A recent article in the JAMA network discussed what the authors termed "evolutionary pressures" being placed on EHRs and provided a critique of some of the shortcomings of these systems in the delivery of healthcare (see: Evolutionary Pressures on the Electronic Health Record). For me, the key quote from the article was the following: Bloated records, devoid of meaning and full of cut-and-paste content, are leading some to call for adopting a “less is more” strategy that prioritizes relevant information. The authors of the article then went on to make the following point:
At present, the spectacular effects of computers in science and in the secular world are not reflected in the EHR, which for physicians remains burdensome, all-consuming, and far from intuitive; this is not surprising, when 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. Deimplementing the EHR could actively enhance care in many clinical scenarios.
I was struck their use of the term "evolutionary pressures" in the article. I interpret this as being synonymous with pressure to make EHRs better adaptive to the needs of healthcare providers. How can this be the case when the suggestion is made in the article that "reimplementing" them could serve to enhance many clinical scenarios? In a Darwinian world, poorly adaptive species are destined to disappear.
Generally speaking and in a free market economy, buyers of a product usually have a major effect on the quality of goods being bought. In short, customers don't buy poorly designed or manufactured goods so vendors vie for business by constantly improving them. It seems to me that there are seven major reasons why we are then burdened by EHRs that don't serve us well:
- EHRs are large and monolithic rather than modular. Many have at least some very old code at their core that was developed many years ago. All of this makes it difficult to deploy meaningful improvements of them.
- Even for those vendors motivated to greatly improve their systems, their monolithic and complex status makes major revisions difficult to achieve.
- EHRs have been designed, as the article above emphasizes, mainly for purposes of efficient billing rather than optimizing the delivery of clinical services by healthcare professionals.
- Hospital executives are much more concerned with the financial status of their hospitals than the efficiency of healthcare professionals who work in these settings. Moreover, few if any of the executives have clinical assignments or work "in the trenches" so they do not experience first-hand the inefficiencies of the "bloated" EHRs.
- There is a quasi-monopoly enjoyed by vendors of EHRs, particularly at the high end, so the market is not a very competitive one. There is thus little pressure for vendors to improve or modify their products.
- Because of the quasi-monopolistic nature of the EHR industry, hospitals clients are unable to exert meaningful pressure on EHRs vendors who exercise a high level of client control over hospitals.
- The federal government, believing that "automation" of healthcare is inherently beneficial, has put pressure on hospitals to deploy EHRs, creating a large and lucrative market for them.