EHRs Aren’t All Bad – What Else Is There?
One of my mentors recently pulled me aside one day and he mentions that he found this website. I didn’t bug him just how he came across this website, because I know he had to have been looking me up on Google or some other search engine site to have found it because I never told him about it. Anyways, we have a discussion about the stuff that I write about and even though he firmly agrees with what I’m saying, he thinks that I’m writing only to badmouth EHRs in the grand scheme of things. That honestly surprised me because that wasn’t the intention tone and vibe that I was trying to give off, so I just wanted to clear up the air. By no means am I saying that the flaws in healthcare and medicine in the USA is due to EHRs alone, no, not at all. It’s an aggregate of factors, some controlled and some that can’t be controlled that has led to these issues and I am simply the most familiar with EHRs that I write about them. Granted, I am more familiar with the crossroads of medicine and information technology, and what better topic to write about then the implementation of EHRs in the past decade?
The mass implementation of EHRs due to Obamacare was done with the best of intentions, it truly was. It was a transition to try and revolutionize and better medicine by improving patient care. That was the simple fact of the matter. It hoped to streamline communications in multiple locations by having patient information and data there already, eliminate errors due to chicken scratch handwriting, provide decision support to avoid harmful drug interactions, and creating a means to check accuracy of patients’ medication lists among many others. Granted some of these benefits are there, but a majority aren’t, and even the ones that have been implemented are seen more as a hindrance than anything else. But along the way, this supposed means of revolutionizing medicine into the modern age ended up becoming a pile of steaming crap whose original intention is now littered with text fields, check boxes, radio buttons among other elements you’d see on an HTML form from the 2000’s.
The way it is depleting a very precious resource, the development of a physician-patient relationship, the growth of trust, the ability to heal people physically AND mentally all for the sake of becoming everyday data punching grunts. This is in no way only the fault of the EHR vendors, but I would say the root of the problem itself lies in the ones that have pushed the bills, laws, policies and whatnot enforcing the implementation of EHRs but lacking in the follow through of ensuring proper transitions and quality assurance. As great as it can sound on paper, no one wants to document every single piece of information just so the hospitals can bill the patient or the insurance company as much as permitted, if it wasn’t for scribes and other healthcare personnel, there would be no time to care for patients at all. It’s the regulations behind it. These electronic records work in other industries (online banking, e-commerce, food delivery, travel etc) simply because these industries would fail if user experience was less than satisfying, but in medicine, it’s not the patients that have to deal with the brunt of the transitioning technology, it’s the ones who provide it. I’ll bring it into another layer of dissatisfaction, these regulations are forcing the healthcare providers to do things that were never in the “job description”. To be more specific, these regulations simply require the caregivers to do data collection and entry, charge optimization, quality improvement among other “burdens” when the only burden that caregivers ever wanted to should was caring for the sick and suffering and ensuring that everybody has a fighting chance in living. You can’t require someone to do something that they don’t want to do and expect to get perfect results. One of the biggest irks as my time as a medical scribe was the SOAP Note, it’s essentially a documentation method in creating a patient’s chart and it stands for (Subjective, Objective, Assessment, and Plan). Granted it sounds like it would be a good method in documenting a patient’s visit, but for repeat patients and chronic offenders, it ends up being ctrl-c + ctrl-v for 90% of the chart, and maybe the last few lines are new information for this visit. What sucks even more is that in some EHRs, there is no copy/paste function because they are checkboxes and buttons to click, meaning you could spend 6-8 minutes just clicking through HPI and ROS (History of Present Illness and Review of Systems) with all of the same information and really only spend 30 seconds on new information, but because of billing levels and necessity, those 6-8 minutes at the start are required otherwise the signed patient charts are just going to get rejected and you end up having to do them again!
But all this aside, I do think there are some things that could honestly work to improve the current state of affairs. Just like how top-down/Keynesian economics have failed us for the past 20 years, top-down administration in medicine isn’t going to work either. If I could, I would make it an amendment that when developing software, you have to ask the users what they want and need, and what they want to see. Technology has advanced, most things are possible nowadays, and it’s just up to both sides to work collaboratively to develop a solution that facilitates and bolsters medicine, not something that is another hindrance to worry about. Another thing that I’ve advocated for is interoperability, and after more research and talking with medical professionals and IT professionals, interoperability is not as simple as just sharing patient information. As someone who’s taken plenty of classes on policy making in IT, auditing, and ethics in IT, I never even thought to recognize that without patient consent in sharing private health information, interoperability would be a moot point anyways.
Interoperability will only be successful if there is a business case that promotes it, good policies, and best practices that govern it. Say a patient ends up going to see a doctor in a new part of town for shortness of breath. Unfortunately, the EHR system is different so the doctor just can’t request the information from the patient’s primary care physician (PCP) to see any radiological images either. So, the current clinician has two choices, either repeat a test or go through a convoluted workflow for an application outside of their own EHR to exchange the data for that patient. Without a doubt, the clinician will just repeat the test because it’s faster, more convenient, and he’ll be the one getting paid for that exam. Plus, what if the patient has no intentions of staying in this new part of town long, why would he be willing to share his private health information with a clinician for a one-time visit? There’s so much valuable information there and it just wouldn’t be worth the risk, especially since data exchange protocols are lacking in the health IT as well. If there is no consent, policies do not enforce a secure manner of data exchange, or even an easy way to share PHI, no clinician is going to embrace interoperability. To make it work, it has to be part of the job/pay program, integrated into EHR and standardized with secure and efficient data exchange.
Lastly is the overall collection of data and patient information. As of right now, it’s the whole “collect everything now and we can sort it out later” …. Well it’s been later for years now and what started off looking as an informative data repository has now become a data swamp where no one really knows how to work with the information and data that is already in there. Granted it’s great for some because it creates a job, but these would have been needless jobs if there were regulations and policies that ensured quality maintenance and management of the data that was flowing into healthcare organizations. Who cares how much data you have if you don’t know how to leverage it. Big data, machine learning, population health, these are all areas that proper data management in medicine could really propel forward, and by analyzing large repositories of patient information, can help with improving quality of care as well as generating insights for healthcare organizations to improve all around. There has to be tools that can incorporate and analyze the data to not only be meaningful for the administrators and clinicians, the data should also be meaningful to patients as treatment plans are considered so that they have all of the details necessary to make an informed decision. One thing I’ve learned where I’m currently interning at is by collecting patient outcomes pre- and post-, it can help with machine learning in helping to tell patients what should be expected. Granted this is used in surgical fields so patients will recognize how they will be feeling, but in doing so and being able to gather the information has allowed the ability to reduce readmissions. By staying engaged with patients and gathering information as it comes, it can help form uniquely prepared care plans and increase patient satisfaction because clinicians are leveraging technology to maintain a strong patient-physician relationship. All of this can be done with technology.