Sunday, June 10, 2018

The EHR Strikes Back!

The last few years have been challenging for the electronic health record (EHR). While the Health Information Technology for Economic and Clinical Health (HITECH) Act succeeded in transitioning the US healthcare system mostly away from paper [1], the resulting electronic systems created a number of new problems [2]. They include diverting attention from patient care, adding to clinician time burdens, and causing outright burnout. Although the underlying problems of quality, safety, and cost of healthcare motivating the use of EHRs still exist, the large-scale adoption of EHRs has yet to solve them in any meaningful way.

I cannot imagine that many would advocate actually returning to paper medical records and fax-based communications. But clearly the new problems introduced by EHRs must be addressed while not losing sight of the original motivations for them. Fortunately, a more nuanced view of the EHR is emerging, and based on some recent happenings I will describe next, it may be said that the EHR is striking back.

The first strike back was an "Ideas and Opinion" piece in the medical journal, Annals of Internal Medicine. Presenting data on note length in the EHR gathered by use of the Epic EHR in different countries, Downing et al. found that the length of notes in the US was substantially longer than those in other countries [3]. The authors contend that this is due the priority of EHR use in the US for billing and other non-direct aspects of clinical care. They suggest that these uses beyond the direct clinical encounter, and not the EHR itself, are the cause for physician dissatisfaction and burnout.

A second strike back is the release of a Harris poll at a Stanford symposium to re-imagine the EHR and make it more useful for physicians. The poll of over 500 primary-care physicians (PCPs) on the EHR showed that these physicians saw value in the EHR but that they also desired substantial improvements.

About two-thirds of these physicians agreed with the statement that EHRs have led to improvement in care (63%) and were somewhat or more satisfied with their current systems (66%). But significant numbers of these PCPs also acknowledged problems:
  • 40% said there are more challenges than benefits with the EHR
  • 49% believed that using an EHR detracted from their clinical effectiveness 
  • 71% stated that EHRs greatly contribute to physician burnout 
  • 59% agreed that EHRs need a complete overhaul
The surveyed PCPs did not see EHRs as powerful clinical tools, but rather found their primary value in data storage (44%), with only 8% agreeing their primary value was clinically related.

Their survey also found substantial agreement on what should be fixed immediately versus in the longer term:
  • 72% believed that improving the EHR user interfaces could best address EHR challenges in the immediate future 
  • 67% agreed that solving interoperability deficiencies should be the top priority for EHRs in the next decade
  • 43% desired improved predictive analytics to support disease diagnosis, prevention, and population health management
A final strike back for the EHR is the announcement by Apple of their new Healthkit, a collection of application programming interfaces (APIs) that add value to the functionality recently added to the Apple Health app that allows people to download their data via the Fast Healthcare Interoperability Resources (FHIR) standard. These APIs will allow new apps to be developed that implement ways to use their data to improve their health and healthcare. Apple has historically been a company that has tended to isolate its ecosystem and has been slow to adopt standards, but this move into the most important data standard for healthcare is to be lauded. The present functionality of being able to download data into the Apple Health app is limited, but the functionality of downloading it with FHIR and providing an API for use of the data opens to door to many applications, some of which no one has even conceptualized.

The EHR has certainly taken it on the chin of late, deservedly so. But with the foundation that has been laid by HITECH, recognition of the problems being more related to the healthcare system than the EHR per se, and new innovations such as those from Apple and others who devise new methods to do interesting things with the data, we will hopefully find new innovations that address problems in healthcare and enable new applications that improve personal and public health.

1. Washington, V, DeSalvo, K, et al. (2017). The HITECH era and the path forward. New England Journal of Medicine. 377: 904-906.
2. Halamka, JD and Tripathi, M (2017). The HITECH era in retrospect. New England Journal of Medicine. 377: 907-909.
3. Downing, NL, Bates, DW, et al. (2018). Physician burnout in the electronic health record era: are we ignoring the real cause? Annals of Internal Medicine. Epub ahead of print.

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