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Tuesday Dec 18, 2018

You Hate Your EHR? Help Develop Something Better

I'm tired of medical professionals complaining about electronic health records (EHRs). I can't escape the exasperated and beaten expressions of skilled clinicians held hostage by flawed technology -- not in my own practice, not in print,(www.newyorker.com) not on social media.(www.youtube.com) Most recently, I called into my health system's monthly provider meeting and heard the raised and animated voice of a longtime physician colleague.

[physician entering data into laptop]

"Based on the way we're talking about it today, I wish I never helped introduce EHR in our practices!" he said.

When I say I'm tired of all the complaining, it's not because I disagree. The tool allows us to know and dissect the electronic profile of a patient, but it also impedes observation of the human sitting right in front of us. It's probably even worse for physicians who aren't millennials. (As much as I dislike generational categorization, it does reflect a truth regarding technological comfort.) To avoid getting in trouble in high school, I learned to make conversation/eye contact with my parents while I simultaneously typed in five different instant messenger chat boxes at 95 words per minute, doing "homework" with friends and classmates. My dad told me I was wasting time, but I'm convinced this skill now serves me well during patient visits, enabling me to both engage with my patients and finish my notes in a timely manner.

This level of efficiency in electronic documentation only works on days when I am physically and emotionally prepared for my patients. On days I am not feeling energized (perhaps because I didn't sleep well or I'm catching up from the day before), typing in the chart is a distraction. If my patients need to share their struggles, disappointments or trauma, I prefer to stop typing, swivel my chair to turn my body fully toward them and just listen. Documentation waits until later. Finishing 22 (or more) notes while mind-numbingly clicking through quality indicator measurements becomes a punishing end to an emotionally exhausting day.

It's in these moments that I wonder, when did our profession become so helpless that we allowed a tool to dictate how we practice our craft?

In 2013, near the end of my family medicine subinternship at the University of Arizona's South Campus hospital, I watched the transition from paper charts to a fully electronic system. South Campus was way behind in adopting the technology compared to the main campus hospital, which had, during the course of my undergraduate and medical school years, renovated its hallways to house shiny flat screens in recessed spaces; these screens took the place of the maroon plastic binders that once guarded patient information, orders and illegibly scrawled recommendations from consulting attending physicians.

At South Campus, wheeling around a shelf of binders on morning rounds was now obsolete. Instead, we rounded with a WOW (a workstation on wheels -- because apparently "computer on wheels" or "COW" could be misconstrued as an insult to passersby). We pulled up lab results, imaging and even notes from previous admissions, all with the click of a button. Throughout the day, we sat at a single workstation, monitored vital signs that nurses entered into the system, placed orders and typed notes. The work felt more isolated and sedentary -- albeit faster and in some ways more efficient -- after the change.

The possibilities of this new technology were endless. We could look at data, aggregate information quickly, automate basic tasks and visually trend labs. But it was by no means an easy transition. In addition to learning medicine, residents had to learn new software. Both the younger attending physicians and the more seasoned but passionate educators were excited about the change. Others, however, chose to retire rather than face the complicated new technology. I couldn't help but wonder then, as I do now, if these physicians, steeped in clinical experience, abandoned their responsibility to guide the new technology toward a better, more clinically relevant design.

Perhaps their departure was simply a harbinger of the loss of control we now feel. As technology becomes more complicated, and as engineers, entrepreneurs and programmers develop health care systems less reliant on physician-patient models, I understand our trepidation. The EHR, as an example, feels imposed upon us, its creation based in incomprehensible coding languages that we've outsourced to wizards who understand it. The final product has catered to the forces that drive and fund its development: profit, lawsuit prevention and government grants. Hence, I speculate, the emphasis on billing and coding, crammed superfluous documentation, and "best practice" indicators.

At its initial development, I doubt the technology was versatile enough to be designed for us: the physicians, nurses, health care practitioners. The "users." But now, even with more adept technology, software and app developers may not consider physicians as users until much later in the development process. A few nights ago, I pushed myself to attend a Meetup,(www.meetup.com) an in-person event organized using an online interest group, that explored blockchain and artificial intelligence (AI) in health care. I attended specifically to learn about the technology and how it might impact primary care. At the Meetup, a group of developers presented a prototype of an app that would allow patients to access health records directly from EHRs for verification of visa and immigration applications by government agencies. As an international traveler, I loved the convenience of the idea. As a physician, alarm bells went off the moment they said these documents needed review by doctors' offices before they could be certified.

"Full disclosure, I am a doctor," I said as I raised my hand.

Everyone else in the room knew each other from previous blockchain and AI meetups, so there was some curiosity as to who I was.

"I just want to make sure that if health care practitioners are interacting with this program to verify records, that they are considered users," I said. "Knowing technology limitations of most practices, especially those in developing countries, I don't want the nonsense of printing out, verifying, signing and then re-scanning documents back into the chart to become an increased burden."

Apparently, no one had thought of that before.

As I walked home in the cold that night, I realized, perhaps, the reason we are the victims of poorly designed technology is because many of us haven't yet elbowed our way to a seat at the table. The developers at the Meetup sought input from health care leaders and grant writers in medicine, but in their haste and excitement to contribute to the ever-expanding med-tech market, they forgot to get input from us, the ones in the trenches.

When it comes to EHR, I admit, even for those of us who are hell-bent on speaking up, transparency is a barrier(jamanetwork.com) to improving EHR usability and safety. In this environment, it is easy to feel defeated, shackled to tools we never asked for. Anger, powerlessness and apathy are only natural.

For better or worse, I believe EHRs will soon evolve away from what we currently use. Rather than focusing on improving the technology in its current form, our energy may be better spent shaping the technology of the future. Simply complaining about EHRs, then, means we are already behind.

Instead of avoiding technology we don't understand, I challenge us to delve deeper and question whether it constrains us from how we want to practice or whether it has the potential to assist in providing good patient care. If the former, I encourage us to find tech that is useful and find ways to drive the markets toward usability by rejecting products that don't do what we need them to do. Seek out developers looking for new ideas and help them obtain funding for tech projects we are passionate about, instead of hoping that someone will come ask us what we need. (Getting physician input early in tech development is one of the goals of the AAFP's new technology initiative.)

It is invaluable, as most good designers will say, to incorporate users from the beginning of the design process to ensure the product or solution is a reflection of the actual problem. So, if developers haven't found us, let's stop complaining and go find them.

Lalita Abhyankar, M.D., M.H.S., is a family physician practicing in New York City. You can follow her on Twitter @L_Abhyankar.(twitter.com)

Posted at 04:05PM Dec 18, 2018 by Lalita Abhyankar, MD, MHS

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