to be about data analytics and capture, cloud solutions or even rollout of mobile apps. I believe that the relationship with healthcare IT should be seen and not heard, it has to have its impact but not make it the forefront.
Lastly, at the end of this mundane and very long post, I want to point out a few of the action items that John Halamka made to the Trump Administration and why I support and identify with it as well. Granted the opinions of a university student still going for a bachelors is moot to a healthcare CIO with years of experience, I believe that support begets support and one day, if I ever make it big, someone will find what I write about and support it as well.
- He mentions enabling infrastructure, and as a data guy. Yes. Yes. And did I say, Yes. With the fragmented EHR vendors that we have currently, it’s important that we create a repository of some sort with all available APIs that allow an application to query and integrate to make data exchange simpler. I don’t think it requires destroying the system and starting from scratch and making sure everything is interoperable, instead I think it should allow current EHR vendors the availability to integrate as needed. Technological ideas aside, he also mentions policy. And as someone who studies information technology policy, I also firmly agree with this. It’s not enough to just have the technological controls and concepts, but it has to be enforced with recognized policy that helps guide user actions, and with how valuable healthcare information is, it’s important to have informed consent for data sharing.
- He focuses on cybersecurity and risk mitigation as a second point. As you may have read my older posts about cybersecurity, you’d understand why I firmly support this idea myself. The most vulnerable part of any organization is the people itself, no matter how secure you make something, it still has to have some sort of availability for users to interact with and it is with the user vulnerability that I believe is the scariest part of any organization. Focus on strengthening technological and security controls, have that aligned with policy and ensure that audits are being done to find weak spots. There is always goign to be some inherent risk with anything, but by focusing on found vulnerabilities will help reduce risk and try to eliminate any threats to success (as my IT Project Management professor would always say). Healthcare organizations and IT professionals need to work together and create and implement best practices