The Health Affairs Blog posted a very interesting critique of EHRs recently (see: The Strategic Challenge Of Electronic Health Records). It was so good that I wanted to cover in detail in Lab Soft News. I should also point out that this blog is not a pawn of the healthcare IT lobby like HIMSS and can be more honest about EHR issues. The article was long and dense so that I have decided to split it into sections and, in this note, will cover only the lead paragraph, that I present below:
Despite a 2005 prediction that electronic health records (EHRs) would save $81 billion, RAND Corporation just validated clinicians’ complaints in a report describing EHRs as “a unique and vexing challenge to physician professional satisfaction.” The American Medical Association also published EHR “usability priorities” – strong evidence that current EHRs don’t support doctors in practicing medicine. In a world of Apple-typified simplicity, why is it so hard to get the right EHR? Because, unlike Apple, EHR designers haven’t started with the question of how value can be created for users of the technology. Technology isn’t the problem. The challenge is in articulating clinicians’ information needs and meeting them by making the right tradeoffs between corporate and business unit strategies. EHRs can, and should, provide relevant information when and where clinicians need it, recognizing that care is not a commodity and that different care processes have different information needs. User interfaces must anticipate clinicians’ needs rather than require individual user design. EHRs need to eliminate low-information pop-ups and alarms and instead provide alerts and reminders that are both timely and relevant. They must be designed with assiduous attention to data entry requirements, replacing blind mandates with thoughtful assignment of the task and the timing.
I have spent a lot of time contemplating the question raised above: In a world of Apple-typified simplicity, why is it so hard to get the right EHR? I have come to the following conclusions in response to it:
- First and most importantly, hospital executives have been saddled with the burden of a premise that is not accepted in any other U.S. industry. It's the idea that it's possible to manage most of the important hospital computing tasks with a single, massive information system. This idea was promoted by IBM in the 70's and 80's with their so-called Hospital Information Systems (HISs) and continues to hold sway today with the electronic health record (EHR). It's easy to understand why this idea had so much appeal for IBM since it was the vendor of "big iron." The leadership of pathology, radiology, and hospital pharmacies never bought into this idea, turning to the software market for specialized departmental systems like LISs and RISs. In truth, IBM never bothered to write software for the hospital diagnostic departments and pharmacy because they did not consider them large and lucrative enough and they also lacked the expertise to do so. Unfortunately, the major HR vendor Epic is now writing software for the diagnostic departments with its Beaker and Radiant systems.
- This assumption of deploying "one big hospital information system" has resulted in EHRs designed primarily to capture patient charges and support billing but also to support healthcare delivery by physicians and nurses. As the article cited above notes, EHRs simply makes their jobs more difficult. If you turned off the LIS or RIS/PACS in any hospital, pathologists and radiologists would revolt. These latter systems have been designed to support specialized lines of business (LOBs) and are carefully selected by the diagnostic departments for optimal functionality. If you turned off the EHRs in hospitals and replaced them with specialized systems that made their jobs easier, physicians and nurses would cheer. Healthcare is the only industry in the U.S. where the federal government needs to bribe the industry with cash payments in deploy IT. This says a lot about the the "usefulness" of these systems.
I am hopeful that hospital executives will soon realize that it is not in their best interests to saddle their highest paid and most skilled employees, physicians and nurses, with such an inefficient tool as the EHR but this realization may take a while to achieve.