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Tuesday Jun 09, 2015

The EHR Conundrum: How We Got Here, How to Change It

In 1966, Lockheed and others introduced what came to be known as clinical information systems. Throughout the intervening years, the concept of the electronic health record (EHR) has evolved and shifted focus,ostensibly to meet the needs of physicians and patients. Transitioning from paper charting and ordering systems to computerized electronic records seemed like a logical step.

Why? Paper charts are heavy, fragile and difficult to correct. Searching through them requires large investments in time, money and personnel. Storage costs alone make large volume data management untenable. Most other industries instituted the paperless model decades before health care did.

Here I am entering data in my electronic health records (EHR) system. Physicians could help improve on the woeful state of the current EHR morass.

Obviously, a data-intense profession like medicine could benefit from a well-designed, properly functioning EHR. From allergies to surgeries and everything in between, we collect volumes of information on our patients. In theory, the EHR serves as searchable, well-organized storage for the information we collect about those patients and their health.

Unfortunately, reality often falls short of theory.

Although it would be easy to blame any one entity or system, the EHR problems many of us encounter daily resulted from many small failures spread across decades. The result, what is probably better termed an electronic billing system, incites almost daily discussion among clinicians across the country.

"This EHR takes too long."

"The extra garbage in this chart makes it unreadable."

"This record was entirely cut and pasted from previous notes."

Not only do the problems lead to errors in communication, they create potential harm to patients. Similar issues existed with paper charts. As a clerical worker in a medical office, I was once tasked with retrieving 40 paper charts for one of the clinicians. She was in danger of losing her hospital privileges if the old charts weren’t completed and returned, so I dutifully loaded the files into the back of my Jeep and ferried them back and forth. Fortunately or unfortunately, without social media and the Internet, we as clinicians weren’t discussing the problems on such a large scale or in such a public forum.

As with many things in the public sector, money caused most of the problems inherent in the EHR morass. For decades, the billing systems we use in medicine consisted of a database of names, addresses and identifying demographics. These existed long before the medical records systems and were often separate pieces of software designed for speed and return on investment. Sadly, most EHR software is built around those same ideas. In contrast, paper charting, while often reviewed for billing purposes, focused more on communication: what problems, medications and long-standing issues existed for each patient. Much of the content was historical and factual information designed to jog the physician's memory on repeat visits or communicate with other physicians.

In the 1970s, Medicare began using the chart as an audit tool for appropriate billing, and the landscape of charting never recovered. In the face of required numbers of questions and physical exam components, the medical chart became a series of checklists with the occasional reminder scribbled at the end. In both the inpatient and outpatient setting, medical records began the slow devolution into a billing document.

Rather than succinct and pertinent information about chronic problems or surgical history, EHRs cobble together long lists of material. Look at most medical records summaries in an EHR, and you’re likely to find redundant and often immaterial information hiding what actually matters. This is partly due to the fact that the information a specialist or a billing and coding program needs varies from information recorded for physician or health care provider benefit. Although the ICD-9 codes support appropriate billing, the descriptions attached to those codes are inadequate to describe actual pathology.

For example, if my patient sprains the anterior talofibular ligament of his or her right ankle, the code descriptor that most EHR programs attach to the appropriate billing code (845.09) is “other sprains and strains of ankle.” Although ICD-10 improves on this specificity, the communication still suffers because I cannot glance at this information and quickly assess the pertinence to my patient. This, in turn, encourages physician requests for more information, which clogs the narrative even further. Careful charting and records maintenance can alleviate some of these issues, but it’s still time-consuming and expensive.

In the hospital setting, this can be even more frustrating because patients see multiple physicians from multiple specialties, each of whom records information according to their own preferences. Template systems, though useful for personal preference and ease of use, often muddy the record further because the displayed information takes different formats from template to template. Dictation improves the narrative form of notes but is often not searchable, decreasing the efficacy of the medical record as a whole. In essence, we have cobbled together several disparate systems to accommodate preferences and costs, but we have sacrificed the overall narrative of the medical record and ease of use.

We check the boxes. We get paid. And, unfortunately, that return on a sizable investment is limited by the utility we receive in addition to billing. Most offices spend tens of thousands of dollars for EHR systems that produce unreadable records and incoherent communication, but they persist in using them because receipts increase once everyone gets on board with the system.

Hospitals attempt to help by subsidizing the system, but expensive components of the EHR are deemed ancillary and not purchased. Communication between EHR software requires costly translation components, and already narrow margins necessitate avoidance. No one entity is at fault, but the snowball keeps rolling and collecting more debris along the way.

Now that I’ve painted such a bleak picture, the question is obvious. How do we fix it?

The answer isn't simple. We need changes in infrastructure from the top down and the bottom up. It’s not going to be cheap. Neither will it be easy. The EHR systems in place are a stopgap to a better system.

Hospitals will need improved communication with vendors, physicians and other health care providers, focusing on accurate and appropriate record-keeping without sacrificing the billing aspects. Emphasis should be placed on enhancing outputs, both electronic and paper, such that records generated for review are not only accurate and complete, but legible and with minimal unnecessary internal markup. Thought must be given to long-term outcomes, not just immediate loss or return of investment. These systems, if correctly designed and implemented, should evolve with changing needs. Thus, a sizable initial investment would provide a viable product for decades, not just a few years.

Physicians, especially those of us in primary care, must contribute design ideas, while respecting the limitations of computer systems. In other words, ask for output, but don’t demand that it be created in a specific way. Too often, the overcrowding we experience in EHR interfaces is due to physician requests. If we limit ourselves to asking for what we need, the conversation becomes more comprehensible for the information technologists. These conversations will require tech-savvy graduates to translate much of the technology used daily by Generation X and beyond. In essence, we need physicians who speak the language of technology to translate the breadth and variability of medicine for the often laser-focused technology world.

All easier said than done. I realize that money, time and resources are finite. I simply posit that we could be using those finite resources more constructively. As new physicians -- most of whom grew up in a world that always contained computers -- we have a unique opportunity to step in and make changes for the better. Volunteer for EHR committees at your hospital. Seek jobs with medical records vendors, even as a consultant. Write notes that you would want to read. Take the time to learn the systems you use most effectively. In the long run, we will be better for it.

Gerry Tolbert, M.D., is a board-certified family physician who practices in northern Kentucky. A lifelong technophile, his interests include the intersection of medicine and technology. You can follow him on Twitter @DrTolbert.

Posted at 04:28PM Jun 09, 2015 by Gerry Tolbert, M.D.

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