Tuesday, June 14, 2016

EHR's Continue To Underwhelm

Late one night early in my career a fellow colleague and I were locked in a debate over the future of home automation systems. Near the end of this discussion he said "Everyone knows how to use a light-switch, and if they don't it's almost immediately obvious how to operate one." He was right, nearly everything on the market that attempted to improve on this design had fallen short because the light-switch in its underwhelming way is really a master of user interaction.

In health care I often think of the "Chart" hanging from the end of the bed as the light-switch. Although not nearly as perfect it too is quickly understandable to the seasoned clinician. Upon first sight you see it's thickness, you can almost feel the weight of the ink clinicians before you have left. The pages are turned up at the edges from the daily flip through the top sheets. Even before picking it up you know this isn't a scratched knee, and you too will have contributed to this unwieldy stack before this visit is through.

Earlier this month The Journal of the American Medical Informatics Association published another article chronicling the shortfalls of the modern Electronic Health Record system, specifically with regards to captured clinical and mental health data. The numbers were damning reaching has high as 60% of outpatient days going undocumented in some cases. This probably doesn't come as a surprise to many clinicians, missing documentation is just another symptom of the EHR diagnosis, terrible design.

These systems were never designed with the patient in mind they were designed, as many systems are, for billing. Capture of data is almost exclusively focused on how you're going to bill. Something as straight forward as open-up an say awe, now requires you to add new procedure - "Visual Cavity Inspection (Mouth)" - inflammation detected. A second interaction now leads to another minute of more clicking and typing, all while attempting to maintain an awkward half focused conversation with the person you are now writing about. It just gets worse from here.

EHR's coming of age was prior to the simplicity design revolution fueled by the massive move to mobile computing. Back then screens where designed with as many data entry fields as possible to maximize it's efficiency. Design was often "inspired" by the paper forms the system was replacing. Iteration after iteration added more fields and more rules to comply with the ever increasing number of regulations now made possible with this technology. Eventually CMS unveiled Meaningful Use and its EHR Incentive programs. The goal was admirable, to push this technology into wide spread adoption and hopefully improve patient outcomes and accountability along the way. What happened instead was a massive suppression of innovation in the name of progress.

As is often the case this story played out with painful predictability. The established companies in the space quickly picked up certifications needed for their clients to receive the meaningful use incentives, and began integrating new customers as quickly as possible. Because the money was subsidized and failure to comply with Meaningful Use could hurt billing revenue, administrators rushed into the open arms of the EHR vendors. For years this continued, innovation virtually ceased as sales pipelines for integration stretched into the years. This shouldn't be a surprise competition is the mother of all innovation, and with so many new customers there just wasn't a need. Sales could be won simply based on when an implementation could take place.

Now 7 years after the American Recovery and Reinvestment act we're beginning to see the effects. Some are good, many are not, patient physician interaction time has plummeted as more and more time is spent maintaining the EHRs. Employee satisfaction especially among PCP's is also on the decline. Integrations to nowhere and walled gardens of patient data are degrading the ability of providers to provide quality care and patients to understand it. As healthcare continues its move to a more outcomes based methodology, so must the EHR systems.

Healthcare organization leaders must challenge their vendors to provide systems that improve the patient experience and not merely document it. Looking beyond which boxes are checked for Meaningful Use incentives but for a definable focus on the patient and there experience as well as the clinicians caring for them. Only then will can meaningful innovation begin to come through.

References: http://jamia.oxfordjournals.org/content/early/2016/04/12/jamia.ocw021

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