Electronic Health Records Blues

Ralph Badanowski, MD, FACEP and Donald Kamens, MD, FACEP, FAAEM

Upon reviewing even just a few of the thousands of review articles on the Electronic Health Record (EHR), it is quite reasonable to conclude that most clinicians would prefer paper.  Why?  [The details are many, but the overall impression one gets is that providers do not really see value in performing tasks that are predominately secretarial, especially when their already overstretched time could be more effectively spent on actual clinical matters, like communicating with patients and staff, decision making, case consideration, addressing safety and risk for their patients, and real-time research.]

Unfortunately, though, an unanticipated secondary tier of clerical tasks accompanies most newly deployed EHR modules, and these wind up, of course, in the physician’s need to do box. Particularly within modules for order entry (CPOE) and chart documentation, such overhead generates excessive demands on provider attention and effectiveness, subtracting from their ability to provide safe, careful, quality care.

At many institutions, un-navigable interfaces trigger frustrations and administrators react by throwing more staff at the problem.  Therefore, we now see an increasing number of extra personnel (medical assistants, physician extenders, and scribes) carrying laptops, tablets, and smartphones, but not bandages and IV fluids.  Is this safety? Does it reflect quality as a priority? Because there is a tendency to sweep EHR deployment shortcomings under the rug, such deficits tend to be addressed by “workarounds” to keep the clinical flow somewhat maintained, even if impaired in comparison to a pre-implementation baseline.  Workarounds tend to live, become enacted, beyond conscious recognition, within the context of virtual promises, in a time soon to come. “We’re working on that.” “Perhaps next year.” Right!

Thus, while hires of assistants and scribes may—on the surface--seem to be made to help provide better overall quality care, the intrinsic, systemic demands placed on a “mouse & keyboard ED staff,” by far exceed those placed on a “pen & paper staff.”  Think of the difference, the overhead now in our laps.  Logic would say that a staff whose workflow and process have actually improved above pre-EHR times, would need correspondingly fewer personnel. Right? All of know that is clearly not the case.  Inadequacies in EHR design and performance, and the necessity of complex workarounds to accomplish simple basic tasks, have instead added to the workload, increased the burden of assuring safety and quality, and have done this, for the most part, entirely beneath the surface, in an almost unconscious plane of operation.

So, since costs also tend to reside in an unconscious plane within ED operations, the department will likely not recognize the true etiologies of these quality impediments for what they are: generated by the very presence of the EHR, itself. Moreover, no EHR vendor intends to clue your department in on this.  After a while, one becomes accustomed to extra medical staff, and extra procedures, as they become embedded features of the landscape. Has anyone said that the cost of medical care has gone down since the advent of EHRs?  No way! Rather, it is continuous, in the other direction—up, always up.  Hence, a few minutes with pencil and calculator can show that the cost of (staff) adoption to support EHR practical use will soon exceed the billions in incentives directly paid to physicians for EHRs adoption through meaningful use.  In the end, this is a significant loss. The struggle to maintain a modicum of practical use of any tool, especially EHRs is tightly tied to the parallel struggle to maintain and improve quality and safety.

This is not to say there is no value in EHRs.  There is indeed some, and there is certainly promise.  In areas such as data collection, decision-making, and legibility, a (very) few EHRs hold promise to make things better, in comparison with care currently able to be provided with just pen and paper.  That’s a problem, because it trades current quality of health care for future promises that do not have guaranteed benefits. Doing so isn’t necessary.  And to put the rate of progress directly on the backs of practicing physicians makes no sense whosoever. Their capacity to deliver quality care, as high-level thinking providers, is covertly hurt, and especially so when the big-picture for the US simultaneously includes major systemic health-care overhaul that is almost impossible to fully discern.  It is a lot to carry all at once. 

In the end, it is patients who suffer when their physicians are overloaded unnecessarily.

