Finding Optimism in the ­Future of EMRs

As a chief medical informatics officer and chairman of a department of family medicine, I endure the grueling process of using our present tools to practice medicine — including electronic medical records. Despite my considerable optimism for the future of electronic medical records, my daily experience in the clinical setting dissuades me from sugarcoating our present state.

One major issue is that even the best-intentioned administrators and healthcare leaders can fall prey to crafty salespeople. The companies that make electronic medical records are earning huge profits and can hire the best people in sales. As a result, C-suites throughout the country have fallen prey to the siren song of profits, interoperability, improved quality, and the ability to run reports with data that would make professional baseball analytics aficionados drool.

Many of us have been told, “We can definitely do that.” Unfortunately, it is rarely followed by “but wait until you see how much this will cost.” It is easy to ask a clinical question and walk away from a meeting thinking your problems will be solved only to be disappointed later.

Several key barriers diminish the potential of electronic medical records:

• EMRs have been designed by engineers unfamiliar with the workflow of physicians, nurses, and other healthcare providers. Medicine has its own specific language and flow developed over time. People without a background in healthcare cannot be expected to design a medically efficient system.

• EMRs were designed to impress the decision makers in healthcare organizations. Primary focus has been the monetization of patient care and accumulation of data. Data are often collected for purposes different from the impact on care.

• The art of the medicine depends on providers using evidence and personal experience to treat the patient in front of them. EMRs can implement standardized orders sets based on evidence, but they lack the flexibility required to take full advantage of the healthcare provider using the tools.

• EMRs gather information based on the collection of discrete data points and require specific “clicking” of boxes. Free text has been considered a barrier. It appears that stream of consciousness is not valued in the financial and data-driven world.

• Third-party payers, hospital administrators, and a plethora of other interlopers have learned that they can attempt to measure quality through discrete data, and healthcare providers are increasingly required to jump through a wide variety of hoops to meet these requirements.

• Due to the growing need to acquire data for these third parties who have little to do with the care of the patient, physicians are spending less and less time in actual patient care and more time on the computer.

So where is the optimism?

Looking Forward

The optimism is in the future. Government regulations that have been onerous in the past (who can forget Meaningful Use) are now shifting to focus on interoperability and care across the continuum. This is where we can see some of the true benefits of using the electronic medical record.

Clinical data and details about medical care provided in the hospital flow into the electronic medical record so physicians have more information than before on which to base decisions. Granted, there are many practice sites where communication is poor because one computer platform cannot speak with another computer platform, but that communication is improving. Cloud storage is making care across the continuum more viable and ultimately patients will be able to carry medical records to virtually any location.

The major companies that develop EMR products are beginning to request provider input and make the technology more user friendly. In addition, the leaders of healthcare organizations are starting to realize that burned out healthcare providers are of limited use to their patients and drain the bottom line. Most importantly, patients are beginning to voice their opposition to the fact that physicians seem more interested in clicking buttons than examining them.

Fortunately, voice recognition systems and products that can work with smartphone technology are available and being improved. A growing number of physicians dictate notes while in the examination room to incorporate critical data in the chart. These smartphone tools also allow physicians to use smart templates that can be adjusted on a patient-by-patient basis.

Some of the leading minds in healthcare have developed apps based on their personal use of smartphones. Tools such as electronic portable stethoscopes and otoscopes are now being sold at the big box stores for people to use on their own and to communicate with physicians. Patients are diagnosing their illnesses based on information that they have read online and supported by an examination they have performed with a kit that cost less than a few hundred dollars. Obviously these diagnoses are not always correct, but I would much rather have patients actively involved in their own care than waiting for an appointment or — far worse — ignoring their need for care.

Some major changes are on the horizon, especially when it comes to scheduling appointments. A growing number of people use their phones to make hotel reservations, trade stocks, arrange transportation, or perform any number of daily tasks simply by pushing a few buttons or asking Siri for advice. Many search for physician offices in their area and select the most convenient time for an appointment with a full expectation that they will be able to schedule an appointment when they need one and that the physician will have access to a complete record of their past care.

This is not to imply that traditional appointments and doctor–patient relationships are a thing of the past, but for an entirely new generation, obtaining healthcare will not be much different from purchasing a product from Amazon.

A Coming Revolution

In the coming decade, developments should revolutionize not only the practice of medicine in the hospital and in our offices, but also throughout the communities we serve. Whether our patients are at home, in assisted living, or in the hospital, we should be able to reach out to them and monitor their health. Whether they are in another country or on an ocean liner in the middle of the Pacific, we should be able to provide them with important health information. Telemedicine is now helping people in the Arctic Circle and in the mountains of Peru.

There certainly will be bumps in the road, but we should be better equipped to address and overcome obstacles ahead.

Additional Resources

Brian McDonough recommends these resources for those interested in further reading:

“Death By 1,000 Clicks: Where Electronic Health Records Went Wrong,” by Fred Schulte and Erika Fry. Fortune, March 18, 2019. https://khn.org/news/death-by-a-thousand-clicks

“Why Doctors Hate Their Computers,” by Atul Gawande. The New Yorker, November 5, 2018. https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers