Health IT a quantum leap from other industries

Many physicians are dissatisfied with electronic health record systems, according to a recent survey of members of the professional networking site Sermo. Forty-four percent of respondents said EHRs are not designed with physicians in mind; 15 percent said they believe EHRs lower the quality of care; and 73 percent said EHRs are a distraction from the physician-patient relationship. Less than a third of respondents had a favorable opinion of EHRs, down from 39 percent in 2011.

That's a big drop. One possible explanation is that, because of the Meaningful Use incentive program, many physicians who don't like the technology are adopting it to obtain the government funds while they can. But the other findings suggest that EHRs are not well designed for physician workflow and that many doctors feel they're being forced to spend more time on the computer, leaving less time for interaction with patients.

A pair of Harvard informatics experts, Kenneth D. Mandl and Isaac S. Kohane, think they have a solution to these problems. In a New England Journal of Medicine article, they say it's a "myth" that healthcare requires complex, highly specialized information systems. They acknowledge that in certain areas, such as "the content of medical rules and decision-support rules," health IT is unique. But on the whole, they argue, EHRs could use many of the generic tools, applications, and database structures that are common in other industries. If vendors followed that approach, EHRs could be much cheaper and the workflow burden on physicians could be much lighter, they conclude.

Some of the paper's criticisms of the EHR vendors are valid: for example, they have been slow to make their systems interoperable with competing products. Most EHRs were originally bolted onto practice management systems, and their raison d'etre was tied to maximization of billing, not quality improvement. But the vendors are starting to change in response to customer demand and the dictates of Meaningful Use. Moreover, I disagree with Mandl's and Kohane's contention that "EHR vendors propagate the myth that health IT is qualitatively different from industrial and consumer products in order to protect their prices and market share and block new entrants."

Healthcare is a quantum leap more complicated than banking or airlines--the two industries that, the authors say, eventually figured out how to simplify their electronic transactions. Perhaps project-management and task-sharing software such as Teambox, Basecamp or Huddle could be adapted to healthcare, but not without a tremendous amount of customizing and reengineering. Even then, it's not clear clinicians would use it.

Similarly, communications protocols like the Direct Project, which relies on the familiar SMTP Internet protocol, are being used to expedite secure clinical messaging between non-related-providers. That's a good fax substitute. But if clinicians want to locate patient records in other providers' systems, they need to use some type of health information exchange, and that's not simple to put together.

Interoperability could be considerably advanced if standard nomenclatures and databases were being used. But health care has an incredible multiplicity of terms for the same concepts, which must be normalized by mapping to a standard terminology. In addition, EHR databases--even those that use standard database storage and query systems such as Oracle and SQL--are all different, making it difficult to send data from the discrete fields of one EHR to another's discrete fields. As for using "flexible, generic toolkits" to create interfaces between systems, this suggestion apparently doesn't reckon with the customization of many EHRs.

Mandl and Kohane are quite right in saying, "The IT foundation required for healthcare is the core set of health data types, the formalization of health care workflows, and encoded knowledge (e.g., practice guidelines, decision-support tools, and care plans)." But it's not a trivial matter to translate any of those elements into a usable EHR that will improve the quality of care and that can be applied to all of the myriad care settings and specialties that constitute health care.

There's no doubt that EHRs could be more usable than they are: for example, new breakthroughs in natural language processing promise to liberate physicians from the tyranny of the drop-down pick box. EHR users also need better, more standardized decision support tools, easier access to patient data across communities, and automated applications to simplify workflow. But to say that we should just throw out today's EHRs and replace them with generic applications from the larger business world is a misreading of the real issues. - Ken


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