Electronic Health Records Have Some Issues To Overcome

[Stephen C Schimpff]

The future of medicine has some bright spots. One medical megatrend relates to the electronic health record. President Obama is aggressively pushing the electronic health record [EHR]. It will be a major improvement to medical care and to patient safety over time. But there are two major problems that need to be overcome before the EHR will ever be fully functional – interoperability and physician documentation. By interoperability I mean that each of the companies that produce the software do so in a proprietary manner. The result is that they cannot interact. So if a patient is discharged from one hospital today and goes to another hospital’s ER tomorrow, the information from the first hospital will likely not be accessible. This must change and it appears that the federal government is attempting to have standards established for all to follow. That will be a big improvement. There are issues however as to who should set the standards – government or a multidisciplinary working group. Either way, standards are needed.
The second obstacle is that physicians find that most of the current systems actually impede productivity rather than enhance it. This is because the software creators have not spent the time necessary to understand how physician work and are intent on making the document easy to manipulate by the computer. Here is an example. Say a doctor admits a patient with pneumonia. He or she might want to insert the following into the chart: “55 year old nonsmoking male, sudden onset of high fever, shaking chills, productive cough and pain at left lower chest with inspiration. Temp 103, pulse 94, BP 128/74, abnormal breath sounds and dullness to percussion in left lower chest. Chest X-ray shows infiltrate in left lower lobe and sputum exam shows gram positive diplococcic. Diagnosis – pneumococcal pneumonia. Treatment – antibiotic.” Sorry for some “doctor speak” but in essence this is a fairly classical description of a pneumococcal pneumonia. It takes about 30 seconds to say, the same to dictate and perhaps 60 seconds to write or type these words. But to enter it into the chart as per the dictates of the software takes much longer because it requires following a long branching tree of choices. You might liken it to using Word for a document that can be read later versus Excel for a spreadsheet that can be manipulated. Physicians really dislike the extra time it takes and the fact that it is not consistent with the way they “think” about the patient and his or her problem. So they rebel and will not adopt. But this problem, like interoperability, can be overcome.
Once these two issues are resolved, the EHR can become a reality, but not before.

[Ronald S. Newbower]

All Dr. Schimpff's points are important, if not critical. Yet, there is an additional dimension to "intraoperability" that will also be important to success of an EHR, yet one which gets much less attention: the automatic electronic input of data from the plethora of medical intrumentats that collect it. Currently only lab tests, and, in some installations, images, get connected to an electronic record. The Continua Alliance has devoted some attention to overcoming proprietary barriers for basic instrumentation -- primarily with an eye towards homecare and so-called telemedicine. However, huge amounts of valuable data are continuously collected by monitors and devices in inpatient and outpatient settings and either discarded or require manual summary and entry. Intraoperability, and, ultimately, full "plug and play" characteristics must be demanded in future designs.
Functional expectations of this are being expressed now by organizations as broad as the AMA, thanks largely to the pioneering efforts of Dr. Julian Goldman of MGH and of CIMIT. For more information on his efforts, see http://www.cimit.org/programs-mdplugandplay.html