The cumbersome EHR: It’s time to implement solutions

First off, this is the first time I have typed an official response to a blog post: “Dear health IT: Please understand our frustrations.”  You might think, hey aren’t you a millennial, shouldn’t you be blogging non-stop?  Like doing everything from my taxes to baking with my smartphone?  No, not really; besides residency doesn’t make it very feasible either.

Yet, the need to respond to Dr. Leap’s blog post was too great to pass up.  I couldn’t help but get off the proverbial couch and write in my thoughts.  As a matter of full disclosure, yes, I am part of the generation that experienced video games, personal computers, the Internet, and smartphones hit the mainstream in my lifetime.  I am also part of the first generation of physicians trained after mass adoption of electronic health records (EHR) technology and the Affordable Care Act.  I write fewer and fewer paper notes.  In the clinic, I write exclusively electronic notes.

If you are waiting for me to say all is good in regards to EHR technology then you would be mistaken.  Newly training physicians are just as frustrated, or maybe more so, than the older generation.  Why?  Because the productivity of the past is applied to our present.  However, I didn’t come here to complain.  I came to discuss some potential solutions.

First, we need to start looking at other industries for answers to the inefficiencies in health care.  We have clinic workflows as if nothing has changed in the last 50 years.  Some of our current clinic model practices are outdated and inefficient.  How does that go over in other industries?  I just have to ask when was the last time you rented a movie from Blockbuster?  Exactly.  Netflix and Redbox did away with the dinosaur business model of going by your local movie rental store.  What changed?  They improved accessibility and made delivery cheaper.  What’s next in the model (I’m looking at you, Amazon Prime), improving quality video and providing larger selections of TV and movies.  So what’s the point?  New technology is only useful when it is applied to improve a situation or solve a problem.  Many early EHRs were designed to organize clinical data, and it’s widely known they did not make the clinic visit more efficient.  Applying EHR technology on old work flows processes has only exacerbated the problem.

For example, how much of your patient history do you enter in by yourself?  Think of all the routine questions you ask your patients on a daily basis.  Now think of how more efficient your visit would be if you had that information available to you before each patient visit.  Suppose their last Pap smear, last flu shot, drug allergies, previous history of appendicitis, and family history of coronary artery disease (and more) was generated in the note by the patient before their vital signs were taken.  The visit goal would change from frantically collecting and recording all the information to identifying and addressing the patient’s problem.  This is of course not a new idea and has been advocated by many before me (Improving care with an automated patient history, Computer-generated vs. Physician-documented history of present illness (HPI): Results of a blinded comparison).  I’m not saying that we completely automate your clinical role, just take the stuff out that a kiosk can do.  You are the high-level thinker, the computer just organizes and records data faster.

The kicker is that front desk kiosks that allow check-in and generate patient history directly into an EHR already exist.  Yet old clinic models die hard.  I know no one wants to fire their clinic staff but if there is a better way, shouldn’t we try and embrace it?  May be the staff could be more useful performing other clinic roles like patient education, nutritionist, or repurpose the money to hire another nurse?

On a personal note, writing notes in our family medicine residency clinic can be very difficult at times.  The other residents and I have similar complaints: It takes too long to document all we do.  So what is our solution?  We are setting up waiting room kiosks to capture more pre-visit patient data.  Will it work?  Not sure yet, but we hope to let you know once we do.  Luckily we are not the only ones trying to find the golden ticket to efficient clinic visits.

There is too much that needs to be improved in our health care system to worry about how computers have made it more difficult.  We don’t have time to go into the payment model, reimbursement rate, insurance companies, etc.  I believe EHRs have become cumbersome in part because not enough physicians were involved when they were created.  But just like other industries, if efficient and lower cost alternatives appear then it will disrupt the model for the better.  Physicians in all parts of their career can continue to moan about their notes, or we can offer ways to make health care more efficient, and as a result, better for our patients.

Troy Russell is a family medicine resident.

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