Yet with quality EHR offerings slim, and pressure to choose high, physicians are correspondingly impaired in their ability to determine what’s best for all concerned vis-a-vis what is available.  Indeed, most initially attracted by meaningful use monies have found it simply not worth the effort.  Of course, administrators and those who oversee healthcare from a governmental level think differently.  Nevertheless—and this is a key point—many responsible for selecting clinical systems, are themselves not providers, have never directly provided medical care, and never will provide medical care with their own, medically trained, hands.  That’s like turning bicycle design over to a group that drives cars to work every day. 

Indeed, after all the effort made with meaningful use, and all the billions spent, there is minimal substantive evidence that quality has improved or that efficiencies have been achieved.  Meaningful use activities may look good from a statistician’s viewpoint, but very few of the processes that necessarily tag-along with EHR implementation have practical function in the real world. For example, handing a patient a paper copy of a continuity of care document CCD*, together with 12-pages of discharge instructions, serves little purpose. Not surprisingly, many clinicians simply do not even know what a CCD* even is--nor should they need to know--any more than we need to know the underlying formatted structure of the receipts we sign in restaurants and retail merchants.  Each format is different from the next, and even though the data elements are identical, we commonly just scan for the bottom-line, whether paying at a restaurant, or understanding what actually happened with a patient. In the case of a patient “represented” by a CCD, chances for successful electronic transmission and succinct presentation of the “bottom-line,” are marginal, if at all present.

Over the last few years, the rush to implement EHRs in time to get meaningful use money has forced hospitals to make decisions based too fully on financial considerations, instead of on finding practical, real, solutions to improve quality of care, and safety. This has led to user (physician) angst and chronic end-user (patient) uncertainty.

Institutions have also tried, not-surprisingly, to solve long-term efficiency issues with computer-based solutions that don’t address underlying issues. For example, an electronic bed board may say that room 222 is ready to be cleaned, but if the system cannot assist  housekeeping personnel to get there in real-time, the patient destined for that room—once cleaned—is still taking up a bed in the ED. An overcrowded ED is an unsafe ED.

Turning providers into “data jockeys” has thus created cumbersome workarounds, increasing risk, decreasing safety, and decreasing quality.  While some of these workarounds are quite creative, it is of value to recall what has been lost from the inherent benefit, simplicity, and efficiency of paper and pen. 

There is hope, though. Perhaps the media will one day say about meaningful use vis-à-vis such simplicity, what Elwood said to Jake in the Blues Brothers (1980) “It wasn’t a lie, it was just bulls_ _t.” 

With costs increasing and reimbursements under constant scrutiny, there will continue to be a huge push to have user friendly Electronic Health Records with Artificial Intelligence features that ensure safety, quality, efficiency, and also save money.  But that’s the future, and it is clearly not yet here.  In the meantime, we have to figure out how to preserve the essentials of safe, high-quality care delivery in the ED, now, in the present, in 2014 and for some years to come.

* The CCD (Continuity of Care Document) is one of several electronic templates proposed by standards organizations to enable interoperability (electronic sharing and reuse) of medical information.  The CCD (as well the CDR, the CDA-R2-CDA, and others) has been constructed to standardize and facilitate rapid transmission of a summary of the patient’s recent course and current condition, readily showing vital signs, family history, plan of care, and so on.  The CCD, however, is not considered the best formulation by everyone. There have been multiple CCD releases over the past decade, all the while trying to establish a standard format into which an EHR can automatically input a summary of the medical history, and output the CCD as an HTML-type document that can be sent to, and read by, other EHRs.  Hence, again in theory, any CCD should be electronically transmissible between differently constructed EHRs, installed by different vendors, and operating cross distances.  Achieving this would be something like building standard fuel pumps for automobiles, so that no matter what the engine happened to be, fuel-pump replacement on a Mercedes would be the identical to that on a Ford. 

Wikipedia says:  “The patient summary contains a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to another practitioner, system, or setting to support the continuity of care. Its primary use case is to provide a snapshot in time containing the pertinent clinical, demographic, and administrative data for a specific patient.[1]"


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