Anyone who follows health issues in the U.S. has to be obsessed with the workings of the Office of the National Coordinator (ONC). During the critical early phases of implementing HITECH and meaningful use, the National Coordinator himself was Dr. David Blumenthal, who came to speak yesterday in the Longwood medical area in Boston.
A long-time Bostonian, where he moved up from being a primary care physician, Blumenthal is now back at Mass General and Harvard Business School. Most of his speech yesterday was a summary of the reasoning behind meaningful use, but some off-the-cuff remarks at the end, as well as vigorous discussion during a following panel, provided some interesting perspectives. Best of all was hearing a lot of facts on the ground. These helped explain the difference between EHRs in theory and in practice.
Which comes first, electronic records or standard formats?
There were a lot of complaints at the forum about the lack of interoperability between electronic health records. Blumenthal declared twice that pushing doctors to adopt EHRs was a good idea because we have to have our information digitized before we can think of interchanging it. Coming from the perspective of having seen systems and standards develop–and having seen the mess that results from products out of sync with standards in areas ranging from CORBA to browsers–I disagree with this claim. Luckily, Blumenthal’s actual work didn’t match the simplistic “digitize first” approach. The ONC built some modest requirements for interoperability into the first stage of meaningful use and plans to ramp these requirements up quickly. Furthermore, they’re engaging in intensive negotiations with industry players over EHR standards (see, for instance, my write-up of a presentation by John Halamka last May) and worked quite early on the ground-breaking CONNECT and Direct projects for information exchange.
I understand that an ideal standard can’t be expected to spring from the head of Zeus. What perhaps the standards proponents should have worked on is a separation of formats from products. Most EHRs reflect an old-fashioned design that throws together data format, architecture, and user interface. Wouldn’t it be great to start the formats off on their own course, and tell EHR vendors to design wonderful interfaces that are flexible enough to adapt to format changes, while competing on providing clinicians with the best possible interface and workflow support? (Poor workflow was another common complaint at last night’s forum.) That’s the goal of the Indivo project. I interviewed Daniel Haas from that project in June.
Incrementalism in EHRs: accepting imperfection
Perhaps Blumenthal’s enthusiasm for putting electronic records in place and seek interoperability later may reflect a larger pragmatism he brought up several times yesterday. He praised the state of EHRs (pushing back against members of the audience with stories to tell of alienated patients and doctors quitting the field in frustration), pointing to a recent literature survey where 92% of studies found improved outcomes in patient care, cost control, or user satisfaction. And he said we would always be dissatisfied with EHRs because we compare them to some abstract ideal
I don’t think his assurances or the literature survey can assuage everyone’s complaints. But his point that we should compare EHRs to paper is a good one. Several people pointed out that before EHRs, doctors simply lacked basic information when making decisions, such as what labs and scans the patient had a few months ago, or even what diagnosis a specialist had rendered. How can you complain that EHRs slow down workflow? Before EHRs there often was no workflow! Many critical decisions were stabs in the dark.
Too much content, too much discontent
Even so, it’s clear that EHRs have to get better at sifting and presenting information. Perhaps even more important, clinicians have to learn how to use them better, so they can focus on the important information. One member of the audience said that after her institution adopted EHRs, discharge summaries went from 3 pages to 10 pages in average length. This is probably not a problem with EHRS, but with clinicians being lazy and taking advantage of the cut-and-paste function.
The computer was often described as a “third person in the room” during patient visits, and even, by panelist and primary care physician Gerard Coste, as a two-year-old who takes up everybody’s attention. One panelist, law professor and patient representative Michael Meltsner, suggested that medical residents need to be trained about how to maintain a warm, personal atmosphere during an interview while looking up and entering data. Some people suggested that better devices for input and output (read: iPads) would help.
Blumenthal admitted that electronic records can increase workloads and slow doctors down. “I’ve said that the EHR made me a better doctor, but I didn’t say it made me a faster one.” He used this as a lead-in to his other major point during the evening, which is that EHRs have to be adopted in conjunction with an overhaul of our payment and reward system for doctors. He cited Kaiser Permanente (a favorite of health care reformers, even though doctors and patients in that system have their share of complaints) as a model because they look for ways to keep patients healthy with less treatment.
While increasing workloads, electronic records also raise patient expectations. Doctors are really on the hook for everything in the record, and have to act as if they know everything in it. Similar expectations apply to coordination of care. Head nurse Diane L Gilworth said, “Patients think we talk to each other much more than we do.” The promise of EHRs and information interchange hasn’t been realized.
New monitoring devices and the movement for a patient centered medical home will add even more data to the mix. I didn’t ask a question during the session (because I felt it was for clinicians and they should be the ones to have their say), but if I could have posed a question, it would be this: one speaker reminded the audience that the doctor is liable for all the information in the patient’s record. But the patient centered medical home requires the uploading of megabytes of data that is controlled by the patient, not the doctor. Doctors are reluctant to accept such data. How can we get the doctor and patient to collaborate to produce high-quality data, and do we need changes in regulations for that to happen?
A plea for an old-fashioned relationship
One theme bubbled up over and over at yesterday’s meeting The clinicians don’t want to be dazzled by more technology. They just want more time to interview patients and a chance to understand them better. Their focus is not on meaningful use but on meaningful contact. If EHRs can give them and their patients that experience, EHRs are useful and will be adopted enthusiastically. If EHRs get in the way, they will be rejected or undermined. This was an appropriate theme for a panel organized by the Schwartz Center for Compassionate Healthcare.
That challenge is harder to deal with than interchange formats or better I/O devices. It’s at the heart of complaints over workflow and many other things. But perhaps it should be at the top of the EHR vendors’ agendas.