Monday, April 23, 2012

Bringing medicine into the age of computers, finally

The economic stimulus package passed in 2009 contained billions of dollars designed to encourage hospitals and doctors to install electronic health records (EHRs).  At the time, an exceptionally small number of health care providers had computerized medical records.  It is hard for those of us who are used to dealing with credit card companies, airlines, automobile service departments, utility companies, and the like to imagine that the medical world was living in the Dark Ages.

Here was an industry that hadn’t even arrived in the 20th century – much less the 21st century -- in terms of computerization.  Accordingly, the idea of the legislation was to both create jobs and also pull the industry up by its bootstraps.

Everyone understood that this would not be an easy task, but it was the right thing to do.  Without EHRs, if you show up at a new hospital and the doctor there needs your medical history from your home institution, the file of paper records needs to be extracted from the archives.  Then, believe it or not, it is faxed a page at a time to the doctor who is treating you.  That’s if you are lucky.  Many times, the process is just too burdensome and time-consuming.  If you are waiting in an emergency room, chances are they will not even try to obtain this information.  The result is that tests you might have had recently will have to be repeated, a high cost, when you enter the new facility.

But not having EHRs is a problem even if you go to your regular hospital.  There, too, your doctor needs to put in a request for someone to dig up your files and have them delivered or faxed to his or her office.  Not only does this create delays, it offers a high probability that your doctor will not have key information about you as he or she begins to diagnose and treat you.

But all is not hunky-dory even in those places that have EHRs.  In many places, doctors and nurses resent having to enter data into the computer.  They say that it interferes with their communication with the patient and takes up too much time.

A recent comment by Kristin Trotter, director of clinical excellence at Northern Nevada Medical Center, properly finds fault with this view.  (I reprint this with her permission.)  After reading a number of comments along these lines in a national patient safety chat room, she noted:

I have been reading this series of emails complaining about what is perceived to be excessive computerized documentation on patient care that takes the clinician away from spending time with the patient.  I think it’s appropriate to remember that documentation is a communication tool.  It’s meant to document the care provided to the patient in a way that lends to communication with other clinical partners that may or may not be available for face-to-face discussion about the patient.  It’s meant to pass along information in real time to other caregivers and provide an up-to-date and historical record of the care provided to the patient during their stay so that I can plan my care based on current information and go back to review, to answer questions that may have arisen, and to adjust my care plan throughout the patient’s stay, based on care that has been given. EHRs can also serve as a checklist to assure that I have done everything that for the patient that is in my care plan.

I’m just saying that maybe you need to reflect on your own practice and really determine what it is that you don’t like about EHRs. Is it about you? Or about the patient?

I know I’m going to make some people mad.  But I have done many chart reviews over the years and dealt with many patient complaints and risk events. I can tell you that I have rarely heard a patient complain about the doctor’s or nurse’s inattention being related to charting. The complaints I receive involve the nurse or doctor not coming into the room, not interacting with them, and not explaining things. All of these things you can do while sitting at the computer charting, examining, and conversing with the patient. 

I think this is really well said.  The core message offered by Kristin is that the task for doctors and nurses is to deliver patient-centered care.  EHRs are a tool that can facilitate this.  However, like all computer systems, unless the flow of work underlying the use of the computer system reflects a clear set of values and procedures that carry out those values, a lot of that new federal money will have gone down the drain.

1 comment:

fairhavenhorn said...

EHRs have a major role to play in improving quality of care, but only if they are designed and deployed with that in mind.

I had experiences several decades ago with manufacturing automation and had the experience of dealing with both a Detroit and a Japanese car maker. The Detroit buyer had a budget for a billion dollars worth of the best robots available. The Japanese maker had a budget a billion dollars to improve quality and reduce costs of their cars.

Both got what they asked and budgeted for. EHR systems are the medical equivalent of robots.