We live in interesting times for the electronic health record: Blessing and curse (and sometimes, just plain cursing). Of the many EHR complaints I have heard from clinicians over the years, the following are chief among them:
- It is too tedious to get what a clinician wants to say into the EHR.
- It is too tedious to get a clear, clinical picture back out.
These two issues are also frustrating for patients who tire – rightfully so – of repeating their clinical histories over and over again. In my career as an emergency department physician, I was asked countless times: “Isn’t that already in the computer?” And the answer: Well…sort of…possibly. It’s hard to know for sure.
The mixed blessing of the EHR
It is a blessing for a clinician to have access to aggregated information in a world where healthcare is increasingly dispersed among multiple providers across disparate settings. However, modern medicine grows more dangerous even as it becomes more effective. Making good clinical decisions is dependent upon having precise and complete input for the data points underpinning those decisions. Insulin saves lives, but only when it’s the right medication, given for the right problem, in the right dose, to the right patient, at the right time. Otherwise, insulin can be lethal. Similarly, fixing a stenotic aortic valve is spectacularly more likely to help a patient than a magical incantation. It is also more likely to kill the patient if the operation doesn’t go exactly as planned.
The EHR is a blessing in part because paper can kill. Paper is not just inefficient, it is deficient because it is so difficult to accumulate all of the sources of data required onto a single paper chart. Without the EHR aggregating data for us, we cannot safely take care of our patients, much less do it efficiently or effectively. In our modern healthcare world, there are simply too many sources of information that must be brought together into a consolidated view for any given patient encounter. A “routine” hip replacement will not be successful without clinical consideration being given to the patient’s history, and meds, and allergies, and concomitant problems, and labs, and studies, and demographics, and social nuances…the list goes on. In a paper world there is no way to collate all of that from all of the varied sources.
At the same time, the transition from a paper-based record to an electronic one has had its challenges. After all, EHRs – much like the people who use them – are not perfect, and proof that they have made care safer is somewhat difficult to come by. But “safer” is not a worthy enough goal. The goal is for care to be as safe as is possible. The EHR can impede patient care by accumulating information without a good strategy that allows a clinician to focus on the right subset of that mountain of aggregated data – some of which is just noise. (Or worse, inaccurate information may make its way into the record because a clinician was unable to enter it in the way she might have intuitively written it.)
“If I’m a doctor, I want to “speak doctor.” I don’t want to be limited to using only terms created for some sort of artificial coding system.”
Juggling competing needs
While safety is an important goal for those using EHRs, it is not the only one. If I’m a doctor, I want to “speak doctor.” I don’t want to be limited to using only terms created for some sort of artificial coding system. If I am responsible for billing, I want the diagnoses on the chart to accurately reflect the clinician’s intent, but I still need to be able to get to the right codes for reimbursement. If I am trying to improve population health using aggregated data, I want the data that has been warehoused from my entire population to reflect what actually happened to each patient. And above all else, if I am a patient, I want the EHR to facilitate the best possible care. Not billing. Not regulatory requirements. Not even privacy. All of those are important, but if we can’t use the EHR effectively to take care of patients, then it does not matter what other goals it helps to achieve.
So, with so many stakeholders, and so much at stake, where do we turn for solutions? We look back to the beginning. We look to terminology.
