How did EHR designers get control of health care?

Wouldn’t it be cool if … ?

Wouldn’t it be better if … ?

Wouldn’t it be much easier when we see patients if … ?

How come we can’t … ?

It seems like every day, someone in our practice comes up with an idea for a way to do something better:

  • From our front desk staff who check patients in, and have to deal with a multitude of electronic systems for registration, insurance authorizations, payments, and identification.
  • Our medical assistants who do vitals and help out with screening questions, asking about pain, smoking, depression, and more.
  • Our staff assistants who talk to our patients, and deal with the phones and the patient portal messages, helping track requests for refills, referrals, and appointments.
  • Our nurses who are trying to educate our patients, helping to improve health literacy and overcome other barriers, vaccinating our patients, counseling them.
  • Our social workers, who are helping us help our patients achieve a measure of health equity, overcoming the barriers they have to gaining access to care, access to medications, access to the support services they need.
  • And all of the providers here who see our patients, who are challenged with trying to give all of the health care our patients need in the few scant minutes we are allotted for an appointment.

Why, in such a complex environment, have we allowed ourselves to become subject to an electronic health record that is not anywhere near as responsive as we would like, when it comes to making things better for patients and providers and the rest of the team taking care of all of these patients?

Since we changed over to our current EHR over a decade ago, we’ve been lucky to have an incredibly supportive IT team, who are in many ways a real part of our practice, some seeing their own patients right alongside us.

They’ve seen the frustrations that the system causes, and have tried to be responsive and flexible when it comes to helping out, and have tried to make changes when they can, trying to improve the little things and the big things that we find interfere with our ability to care for our patients.

But even they have said that there is only so much they are able to do, even the best suggestions we come to them with often fall on deaf ears of the company that produces the system, and we are told that things have to be that way because that’s the way they are.

It seems strange that since health care providers across this country are paying thousands, tens of thousands, hundreds of thousands, and even millions of dollars to the EHR vendors, and since getting this right is so critical to being able to adequately care for patients in the challenging health care environment we are all practicing in, you’d think that the companies that make these things would be getting the message that what we have is just not enough.

It feels like we’ve complained for years about interoperability, transferring data across platforms, getting a CBC in my system to look like a CBC in someone else’s system, being able to view an X-ray done in an ER in another state. We recognize that the challenges involved are immense, that doing this requires the companies to deal with incredible bureaucracies and government regulations, as well as the technical hurdles, that make this even harder than it should be.

But when one of my providers says, why is it that we can only get consent from the patient for us to view their records at another hospital that uses the same EHR when the patient is physically in front of us at an appointment? Why can’t this be changed?

If my patient tells me over the phone that they went to another hospital with a medical emergency, shouldn’t there be a button that they can click in their secure HIPAA-compliant patient portal that authorizes me to see those records? Why is it they have to come in for me to print out a paper copy of the consent that they must sign by hand and then I can scan this back into the chart, and then and only then can I see those records?

When a provider comes to me and says, wouldn’t it be great if we could move all of the screening questions to the front of the visit? And all of the best practice alerts that use intelligent analysis to figure out what our patients are due for, maybe we could move those to the order section, so that we can see them at the time we are ordering labs, referrals, imaging, and other things for patients at the time of visit.

Aligning the EHR with the natural flow of work through the practice makes sense.

We recognize that making changes in such a big complicated program is hard. If I don’t like the way PowerPoint looks, I don’t think Microsoft is going to change it just because I send a request saying could you make this font a little bigger, could you make that animation a little slower, could you make that color a little brighter?

But EHRs have evolved to try and replace the medical charts we used to keep on paper, and the people who build them should be willing to adapt to the flow of how we think is the best way to take care of patients, rather than some cookie-cutter design that was created by people not actually out here talking to patients, caring for them, trying to get them what they need.

If my patient’s vitamin B12 level is low, and I see that result in a lab, I should be able to order a shot for them as a “facility administered medication” (a vaccine, medication, or treatment given in the office) right from that lab result. We have discovered that facility administered medicines are only orderable in office visits, since whoever built this system decided it should be that way. Why would we be ordering something to give the patient when they’re not right there in front of us during an actual office visit?

Because health care (and life) doesn’t always work that way.

When we ask for these changes, we are often told that we can’t make changes to our version, because this will affect every other place that uses this EHR, that the system is not so flexible that it can be customized to each individual user or practice.

They tell us that there are workarounds, there are tools we can use to build macros, templates, easier ways to get things done.

But this is their version, their view, of how easier to get it done should be.

We are the ones seeing the patients, checking them in, screening them for falls and depression, trying to get them to understand their health conditions and better manage their diabetes or their high blood pressure, working to enhance collaboration between specialists, working to get our patients access to healthy food, affordable medications, housing, social supports, and other services they need, working to ensure that the best evidenced health maintenance is delivered to them in a timely fashion.

As much as we’ve complained about these things through the years, it feels like we’ve been unable to move the needle away from the creators of the program controlling the content, how it looks, what we have to do to click the buttons to get through our day, rather than us, those of us who take care of the patients, who, believe it or not, probably know best what an EHR really should look like.

Our patients are not PowerPoint slides, and we are not presenters standing up in front of an audience where it’s okay if the slides don’t look exactly like you wish they looked.

The electronic record should be there to help us get it right, not the other way around.

Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at MedPage Today’s Building the Patient-Centered Medical Home.

Image credit: Shutterstock.com

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