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King Arthur or Don Quixote: What Kind of Knight are EHR Systems?

debGuest Post from Deborah L. Benzil, MD, FACS, FAANS
Chair, AANS/CNS Communications and Public Relations Committee
Vice Chair, Neurosurgery
Cleveland Clinic Foundation
Cleveland, OH

Electronic Health Records (EHRs) danced into the medical arena like a knight in shining armor.  Promised were the magical stuff of legends, like King Arthur and Excalibur including:

  • Legibility;
  • Speed;
  • Cost containment;
  • Improvement in quality outcomes;
  • Patient education; and
  • Patient empowerment.

ehr 3After its introduction and voluntary adoption by a small portion of the medical community, a $20 billion provision of a stimulus package in 2009 was designed to encourage use. The American Recovery and Reinvestment Act (Pub.L. 111-5) included the Health Information Technology for Economic and Clinical Health (HITECH) Act and with it, incentives from the Centers for Medicare & Medicaid Services (CMS) known as “meaningful use” or MU. It was, however, a bait-and-switch operation. Physicians were promised that the financial incentives would help offset the costs of acquiring electronic health records (EHR) and the regulatory burdens of the MU program were downplayed. Instead, the financial incentives came nowhere close to offsetting the real costs associated with implementing EHR systems, and MU has proven to be one of the most burdensome and frustrating federal government programs.

Thus, the reality of MU and EHR implementation has been more like the mad Don Quixote, tilting at hallucinatory windmills! Basic problems include:

  • Acquisition of EHR systems was expensive and time-consuming;
  • The better software systems were particularly costly and difficult to modify (and necessary modifications could not be shared across institutions);
  • Smaller practices often chose very basic systems that performed poorly;
  • Many practices opted out, accepting the penalties;
  • Physicians were rarely consulted in design of the systems resulting in administratively clumsy systems, ill-equipped for clinical and patient use; and
  • Health care settings were not designed to incorporate EHR use in a way conducive to enhance the patient-physician relationship.

Beyond these general issues, was yet another regulatory requirement to include patient education within the EHR system. Again, the purported goal of enhancing patient education was laudable, but the required implementation faltered badly. It was a predictable scenario because, once again, practicing physicians were not adequately involved in establishing the program requirements and components. What we got was EHR vendors creating milquetoast write-ups on limited topics sold at additional costs. Some examples:

  • Back pain material consisting of three paragraphs saying this is a common problem, not usually serious and call your doctor for any concerns;
  • No material on brain tumors; and
  • No content on routine post up for common spine surgeries.

This information is not regularly updated and is not held to any standard in form or substance. To make these educational documents available to patients, a physician must execute a series of 10-15 additional clicks on the computer to find and produce this mediocre material  (time the physician spends facing the computer rather than interacting with the patient). No “credit” is given to thoughtful, personalized patient information many doctors created for their practices or for the provision of information about excellent, unbiased website sources such as disease-specific groups (such as the Muscular Dystrophy Association, American Brain Tumor Foundation, or the Parkinson’s Foundation).

The educational elements of EHR were particularly onerous for surgeons and the surgical specialties. For one, we often see patients multiple times before and after surgery for a single problem (herniated disc, ruptured appendix, torn rotator cuff, etc.). As each of these visits counts separately, to avoid financial penalties, a physician has limited choices:

  • Provide the same material for each visit (how would you feel as a patient if your surgeon did this?);
  • Risk not meeting the requirement by only providing the information at the appropriate visit;
  • Supply unrelated information; or
  • Smudge things by clicking all the keys but then not giving it to the patient.

None of these options seems appropriate.

Recently, I was skimming through my Brown Medicine Magazine and was encouraged by some of the work being done that has real potential for lifting current EHRs much closer to King Arthur status. Elizabeth Toll, MD, a dedicated physician educator, refused to accept the miserable status quo of the EHR. Her efforts led to a multi-disciplinary conference, “The Patient, the Practitioner, and the Computer. Holding on to the Core of Our Healing Professional in a Time of Technological Change.” The work of this group recognized and acknowledged the potential benefits of these systems, especially for increased patient access to information and educational benefit but also the undisputed downsides. Notably, these include physician burnout and cost. Around 50 percent of a physicians’ time may be spent between the EHR and other desk work; an average emergency room visit is estimated at over 4,000 clicks! Because physicians are not involved in EHR design, decision-making and implementation, physician workflow is not the driver of the systems (the Israeli system was called out as a singular exception).

In related efforts, the Brown Center for Biomedical Informatics is devoted to finding functional and viable means to mine and coordinate real data, including extraction from commercial EHRs (currently a monumental challenge and gaping inadequacy of these systems) with the goal of improving quality and value across medical care.  The founding director, Indra “Neil” Sarkar, PhD, MLIS, astutely noted, “One thing that is essential in informatics is to avoid getting in the way of a doctor being a doctor.”

Many regulations have an origin of knightly purpose, as did the educational requirement heaped onto other meaningful use criteria of EHRs. The challenge is to ensure the resulting red tape does not lead to madness, to deterioration in the core of our healing profession, or to counter-purpose. In Don Quixote, Cervantes perceptively states,

“When life itself seems lunatic, who knows where madness lies? Perhaps to be too practical is madness. To surrender dreams — this may be madness. Too much sanity may be madness — and maddest of all: to see life as it is, and not as it should be!

“For neither good nor evil can last for ever; and so it follows that as evil has lasted a long time, good must now be close at hand.

“Too much sanity may be madness and the maddest of all, to see life as it is and not as it should be.”

The time has come to cut through many of the EHR mandates, to engage willing physicians in design and implementation, and to harness real technological power to create systems that deliver on the magical Excalibur promise.

Editor’s Note: We encourage everyone to join the conversation online by using the hashtag #RegRelief.

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