We live in a world where an app notifies me if my flight changes times or gates. I can take a photo of a check and deposit it. With two clicks on my watch I can pay for groceries, apparel, and more. Yet, as health care providers, we use electronic health record (EHR) platforms that look, feel, and navigate like something from Windows 95.
For an industry that routinely boasts about technological advancements, it’s embarrassing that we are using EHR tools from a decade ago.
When it comes to how health care organizations are working (or coping or struggling) with EHRs, it’s an understatement to say that we live in interesting times. What we once hoped would be a transformative tool for health care improvement is too often a source of confusion, frustration, and — worst of all — potential harm to patients.
The Biggest EHR Challenges
- The primary focus of today’s EHR design is the long list of regulatory reporting and billing requirements. One example is ensuring we get “full credit” for the “patient education” Meaningful Use requirements. Each time a provider generates a note in the record, they have to check a box indicating that “the patient understands their diagnosis and treatment.” Instead of focusing on the care outcome, documentation has been the measurable event. I challenge the assumption that checking this box results in greater patient understanding.
- Clinical decision support has been a big focus as Meaningful Use evolves. Pop-up alerts in the EHR when clinicians miss critical steps for high-risk events are valuable, for things like ensuring ventilator bundles are in place. Alerts do not make sense, however, when there are too many of them — for example, reminders about the dozens of ways to assist someone with the control of their weight, blood pressure, or diabetes. Reminders like these add work and distract from conversation with patients as providers bury their faces in computer screens to make sure they record all of the measurable requirements during the 15-minute office encounter. Better documentation does not necessarily lead to better health care.
- The requirement to exchange patient information between vendors is a nightmare. Various EHRs assign different codes to medications, care events, education events, labs, etc. Interfacing between these data sources to standardize all of it is extremely difficult. Resolving these conflicts will be a huge but necessary undertaking. This is a problem which exists mainly because the design focused on vendors and organizations, and not on the people served.
Opportunities to Use the EHR to Improve Quality and Safety
By using customer behavior data, the retail industry can predict if you are going to get married, divorced, have a child, go to college, or buy a home. They do this by identifying patterns. Yet, despite all the data at our disposal, we in health care cannot seem to recognize a negative health care trajectory (let alone what to do about one). Why? Because the technology we have focuses on disease, payer models, and standardized clinical protocols.
Health care has the opportunity to do something very different as we move into the future, but only if we change this mindset. We don’t need to do more work; we need to better analyze the work we already do.
For example, at Southcentral Foundation in Alaska, we analyze data from a patient-centric perspective. As the customers we serve move between different care settings (e.g., the ER, office practices, pharmacies, labs, mental health counseling, the hospital, etc.), our master index has unique identifiers for each of them that can help us identify patterns. We can link these patterns to measurable outcomes in cost, satisfaction, and visit types. Using this data, we can then attempt to create new models of risk prediction based on measurable events, like the amount of medication prescribed and dispensed, or admissions and readmissions to the hospital.
Imagine looking at the data on the collective behavior of the clinicians in your entire organization and directly comparing this to clinical costs and outcomes of the people you serve. Health care is not about the organizations and people that provide care — it’s about the patients — and thus we need to start working more as one health care team, instead of dividing ourselves into specialists, acute care, primary care, etc.
The Risk of Retrofitting
As we create new EHR systems, the struggle will be to avoid the temptation to “copy and paste” the old world into the new one. Simply moving the same practices developed for paper-based records into an electronic records platform would be a failure of such magnitude that it would take years to undo.
Think of it like spending $300,000 on the latest technology for a home theater system and connecting it to a VHS player. This is not what we want or need.
Until the health care industry can be truly patient-centric — that is, focused on the people we serve and not on making money — we are not going to change.
While there is risk in all new organizational behavior, there is also risk in avoiding change. In the rapidly evolving health care environment, staying the same creates more risk than it avoids.
Southcentral Foundation’s approach to redesigning our health care system focused on asking the people we serve what they wanted. They requested bold changes, including same-day access, integration of mental health care, a single medical record across all disciplines, complementary medicine, traditional healing, workout facilities with exercise and wellness coaches, domestic violence and addiction support programs, and a medical home focused on the family. Many of these programs, even today, still have no reimbursement and the organization had to make the choice between quality focused on the consumer, or revenue driven by an older model of care. As a result, however, Southcentral has achieved unprecedented results, including a more than 50 percent drop in ER visits, hospital days, and specialist visits; an employee turnover rate of less than 12 percent (annualized); and more than 90 percent customer and staff overall satisfaction rate.
What do your patients want? And how can your EHR help you get there?
Steve Tierney, MD, is Medical Director for Quality Improvement at Alaska’s Southcentral Foundation, and a member of the IHI Leadership Alliance EHR workgroup.
You may also be interested in:
A Framework for Selecting Digital Health Technology: IHI Innovation Report
WIHI - Optimizing Safety with the Electronic Health Record: The Latest on Glitches and Fixes from the Frontlines