The following is a guest post by Kyna Fong, Founder of Elation EMR.
In healthcare, there’s a generally accepted rule of thumb. Before providers are asked to change how they deliver patient care, they must first be convinced that the change adds clinical value, i.e., improves patient care.
The adoption of EHR’s should fit squarely in this category. Given the enormous dollar amounts spent on training, providers are clearly being asked to change their behavior, but somehow EHR’s have avoided the clinical value question before being proliferated and powerfully incentivized by the government as a best practice. Certainly, there’s no question that EHR’s can be clinically valuable. The question is — are they today?
Amidst the popular EHR topics of workflow, efficiency, and billing optimization, when clinical impact of EHR’s does get discussed, the conversation is much more focused on the promise of clinical value than delivered value. Without a doubt, having all patient information digitized in structured EHR data repositories will one day lead to major medical discoveries that can impact large numbers of patients, and will also eventually support connectivity and information availability that can save countless lives. But what about the act of actually digitizing that data, the onus we are placing on physicians today to get patient information into these data repositories to start with? Is today’s physician use of EHR’s providing clinical value to today’s patient at the point of care?
For the sake of discussion, let’s flip the question on its head. There are some obvious additions of clinical value that come with most mainstream EHR’s — algorithmic decision support, remote access to patient records, avoidance of illegible handwriting, connectivity, etc. But let’s ask the opposite, less frequently asked question. How do EHR’s subtract clinical value today?
Here are five common scenarios where physicians are finding EHR’s subtracting clinical value, which I base on our experiences observing physicians and talking to them about their use of mainstream EHR’s.
- Disruptive collisions between the pre-engineered EHR workflow and the in-the-wild flow of a patient visit. E.g. You get frustrated when your patient brings up another problem after you’ve finished dealing with what you thought were all the problems, forcing you to disobey the EHR’s pre-defined SOAP workflow and endangering your ability to complete the note. In the name of workflow, many EHR’s have engineered severe navigation constraints into the software that are unforgiving when what happens is not according to the strict linear plan.
- Failure to provide a basic need: quick access to the story of the patient’s health. E.g. You prefer not to bring the EHR into the exam room because there’s no reason to — it isn’t helpful, even for complex patients. There’s certainly a valid argument that interacting with a computer during a patient encounter can make the provider seem cold and distracted. At the same time, the EHR is supposed to do what its predecessor — the paper medical chart — did: help you quickly access the story of the patient’s health. Unless you have a photographic memory, if you enter the exam room without the EHR, you’re either under-prepared or the EHR isn’t doing its job for you.
- Difficulty documenting the patient’s story, distracting the clinical train of thought. E.g. You run into trouble documenting important information the patient tells you because either it doesn’t fit the EHR’s structured forms and required fields, or inputting the information simply takes too long. Sometimes you interrupt the patient and ask for an awkward pause while you catch up, or when it’s a busy day, you plunge forward the best you can and make a mental note to document later — unsurprisingly you often forget, as indeed you are human after all. In the name of collecting structured data for optimizing billing and running administrative reports, the engineering of most EHR’s has leaned heavily on required fields, dropdown menus, and limited entry fields. While that enables the EHR to be excellent at capturing information in the right format, an unfortunate result is the EHR often fails to capture the right information.
- Clinical information stored in multiple repositories. E.g. You know that not all clinically relevant information about a patient is in your EHR. Often, the culmination of frustrations like those above, and the lack of flexibility of the EHR itself, results in information being stored in another data repository — like a separate paper chart, sticky notes, emails, word documents, etc. — places other than the EHR. This leads to significant challenges as the opportunities for lost information and missed data grow exponentially as the number of data repositories increases, reversing data accessibility, one of the core values of the EHR in the first place.
- Struggles understanding previously documented notes. E.g. When you look at your colleagues’ or even your own old visit notes, all you read is the assessment and plan sections, as the rest of the note is a flood of auto-generated templated text combined with pasted copies of prior notes. With mainstream EHR’s, we’ve traded concise notes with at times illegible handwriting for very dense notes that overwhelm the human brain. Arguments can be made both ways regarding where the clinical value equation nets out here, but undoubtedly there’s value being left on the table.
These are just some observations I’ve noticed. I’m sure many of you reading this post have plenty of experience with EHR’s and perspectives on these questions. What do you think? I’d love to hear your views in the comments section, or feel free to email me directly at kyna.fong at elationemr.com.