Last week, when I read a commentary from physicians in the Journal of the American Medical Association (JAMA) about their dissatisfaction with electronic health records (EHRs), I was particularly intrigued to see that the authors went to the next level in terms of specifically pinpointing their frustrations.
The piece, penned by Donna M. Zulman, M.D., Nigam H. Shah, Ph.D., and Abraham Verghese, M.D., all with affiliations to the Stanford University School of Medicine, titled “Evolutionary Pressures on the Electronic Health Record,” kicked off by mentioning that EHRs “have the potential to prevent medication errors and decrease duplicative tests, contributing to the safety and value of care.” But, the authors said, “The evolution of EHRs has not kept pace with technology widely used to track, synthesize, and visualize information in many other domains of modern life.”
More specifically, the authors said that the tools are not integrated in a way that supports tailored treatment decisions based on an individual’s unique characteristics. “Existing EHRs also have yet to seize one of the greatest opportunities of comprehensive record systems—learning from what happened to similar patients and summarizing that experience for the treating physician and the patient,” they wrote. They added that the most important shortcoming of the EHR might just be the absence of social and behavioral factors fundamental to a patient’s treatment response and health outcomes. “In this world of patient portals and electronic tablets, it should be possible to collect from individuals key information about their environment and unique stressors—at home or in the workplace—in the medical record. What is the story of the individual?” they wrote.
Of particular interest, the authors also stated that the amazing effects of computers and science are simply not seen with EHRs, leading to extra burden on physicians. “The dominant EHRs are designed for billing and not primarily for ease of use by those who provide care. In fact, a measure of successful EHR evolution may be that physicians spend much less time with the EHR than they do now,” they said. They continued, “Deimplementing the EHR could actively enhance care in many clinical scenarios. Simply listening to the history and carefully examining the patient who presents with a focused concern is an important means of avoiding diagnostic error.”
I’d like to touch on a few key points here: 1) These authors are hardly the first, nor will they be the last, to feel that EHRs as currently designed are essentially “billing machines” that don’t offer much in the department of improving patient care. 2) It has now become a must for provider organizations and the vendor community to move past the EHR adoption stage and into one where they will be able to optimize their investments. 3) A comparison of EHRs to the evolution of other technologies needs some perspective.
No, it’s not a surprise in the least to hear doctors complain about EHRs. Just yesterday, I read commentary from Niran Al-Agba, M.D., a pediatrician in Silverdale, Wash., who wrote about what her “ideal EHR” would look like. Al-Agba said she would like if the paper chart was simply replicated on the computer screen. “The first page would be a standard intake form providing the general health background, birth history, past medical and surgical histories, allergies, immunizations, medication list, and pertinent family history. The second page is the problem list and other necessary details depending on medical specialty. The third and fourth pages would be growth charts and then the immunization record follows. Those pages could be accessible by tabs on the left hand side of the screen to review or update when necessary,” she wrote.
Al-Agba argued that this level of simplicity—and with the note dictated into a SOAP (Subjective, Objective, Assessment, Plan) format—would accomplish the fundamental purpose of medical records, which is to chronicle all the diagnoses, treatments, and follow-ups for a variety of medical conditions. As such, providers would be happier given the ease of these “ideal” systems.
Undoubtedly, healthcare’s investment in EHRs and other technology has been a hefty one, to the tune of $30 billion as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 alone. Although data released earlier this year by the Office of the National Coordinator for Health IT (ONC) revealed that in 2015, 84 percent of the nation’s hospitals reported adoption of at least a basic EHR system—a nine-fold increase since 2008—physicians who continue to be hampered by these systems can’t help but wonder when they will see a return on the investment that can cost a single physician hundreds of thousands of dollars, according to at least one estimate.
Indeed, in the JAMA commentary, the authors noted how “the spectacular effects of computers in science and in the secular world are not reflected in the EHR,” and that “there is building resentment against the shackles of the present EHR; every additional click inflicts a nick on physicians’ morale.” They added, “Current records miss opportunities to harness available data and predictive analytics to individualize treatment. Meanwhile, sophisticated advances in technology are going untapped.”
I certainly don’t doubt that the extra clicks and effort spent by doctors only increases their irritation with the technology. Nor do I deny that EHRs are probably not as sophisticated as they eventually will be. However, it’s important to have some perspective. As noted above, hospitals have seen a nine-fold increase in EHR adoption in the last eight years. The same study found that nearly all reported hospitals (96 percent) possessed certified EHR technology to meet meaningful use requirements in 2015. Eight years might seem like forever ago, but it’s really not. These sorts of major technology implementations and culture/workflow changes take a lot of time.
A second ONC data brief released around the same time found that interoperability among EHRs is largely a mixed bag, with shared information not being available to clinicians in their EHRs the biggest barrier. This data sharing phase is the next jump EHRs must make, and is also one of the main causes of aggravation for providers. But clearly, the federal government has made interoperability its next core goal for health IT. “Efforts that have focused on EHR adoption now are shifting to interoperability of health information, and the use of health information technology to support care delivery system reform,” that ONC data brief confirmed.
As such, it would be unfair to criticize all EHRs based on the current stage of evolution they’re in right now. But rather, what’s their trajectory? I compare it to before we had “smartphones.” Believe it or not, not too long ago, most of us just had plain old Nokia cell phones that really only had the ability to make and receive calls. Now, nearly seven in 10 U.S. adults own smartphones that possess the ability to essentially connect to anywhere in the world digitally. That smartphone ownership number has doubled in just the last four years, according to Pew Research.
Healthcare, of course, is a whole different animal with a wealth of data unmatched by other industries. But, that should make this point clearer: EHRs’ evolution must go through multiple stages, each of which might take years. So while I completely get providers’ qualms with EHRs, we need to also understand that technology won’t fail us; it rarely ever has. And before long, docs, your Nokias will become iPhones and Androids, too.