Just this week, I read a fascinating thread on a listserv created and maintained by physician informaticists. Here’s the opening comment from that particular thread, which was commentary based on the poster’s interpretation of a recent journal article: “Process redesign around an EHR [electronic health record] is just paving a more inefficient cowpath, because EHRs do not automate a clinician’s most time-intensive task—documentation.'
And here’s the first part of the first response to that post: “This is spot-on, but the resistance of companies and hospital administrations to putting emphasis on this is significant. When we make a long-distance call, we don’t then call the phone company and tell them we spoke to Uncle Luis for 10 minutes about the weather.”
Another listserv member wrote, “I can’t agree more with this analysis. Unfortunately, [the] EHR not only has wiped out the uniqueness of every … physician… but at the same time, leaves us open to more errors while looking at enormous data, not forgetting that we have become closer to our computers and far away from patients.”
Now, not everyone responding to the first poster’s comments agreed; one informaticist wrote, “I can’t agree less with this analysis… I believe you have to acknowledge that nothing is faster than the pen, and nothing creates more error than the pen. No EHR will ever stop all errors,” that commenter wrote, “because humans are involved, and as much as doctors think they are superhuman, they are just like the rest of us.”
Obviously, any discussion among clinical informaticists about the issues surrounding physician documentation, physician workflow, and the EHR, is going to be lively, and most likely even contentious. But what the thread I read underscores (and there were many additional responses that followed the original comment) is how central we all need to make a focus on physician workflow and acceptance.
Indeed, I was reminded of that need during two recent conversations; one, a brief discussion I had with my own primary care physician during a recent checkup visit, and the other a casual conversation with a cardiologist whom I know.
I’ve had numerous conversations about what I do, with my PCP, over the past couple of years, as I’ve come in for checkups and he and his colleagues have gone through the various stages of their EHR implementation. My personal physician has moved steadily through what I would call the EHR-adoption equivalent of Elisabeth Kubler-Ross’s “Five Stages of Grief” process. He’s currently in the anger stage (and moving towards “bargaining”), but, seriously, he really does have great comments to make regarding some of the ways in which his organization’s EHR (one of the most-implemented these days) falls far short in terms of facilitating smooth ordering, clinical decision support, and physician documentation.
Indeed, the last time I had a visit with my PCP a couple of months ago, he showed me excellent examples of exactly where his organization’s EHR is failing to meet his needs in those areas. And though some CIOs, CMIOs, and other healthcare IT leaders might prefer not to address the concerns of in-the-trenches docs like my PCP, they would be foolish to ignore the kinds of legitimate issues he’s mentioned to me; because, clearly, it’s PCPs like him who will make or break any EHR implementation—in the short term, medium term, and long term.
The good news is that for some specialists, like a friendly cardiologist I know, the workflow issues are fewer, and less intense and complex. The particular cardiologist I know, who practices in the same integrated health system as does my PCP, is quite happy with their organization’s EHR, and has few issues with it.
But I would urge CIOs, CMIOs, and other healthcare IT leaders to think more about the complaints of physicians like my PCP than to congratulate themselves upon hearing benign comments like those of the cardiologist I know, if they want to move their own organizations, and our healthcare system, towards where we need to go, in facilitating physician documentation. Because five years from now, it would be truly cringeful if the same types of “cowpath” comments were as common then as they are now, when what we really need to be doing is to be helping physicians to join their colleagues in creating the new healthcare—a healthcare system of higher quality and patient safety and greater cost-effectiveness, value to purchasers and payers, accountability and transparency.
In short, if we’re going to ask doctors to join us in making the great leap forward, we’ve got to offer them the chance to ride a new healthcare data and information superhighway—not a cowpath that leads only to confusion and frustration.