I am not an expert on Electronic Health Records (EHRs), and I never want to be. Nor do I want most people to be experts on EHRs. For that matter, the vast majority of doctors, nurses, and other healthcare workers should never have to become experts on EHRs or even pay much attention to them. But there is a frenzied flood of discussions of EHRs in the healthcare reform debate that has too many people paying too much attention to EHRs and not enough attention on how we can use them to deliver care differently. We are obsessing with the tools and plumbing of healthcare, as if each us should also be an expert on the minute details of components and standards for the wiring, piping, and architectural specifications of every building that we walk through.
Don’t get me wrong. An EHR is a critical piece of infrastructure for reducing healthcare costs, improving patient safety, coordinating care across multiple providers and specialists, doing new drug and treatment discovery, engaging patients in adherence to their care plans, and delivering care to patients remotely and in their own homes. I have personally suffered as a patient at the lack of EHRs: from wasted time and money as I have been sent back to the clinic for repeated tests because my doctors can’t find the faxed copies that the nephrologist sent over…to more dangerous situations where I have several times been over-prescribed blood pressure medications because the specialists weren’t operating from the same medication list of what I was taking.
But the frenzy over EHRs threatens to undermine their very value. We are whipping up such high expectations for what an EHR can accomplish that no solution will ever meet those impossible requirements. Here are some of my worries about how EHRs are being conceived of and talked about.
1) Over stimulating the focus on tools, not tasks: As someone working in the technology sector, I don’t mean to seem ungrateful about the $17B in the HITECH part of the stimulus package designed to help physicians and hospitals adopt EHRs. But this flood of money is driving people to rashly focus on EHRs and the tools without much attention to what tasks they want to accomplish in their organization. It’s hard to choose the right EHR for the job if you aren’t clear up front what you want to do with it…what problems you want to solve in your practice or what new care models you want to enable. Perhaps the definitions and requirements from CMS for “meaningful use” of an EHR will help insure that the EHR adoption is guided by a right-tool-for-the-job mentality, but it’s too soon to tell. As I heard U.S. CTO Aneesh Chopra put it recently, “let’s focus on the verbs, not the nouns.” The verbs are those practices, solutions, services that we want to do with an EHR…which should be top of mind before any organization heads down the EHR path.
2) Perpetuating the mainframe healthcare model: If we spend all of these billions of dollars to get clinicians up on EHRs that perpetuate the old way of doing healthcare (reactive, mainframe-focused health care through face-to-face-fee-for-service visits), then we’ve only entrenched 19th century thinking in 20th century technology for 21st century challenges. We need organizations to be thinking about how to serve their patients and to deliver care differently in the very near future…and then choose EHR solutions that help them achieve that mission. For example, what does an EHR designed for a team-based care paradigm look like? How different would an EHR be if it is designed up front to send knowledge and training to the patient in their own home? If we’re going to pay based on outcomes and quality, not quantity of visits, does that change the way EHRs are designed and deployed? Let’s make sure we’re building infrastructure for the healthcare information highway into the future, not the past.
3) Health IT = EHR = Hospitals = Doctors: Based on the 100s of meetings I have had with healthcare policy makers, I can tell you that their horizon of imagination for health IT doesn’t go much beyond EHRs. Even worse, most are so focused on getting EHRs installed in hospitals and acute care settings that they ignore the different needs and requirements of key sectors like long term care and chronic care. Their discussion defaults to “doctors” which may just be a linguistic problem of using the word “doctor” to refer to all healthcare workers. Or it may be a more serious problem if we are truly ignoring nurses, for example, who we have seen in our fieldwork over the past 10 years to have very different needs, vocabularies, data sets, and workflow experiences than doctors. (To be more accurate…there are multiple kinds of “doctors” and “nurses” who have very different needs from an EHR…so we really need even more segmentation than our common language allows). If we only provide stimulus for doctors in acute care settings, then the un-interoperable era of fax machines, redundant labwork, and clinical guesswork will continue.
4) Small medical practices are being ignored: The other revealing assumption that I hear in the EHR discussion is that there is a healthcare Chief Information Office or Chief Technology Officer…or even “some IT person”…to handle the selection, installation, and implementation of an EHR. In my own fieldwork experience—and in the comments I hear from experts at conference after conference—the majority of physicians and nurses in the United States practice medicine in small clinic operations. There is no CIO, CTO, or health IT specialist on staff. More often, we’ve seen one physician who is tech savvy try to learn enough and inspire the rest of the clinic enough to “go electronic.” If we truly want to drive EHR interoperability and adoption across America, then we’re going to have to develop a “small business” package of stimulus and training that reaches the majority of clinicians who aren’t supported by a big IT enterprise like a hospital is.
5) Better is the Enemy of the Good: There are way too many EHR vendors and solutions and, as a result, there are probably way too many consultancies thriving on this complexity and confusion to “help” clinicians adopt EHRs. I counted over 300 EHR companies on a list I saw here and there were a frightening number at http://www.emrupdate.com/ as well. Over the years, I’ve had the privilege of working with Andy Grove, an Intel pioneer and our former CEO, who frequently and wisely says some version of “don’t let the ‘better’ be the enemy of the ‘good’.” We should aim first for basic interoperability between clinics and specialties…surely the market is not yet ready for hundreds of different solutions, if it will ever be. Aiming for a “good enough” baseline of standards, interoperability, and functionality will become the “platform” upon which much more innovation can occur. But if we persist in overwhelming this fledgling market with too much specialty, customization, and complexity too soon, we may never get there.
6) Cultural change is the real adoption problem, not cost: Finally, I feel like there is one grand myth that stands in the way of widespread EHR adoption: that cost is the problem we have to solve. That “if only EHRs were cheaper, then more people would use them.” The social scientist in me is convinced that even if EHRs were free, we’d still have a major adoption problem. And I’ve seen this time and time again as I have studied small and medium-sized clinics who are going through the process of adopting EHRs. The doctors and nurses will make all of the classic arguments (often in this order): “we don’t need it!”; “it’s too complex and difficult to use!”; “it’s too expensive!” But when I observe them eventually knocking down each of these barriers (they figure out what they want EHRs to do for them, which ones have good usability, and find ways to pay for it), they are faced with the real problem: how to change their culture and behavior to integrate this new system into their daily lives at work.
It is this cultural adoption problem that is the biggest challenge—the biggest fear—that policy makers and providers both need to understand must be overcome as we “stimulate” EHR adoption in America. Through the powers of Google, I just found a whitepaper that Intel anthropologist John Sherry and I wrote ten years ago called Changing Practices: Computing Technology in the Shifting Landscape of American Healthcare. While those findings still resonate with things I see happening today, that double-meaning title still underscores the big challenges for EHRs and reform: 1) we have to change the everyday practices of healthcare workers…and 2) our notions of what it means to “practice medicine” have to change. Change is scary. Change is hard. Change is often resisted with every excuse that we inventive humans can come up with. And that’s the real reason we come up with lots of other reasons to avoid adopting EHRs.
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