An electronic medical record has been recognized for almost two decades as a critical vehicle to give all appropriate caregivers access to all health information on an individual. The information needs to be complete and presented in a form that allows expeditious knowledge of current issues with easily accessed links to all background material including images. Additionally, information entry must be formatted so that all necessary data is collected with minimal time spent on the part of the clinician.
The Current Status of the Health Records System
The importance of an accessible electronic health record in minimizing the concerns regarding the documented high rate of medical error and the substandard health results in the United States was recognized in the 1990’s. Pressure was brought to bear on hospitals and care providers to move to an electronic format. In the economic stimulus legislation of 2009 money was allocated to provide economic help to facilities moving to computer driven medical records. This allocation now amounts to around $37 billion. To set standards for these records and to set criteria for content an Office of the National Coordinator for Health Information Technology (ONC) was established. ONC together with the Centers for Medicare and Medicaid Services (CMS) began to set rules for “meaningful use” to maximize the value of the investment.
In spite of the money invested and the regulations applied the current status of the EHR is recognized as clearly suboptimal in achieving the majority of the original goals. An editorial in the Wall Street Journal in March of 2018 by pediatrician and a nephrologist state the current attitude of many, if not most, clinicians: “…EHRs divert doctors’ attention from the patients. Physicians often rely on visual cues when taking a patient history, but now what’s visible much of the time is a computer screen. The outdated EHR technology is difficult and time consuming, contributing to doctors’ stress and burnout. The unintuitive interfaces consist of multiple drop-down menus and forms as well as countless boxes to check and pages to navigate. The screen often freezes. It takes seven clicks to order basic antibiotics, 14 clicks to order stronger ones. It’s death by a thousand clicks and it’s killing the medical profession.”
All this negative experience is in the presence of a failure of the various brands of medical records to communicate or provide easily available information. The positive is that the vast majority of hospitals and physician practices are now using some form of electronic format. The problem is: “Along the way, however, we lost the hearts and minds of clinicians. We overwhelmed them with confusing layers of regulations. We tried to drive cultural change with legislation. We expected interoperability without first building the enabling tools. In a sense, we gave clinicians suboptimal cars, didn’t build roads, and then blamed them for not driving.” “Instead of a gift horse that reduced clinician burden, the EHR became an expensive Trojan horse loaded with an array of new regulatory requirements.. ” (Halamka & Tripathi: Perspective: The HITECH Era in Retrospect, N Engl J Med: 377: p.907-909, Sept 7, 2017).
Collecting quality data on hospitals and physicians was an integral requirement of ONC. The idea was that the quality measures could be accessed easily from the EHR. This goal has not evolved successfully as yet. A recent survey showed that the data acquisition requires expensive software and a high level of IT expertise while producing data that the clinicians find of doubtful validity. (Cohen, D. J. et al: Primary Care Practices’ Abilities and Challenges in Using Electronic Health Record Data for Quality Improvement. Health Affairs 37: p.635-642, April 2018). The outcome of this effort is to create substantial, and probably unquantifiable, costs that are part of the administrative costs of medical care in the United States that are higher than those in the rest of the world (Shuster, MA: Viewpoint: Measuring the Cost of Quality Measurement. JAMA 318: p1219-1220, Oct 3, 2017 and Papanicolas I et al: Health Care Spending in the United States and Other High-Income Countries. JAMA: 319:p1024-1039.).
Suffice it to say, that the current versions of the EHR are not able to accomplish the potential pivotal role of this technology in facilitating and coordinating patient care while easily providing the quality data that quantitates the success of medical progress. What do we need to expect of the EHR if we are to achieve our goals of the best healthcare model?
What Is Required for an Efficient Medical Records System?
First and foremost: Interoperability: Any healthcare provider needs expeditious access to the patient’s complete medical record at any encounter. Currently each vendor uses their own format and their own nomenclature so that interchange is simply not feasible. Meaningful Use has brought pressure,deleting has begin to use a common nomenclature such as SNOWMED-CT (Systemized Nomenclature of Medicine-Clinical Terms) starting the transition to interoperability, but the process seems slow given the critical need for this aspect of the medical record. As long as each clinician caring for the patient does not have access to the patient’s current history and cannot enter any evaluation and intervention into that record we will not have the level of coordinated care needed to differentiate the United States in reaching a higher level of individual health and survival.
- A Standard Format: A standard, intuitive electronic format should be used so the clinician can expeditiously navigate the record regardless of who or where they are.
- A Current Patient Problem List: There should be a list of all difficulties with which the patient is currently addressing as the first material seen on the record. Each clinician should enter their findings and activity into the appropriate problem area on the record. When a problem is alleviated the treating clinician should move this affliction to the past history. There does need to be a complete past history and social history with pertinent updates on the social history section as the patient’s situation may suggest.
- A Current List of Medications and Allergies: In the past there was a push for “medication reconciliation” with every hospital admission. This proved immensely difficult as the patient was taking medications from various sources and often was not clear as to what these were. Accurately identifying exactly what medications the patient was taking often required the work of a doctor of pharmacy and multiple phone calls to pharmacies from which drugs were acquired. Each time a clinician reviews the record he/she needs to verify the current validity of the list. Since patients are not always taking what is prescribed an optimal addition would be for the pharmacy to input each time a drug was renewed so that the care givers would at least know how often the medication was purchased on the concept that if the patient goes to the effort of acquiring the drug there is a reasonable chance they are taking it.
- Quality Measures Standardized and Easily Accessible: As mentioned, the input and acquisition of quality measures has become a major inconvenience and cost. It is clear that meticulous data must be available to assure that excellence is rewarded and that failure is apparent and can be addressed. The EHR format should be constructed so that all necessary quality data points are captured and collated with minimal unnecessary effort on the part of the caregiver or the administrative staff.
- Privacy of the Record Should Be Controlled by the Patient: The patient record belongs to the patient, a concept that has not always been a reality. There should be some means by which the patient allows access to the record. The methodology to accomplish this goal may be a challenge in that limiting access should not add to complexity. The patient carrying a version of the French Carte Vitale, a credit card format with pertinent information stored, is a potential possibility but this may not be the best solution as the US program evolves. An added challenge is that there needs to be some method to reach the record if the patient arrives unconscious or otherwise in a state not able to cooperate sufficiently to use the usual access method.
How Can Transition to the Optimal Electronic Health Record Be Accomplished?
As a rule the solution to evolving an optimal medical record should be the product of competition with the market rewarding the most effective and efficient product. In this situation the market place has failed. The multiple competing EHR vendors have created a Tower of Babel that does not serve the patient or the caregiver. It is difficult not to conclude that there will need to be a central expert group designated by government that will establish the road to the standard medical record. The “meaningful use” effort seems to be too incremental and protracted to make the expeditious leap that will be required. A truly expert group, free of influence of lobbyists who would impede the process, will be required. This might be the National Academy Medicine. Whatever group is given the task they must have both authority and prestige to make this necessary upheaval successful.