This appeared a little while ago.
EHRs: Expecting Too Much, Too Soon?
In 2014, health care record-keeping and communication are finally emerging from the Stone Age and entering the 21st century, moving away from the pen-and-paper processes abandoned by the rest of the modern world decades ago.
This revolution is driven primarily by the HITECH Act and accompanying meaningful use program. These initiatives drove greater adoption of electronic health records by doctors and hospitals in the last five years than in the previous 40. According to one estimate, EHR adoption by physician practices rose from 17% in 2008 to 48% in 2013 and hospital EHR adoption increased from 13% to 70% during the same time period. These EHRs will play a central role in the move to accountable care and population health management.
A principal HITECH objective was to improve patient care, but a number of recent publications challenge the program's success and EHRs' value -- from both the perspectives of physicians using EHRs and researchers who are decrying a high level of patient safety events across the industry. One article points out that a substantial minority of physicians are dissatisfied with the effect of the EHR on office operations; others suggest EHRs are failing to live up to their promise of reducing patient harm.
Should we be disappointed that this technological revolution hasn't yielded all the anticipated benefits? We think this would be premature. Here's why -- and who's doing it right.
Managing Expectations for the EHR
EHRs can facilitate patient care improvements through three basic mechanisms:
- Better information capture and documentation;
- Better sharing of information across settings; and
- Most importantly, application of computerized clinical decision support (CDS) and data analysis.
The early literature supporting the value of CDS -- on which the meaningful use criteria were largely based -- was derived mostly from a handful of academic institutions with custom-built EHRs that they had constructed and tuned over decades.
It is unreasonable to expect that the majority of organizations that have implemented commercial EHR products in recent years will achieve the kinds of care improvements in a short period of time (two to five years, or "overnight," in health care industry terms) that took the early academic centers many years to achieve.
While in recent years we have learned more about how to design and implement effective CDS, most organizations have neither the staff expertise nor the budgets to commit to drive changes of this magnitude in a short time. Commercial EHR products are equipped with many of the ingredients needed to support clinical workflows and build robust CDS, but they bring with them their own inherent constraints.
Perhaps more importantly, we know that driving rapid technologic and workflow change in organizations is both difficult and hazardous. One way hazards can manifest is through unintended consequences of computerization. Sometimes problems arise from improperly designed or coded software containing errors; however the great majority of unintended consequences arise from the gap between vision for the system as designed and the reality of the system as used. It is virtually impossible to anticipate the full spectrum of individual human and workflow interactions with the system and the resulting manner in which the system gets used.
Some good examples of what has really seemed to have worked and the implementation issues can be found here:
If you consider each of the 3 mechanisms to make things better you can see that we are by no means at the end of the journey. Information capture is not all that efficient and easy, interoperation is still a work in progress and decision support is not universally working as we might hope.
In summary - we are getting there - but more effort is needed for a good while yet!
David.
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