The frontlines of health care have been transformed over the last decade as electronic medical records have been rolled out across America. Unfortunately, information technology has yet to live up to its immense promise in health care — a topic that I frequently write about. As somebody who has worked with every single major EHR on my travels, I am being brutally honest when I say not a single one has impressed me.
There are huge obstacles to overcome with usability and efficiency. Of equal concern are the morale effects this is having on the hundreds of thousands of physicians toiling away for their patients. At a time of escalating physician burnout and job dissatisfaction, all current studies list the burdens of health care information technology as the number one daily contributor.
At the crux of this problem are three fundamental gigantic flaws in how IT has been implemented at the medical frontlines: 1) The end-user of the product is viewed by the IT company as the hospital administration: not the physician (imagine how bad the iPhone would be if they didn’t care about the end-user experience); 2) Most EMRs have been built primarily as giant billing systems rather than patient care systems; and, 3) EMR systems are monopolies once installed and have almost zero incentive to improve after they’ve signed their multi-million dollar contract with the health care organization. Not only are monopolies bad for any kind of progress, but it’s also a very un-American state of affairs.
And even away from the problems with the actual technology itself, are also some real concerns with how the roll-out of health care IT can impair good and thorough medical care. Much of my current work focuses on this very intersection between IT and the human experience.
Here are 5 concerning ways communication and patient safety can actually be impaired with ill-thought out computer systems:
1. Reviewing results. Electronic medical records present physicians with vast swathes of data, often redundant. Unfortunately, it’s become far too easy to mindlessly click on a box, import results into, for example, a progress note—without actually reading it and thoroughly reviewing what’s in front of you. In the days of the paper chart, doctors were forced to write down anything abnormal in their note. Not anymore. Remember that clicking a button does not necessarily mean that the human mind has processed and acted upon information.
2. Physician alert fatigue. In the new health care IT world, physicians are faced with a monumental number of continuous alerts appearing on the screen in front of them. Far too often to act upon properly. The threshold for all alerts needs to be carefully thought out (the same phenomenon exists for machines that beep every few seconds). After a while, any professional who already has a lot of work to do, simply starts ignoring them. I always draw a comparison with the airline industry, since so many “experts” in our field keep wanting “health care safety to be like aviation safety.” How safe would planes be if pilots kept having their workflow and concentration interrupted every few seconds with redundant alerts?
3. Computer-generated output. The computer print-out that we give to patients, is pretty terrible in most institutions! It could be a discharge summary, prescription list, or follow-up instructions. For the most part, it’s a mishmash of machine speak, poorly designed, and not very eye-pleasing to read. Keep in mind too, that most of the time we are giving these hard copies to older patients.
4. Failure to update. I have lost count of the number of times I’ve reviewed something with a patient, and information which has been in the computer for a long time, turns out to be completely wrong. Because of the overwhelming bureaucratic burden that physicians face, it’s sometimes several visits before any doctor finally turns around, spends time with the patient and asks: “Is this the case?” or “Are you still taking Medicine X?”. Likewise, I have had large numbers of patients speak to me, concerned about information that has wrongly been stuck in the computer system for a while. My advice to any patient is to always make sure that what’s in the computer is correct, and double-check that your doctor isn’t mindlessly clicking boxes!
5. Time with patient. The amount of time that doctors spend with patients in direct patient care, is on life support. Some studies shockingly suggest as little as 10 percent of the day, with the majority of the rest typing and clicking away. It’s frequently 5 minutes with the patient, then 30 minutes documenting what just happened. Take that in, because in no other profession would one spend X amount of time practicing their art, and then 5X that amount of time documenting what just happened! In between all of the modern medical advancements and technology, we have somehow lost track of the most important part of the day: the doctor-patient interaction. That is sacred, and is the connection that lies at the center of all good health care. It’s terribly disheartening that due to modern electronic health records and their overwhelming burden, the “patient in the computer” is the one we are treating most of the time, and the real human being almost becomes an afterthought. Even during actual office visits, I’ve regularly heard patients complain to me about how their “Doctor hardly looks at them in the eye anymore.” Appointment times are always being squeezed, with less and less of that time spent talking face-to-face.
Over the years, I’ve probably met hundreds of technologists through my everyday hospital work and also at various conferences around the country. I am disappointed by the fact that so many seem either disinterested, or quite frankly, in denial, about the fact that health care IT needs to improve. The same goes for health care administrators. To improve the situation, IT companies and hospital administrations need to engage with frontline doctors. Note: that means the doctors who will be using the systems—not the ones who are de facto administrators or self-professed “IT experts” who don’t even work at the frontlines. Here’s what we need:
1. A simple acknowledgment from EHR vendors, IT experts, and health care organizations, that this is an issue that needs to be addressed urgently
2. Dedicated department units or teams that engage frontline physicians (again I emphasize the word practicing physicians) to identify specifics in EMR systems that need to improve (such as user-interface and “click burden”). There are always a ton of simple tweeks that can be made to make life just a little bit easier for physicians.
3. Continuous feedback loops with EMR vendors to ensure rapid evolution towards ever more seamless technology
Health care is a unique field. Solid communication and thorough clinical care is at its core.Technology is a wonderful thing, but all too often actually impairs communication in health care, rather than enhancing it. We need to do better, and I believe we can as long as technology is properly thought-out and implemented.
Having said all of the above, let’s pause for a moment to remember the tremendous benefits of health care IT in terms of rapid information retrieval, analyzing data, and potential for population health and research. The answers to the above problems do not lie with going back to pen and paper, any more than the answer to the first automobiles flunking wasn’t to go back to horse and cart. The answer is to improve health care IT and reconcile our systems with frontline clinical workflow. By working together, we can fulfill the enormous promise of health care IT and give our dedicated frontline professionals, and more importantly our patients, the technological future we deserve.
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