New Ideas About Electronic Health Records
I got a flyer in the mail the other day from a young man (judging by his photograph.) He was writing as someone whose company tries to help organizations create medical data warehouses. The first problem, in his opinion, was the fact that clinicians preferred unstructured data, which made it harder to construct large databases than would be the case if they would just use check boxes. He expressed the hope that as medical training changed, younger doctors would be less resistant. Speaking as an old doctor, I sincerely hope they do not.
The fact is physicians must hear and report the patient’s story. Assessing the quality of evidence, as the lawyers would say, is an act of judgment tempered by experience. The medical history is not data in the sense a lab test or a blood pressure reading is. In fact, I think the problem with the current generation of electronic records is that they were designed by computer and data scientists and accountants, who thought re-training the doctor was a perfectly reasonable cost of doing business.
Fortunately, I have seen two articles recently which give me hope that the next generation record may actually help patient care. Curiously, both of these were published in the Harvard Business Review. The first paper describes the efforts of the Mayo Clinic to make the EMR useful for the care of patients in the intensive care unit.
“The sheer volume of data in EHRs creates a staggering challenge in complex environments such as intensive care units (ICUs) and emergency medicine departments. Individual clinicians may have to sift through more than 50,000 data points to find key information. This proliferation of data (both meaningful and meaningless) and the workload created by EHR systems have been key drivers for clinician burnout and, paradoxically, introduced new threats to patient safety.”
The investigators created a multidisciplinary team of clinicians, researchers and experts in clinical informatics to develop “information-technology tools that can help, rather than hinder, clinical care.” They used an “ambient-intelligent” approach that prioritized “a deep understanding of clinicians, the way they work, and the environmental factors they face.” After 1,500 interviews, they identified 60 pieces of critical data that needed to be access quickly for effective care, instead of the unfiltered 50,000. They then developed software that locates, tracks, and displays these 60 pieces of data in ways that make it quick to spot issues.
“Compared to standard EHR interfaces, AWARE improves cognitive performance, efficiency, and reliability of human decision makers. It also saves three to five minutes on chart review per patient per day…In addition the length of ICU stay decreased by 50%, length of hospital stay by 37%, and total charges for hospital stay by 30% ($43,745 per hospital admission.)”
Of course, it has taken an unstated amount of money to create the program, which they have licensed commercially. They also don’t say what constitutes “break even” for the effort. Nonetheless, it is encouraging to see someone trying to use the computerized tools to help doctors do their jobs, rather than trying to make doctors extensions of the computer program.
The second article, by Robert Wachter and Jeff Goldsmith, begins with a litany of the usual observations about how and why current systems perform badly. Their prescription is lengthy, but worth quoting.
“For EHRs to become truly useful tools and liberate clinicians from busywork, a revolution in usability is required. Care of the patient must become the EHR’s central function. At its center should be a portrait of the patient’s medical situation at the moment, including the diagnosis, major clinical risks and trajectory, and the specific problems the clinical team must resolve. This “uber-assessment” should be written in plain English and have a discrete character limit like those imposed by Twitter, forcing clinicians to tighten their assessment. The patient portrait should be updated frequently, such as at a change in clinical shifts. Decision rules determining precisely who as responsibility for painting this portrait will be essential…While one individual should take the lead, this assessment should be curated collaboratively, a la Wikipedia. This clinical portrait must become the rallying point for the team caring for the patient.”
After painting the picture, the computer has to function as “groupware” enabling communication, not drowning it. They actually propose most “notes” should disappear after a few days, but I can’t imagine the lawyers will sign off on that—maybe they just autohide. They also note typing and point and click have to go—replaced by voice recognition software that can transcribe, do order entry, and create commands for the computer. They also recommend using artificial intelligence (AI) programs to create visual presentations of data. This sounds to me like a computerized version of the old one-page graphics sheet in the days of the paper record. For those who never used them, they were what you needed to know seen at a glance.
I don’t expect either of these developments to spread in epidemic fashion, but it is encouraging to see that thought leaders aren’t settling for the status quo. I really would like the young man in the flier to re-think his approach, as I think we need to recapture narrative and make it the heart of the chart as suggested in the latter article and filter the data quickly and graphically so information transfer, as opposed to data transfer, can occur. Maybe there is a basis for faint hope.
30 April 2018
 Herasevich V, Pickering B, Gajic O. How Mayo Clinic Is Combating Information Overload in Critical Care Units. 22 March 2018. https://hbr.org/2018/03/how-mayo-clinic-is combating-information-overload-in-critical-care-units.html.
 Wachter R, Goldsmith R. To Combat Physician Burnout and Improve Care, Fix the Electronic Health Record. 30 March 2018. https://hbr.org/2018/03/to-combat-physician-burnout-and-improve-care-fix-the-electronic-health-record.html.
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