I admit that on one level hearing and reading about the many complaints from physicians about the changes in health care that make their daily practice steadily less productive, less enjoyable and less satisfying along with insights into all the reasons why our system is dysfunctional is helpful in at least knowing my pain is widely shared.
Maybe it’s the simple act of venting that bonds us to some small degree, but on another level it’s dissatisfying that so many well educated and smart people who share the experience of trying to practice in an increasingly dysfunctional system seem limited in their responses to these challenges. We have been, and are still, astoundingly ineffective in fighting these changes. The biggest source of dissatisfaction is the EMR products we are mandated to use. They are at once the biggest failure, and potentially the best hope for health care. I will explain.
As John Caulkin stated, “We construct our tools, thereafter, they construct us” and that is pertinent here. This also captures a tenet of bioinformatics that teaches us what data we acquire informs how we work. We know that much of the data collected from the EMR is for billing and regulatory purposes. Further, documentation largely serves those purposes as well. My efforts to convey my thoughts, plans and interventions for any patient are poorly performed because the EMR structure does not have that task as its primary goal. The structure it imposes on documentation is ignorant of physician workflows. The disruption of my daily work and, importantly, my thought processes during any patient interaction is adversely impacted by those structural demands. Because of this, the experience we have multiple times a day with patient encounters may well be the best example of the “productivity paradox” many experience with computerized processes in their workplace.
We can learn from any number of disciplines why our EMR s are so difficult to work with. Bioinformatics, engineering systems, complex system dynamics, the constructual theory and even evolutionary dynamics are all informative of how current EMR structures are simply not constructed well for what is claimed to be their tasks.
However, expertise also exists (Thomas Landauer, The Trouble with Computers. MIT Press, 1993) in the proper and effective way to decide, 1) Are there elements of your workflow that would be enhanced by a software product; and, 2) How should that software be constructed. Appropriate task analysis of what doctors do during patient encounters has not effectively been done to answer those questions.
Simply imposing a software platform forcing us to document care based on some programmer’s calculation of what we need or what information some administrator wants is ignorant of the abysmal track record of “second wave” applications of computerized programs for (especially) documentation purposes. That misapplication of software programs to all manner of human tasks (across almost all businesses not just health care) under the impression that because it is computerized, those tasks must certainly be better — more efficient and less costly — has resulted in increased costs without evidence of improved productivity. The productivity paradox that we in health care enjoy is probably the best example of this. There is no reasoned argument or explanation how these inappropriately constructed platforms at their very foundation can be tweaked to then yield a true productivity gain. More of a bad thing will not result in a good thing. It’s just more of a bad thing.
So here is, I believe, the good news and the bad news. Both make us as physicians accept what I propose are some truths. Our continued complaints about EMRs and all of those onerous regulatory demands that consume so much of our time with little appreciable gain must be made with the realization that we, as a profession, let it happen. We must also recognize that we, as a profession, have to effectively answer the problems of health care as a financially nonsustainable burden to this country (at least as has been practiced to date). The future of our profession includes processing (exponentially) expanding knowledge and data from genomics, epigenomics, proteomics, metabolomics, microbiomics and the growing availability of patient-centric health-related apps and wearable devices. This lays bare the obvious tension between current pushes to standardize care and eliminate provider variability with the clear trend to ever more individualized care such data will demand, and that will add further costs to the system. Costs financially and costs in physician time.
The drive to care standardization currently being pushed certainly serves the wants of the administrative elements of health care since uniformity helps in efforts to control — not just costs but physicians. We, in effect, subsidize the financial gains desired by such administrative efforts. Of course 2 obvious consequences of their use are the steady move towards ever more homogenized patient profiles (every diabetic with hypertension looks like every other diabetic with hypertension) and the inability to recognize or identify innovation through data analytics based on the EMR. There are more philosophical concerns with such standardization, but more immediately compounding this problem will be how to incorporate all of this growing patient-centric data into our EMR platforms. We can expect our time commitment to channeling such diverse patient information through the EMR will be more and more cumbersome since EMRs by the very nature of their structure do not have this reach. Having such reach requires universality of structure. Universality meaning, here, not structural similarity of platforms, but a foundation based on clear and simple rules that allow infinite growth, so that no matter how much individual data is added to a patient’s record, it is incorporated easily and accurately. This is the structure that allows layers of complexity to emerge versus the layers of complexity being imposed by current products.
That is the bad news (well, not all since we can expect more immediate continuing documentation demands that will require ever more time by physicians as the ICD-10 codes and newer meaningful use criteria demonstrate — they will surely not be the end). The good news is that there is an effective mechanism to control and manage health care delivery while simultaneously decreasing the financial costs, disruption of workflows and the increasing physician and patient dissatisfaction we see today. An EMR constructed with an appreciation for physician workflows can capture simple data points and simple documentation elements that serve to construct accurate patient profiles and allow rapid feedback to physicians (or any provider) showing the accuracy and efficiency of their diagnostic and therapeutic efforts. Such a structure not only requires less of a physician’s time but also has a universality of structure that then has the needed reach to incorporate expanding patient data streams for ever more nuanced patient profiles that can accurately capture patient heterogeneities. Rapid cycle feedback to physicians demonstrating their diagnostic and therapeutic effectiveness (measured against, and actually informing, best evidence practices from multiple sources, and kept out of the public sphere) addresses the fundamental issue of health care, the patient-physician interaction, and drives it to continually greater value. Oh, this can also be constructed at low to no cost to physicians.
Why is an alternative necessary? As a profession we must take ownership of the largest part of health care expenditures, or, as we are now witnessing, others will. It is not enough to complain relentlessly about the effects of all our experiences starting with HMOs to the burdens that EMRs and the regulatory demands such as CPOE, meaningful use criteria, and ICD coding now impose. Again, the ledger measuring the benefits versus the costs of these impositions on physicians and the larger world of overall health care costs is deeply in the red. It is also not enough, even if we could see physicians do so in large enough numbers to change our current landscape, to simply refuse to participate in or utilize an alternative to the tools of governmental agencies or corporate health care providers and payors. Having the tools that clearly drive us to more effective, efficient and cost appropriate care is the necessary foundation that would allow physicians to reestablish themselves as the leaders and drivers of health care and also offer the best chance to maintain or regain independence.
By accepting this leadership paradox — leading while acquiescing to data to make you accountable for what you do — we at least can do more than continually complain no matter how well informed, logical and insightful those complaints are. It is folly to think anyone other than physicians really have the necessary understanding of the factors formulating those complaints. It is folly to think that someone somewhere will change the course health care is currently on out of sympathy garnered from the cries of doctors.
Unless we, as a profession, gather enough of us to not only say “no more” but to demonstrate the leadership to show (the world really) a better way to deliver health care, our profession will continue on this path. As a profession, solving problems is what we do. Problems are inevitable, they are always and everywhere present. Health care’s problems have not and will not be effectively solved by non-physicians. As bad as it is, the trajectories would suggest our current path will only get worse. To hope otherwise is folly.
Joe Heit is a physician.
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