In Health Technology the Distance between Theory and Practice Remains

Senator Bill Cassidy M.D. (Louisiana) recently chaired a Senate hearing on “Achieving the Promise of Health Information Technology: What Can Providers and the U.S. Department of Health and Human Services Do To Improve the Electronic Health Record User Experience?  It would seem that the promise has not yet been met.

As reported on the Commonwealth Fund Web site, Dr. Cassidy let his feelings about electronic health records (EHRs) be know: “As a physician, time is better spent looking into a patient’s eyes . . . as opposed to clicking through a computer screen to document something unimportant to her and required by someone far removed from the exam room.”

The idea that EHR’s have the unintended consequence of removing physicians from the direct care of patients in order to get them to document that care is a common complaint among doctors.  Dr. David Lee Scher writing in Medscape explains “Decreasing face-to-face time with patients, the demands of data entry, the inability of diverse EHRs to communicate with each other, and poor usability have not only failed to accomplish promised goals and meet physician expectations but have also contributed to job dissatisfaction.”

 Dr. Vindell Washington in his testimony to the Senate describes the “Complaints of increased time burdens on the practitioner, loss of provider interactions with patients, and frustration with new requirements and changed workflows…” as part of the EHR experience.

It is interesting to reflect on how an almost universally praised idea can cause such headaches in practice.  It is a prime example of that disconnect in medicine between the promise of systemic planning and the realities of practice.  At the core of this disconnect is the increasingly important distinction between ‘doing the work’ and ‘documenting the work.’  Or, and this is the way that many doctors experience it, everything that is not documented is becoming in a very important sense less real in the medical environment.  If it cannot be recorded in the medical record it is as if it was never done.  And we all know that a lot of the art of being a doctor cannot be recorded in a checkbox.

Scott Wallace, writing in Health Affairs, sees physician frustration with EHR’s as a flaw in how many EHRs are designed.  He writes “… most EHRs were designed around corporate priorities—billing and high-level record keeping—and their support of the corporate strategy comes at the expense of the service lines. These EHRs treat care as a commodity and raise costs by shifting the burdens of data input onto clinicians. As a result, these EHRs don’t add enough value to care delivery, even though care delivery is why hospitals exist.”

Perhaps beyond defining care as a commodity the EHR defines, intentionally or not, what the medical system finds valuable and not valuable in physicians’ work. Physicians of course find this frustrating because the EHR does not behave like a typical colleague. It is rigid and does not respond to debate. Physicians’ demand for a better conversation about EHRs is a theme in the literature and one that we need to take seriously. The AMA, for example, talks about “user input into product design and post-implementation feedback” as a demand for the future of EHRs.

But as the distance between planning and practice widens, we wonder if anyone knows what that ‘input’ and ‘feedback’ really looks like.  Or, to put it another way, if a portion of the time physicians spend on inputting data into EHRs was spent getting physician input and feedback about what works and doesn’t for patients and physicians on EHRs, would physicians’ practices and patients’ experiences improve?