The other day, I had lunch at DC’s Soupergirl with the redoubtable Chuck Webster, workflow tool maven and evangelist. We talked a lot and discovered that both of us had a warm spot for the classic neighborhoods near Atlanta’s Piedmont Park. He as a transplant and I as a native.
More to this blog’s point, we discussed the state of EHRs and their numerous problems. Chuck wondered if EHR, per se, had become a bad brand? It’s a good question. Have we seen a once promising technology become, as has managed care, a discredited healthcare systems? It’s an easy case to make for a host of reasons, such as these:
Poor Usability. There are scads of EHRs in the marketplace, but few, if any, have a reputation as being user friendly. Whenever I first talk to an EHR user, I wait a few minutes while they vent about:
- How they can’t put in or get out what they need to,
- Their PCs being poorly located, inflexible or the wrong footprint,
- Data that’s either missing, cut off or hard to find,
- Logging in repeatedly,
- Transcribing results from one system to put it in another,
- Wading through piles of boilerplate, to get what they need etc., etc.
- Having to cover PCs with sticky note workarounds.
As for patients, my friend Joe, a retired astrophysicist, is typical. He says when his doctor is on her EHR she doesn’t face him. She spends so much time keying, he feels like he’s talking to himself.
Now, it’s not completely fair to blame an EHR for how it’s implemented. The local systems folks get a lot of that blame. However, vendors really have failed to emphasize best practices for placing and using their systems.
Missing Workflows. EHRs, basically, are database systems with a dedicated front end for capturing and retrieving encounters and a back end for reporting. To carry out, their clinical role they have to be flexible enough to adapt to varying circumstances with a minimum of intervention.
For example, when you make an appointment for a colonoscopy, the system should schedule you and the doctor. It should then follow rules that automatically schedule the exam room, equipment, assign an anesthetist, and other necessary personnel, etc.
When you come in, it should bring up your history, give your doctor the right screens for your procedure, and have the correct post op material waiting. General business software workflow engines have done this sort of thing for years, but such functions elude many an EHR. EHRs without needed workflow abilities increase staff times and labor costs. They also mean users miss important opportunities and potential errors increase.
Data Sharing. Moving from paper to electronic records promised to end patient information isolation. Paper and faxed records can only be searched manually. However, with a structured electronic record, redundant entry would be reduced and information retrieval enhanced. Or so the argument went, but it hasn’t worked out that way.
While there are systems, such as the VA, Kaiser and various HIEs that fulfill much of the promise, it is still a potential rather than a reality for most of us. There are two basic reasons for this state of affairs: ONC’s mishandling of interchange requirements and one member of Congress’ misplaced suspicions.
ONC’s Role. ONC’s Meaningful Use program is meant to set basic EHR standards and promote data interchangeability.
When it comes to these goals, MU fell down from the start. MU1 could have been concise requiring an EHR to capture a patient’s demographics, vitals, chief complaint and meds.
Most importantly, MU could have made this information sharable by adopting one of HL7’s data exchange protocols. This would have given us a basic, national EHR system. Instead, MU focused on too many nice to have features, leaving data exchange way down the list.
ONC has tried to correct its data interchange a failing in MU2 to a degree, but it’s not there yet. Here’s what GAO, has to say about ONC’s efforts:
HHS, including CMS and ONC, developed and issued a strategy document in August 2013 that describes how it expects to advance electronic health information exchange. The strategy identifies principles intended to guide future actions to address the key challenges that providers and stakeholders have identified. However, the HHS strategy does not specify any such actions, how any actions should be prioritized, what milestones the actions need to achieve, or when these milestones need to be accomplished. GAO Report-14-242, March 24, 2014. Emphasis added.
Ron Paul. The other important obstacle to interchange came from Congress. When Congress passed HIPAA in 1996, it mandated that HHS develop a national, patient ID. However, in 1998 Ron Paul, (R-TX) deduced that since HHS wanted the ID system, it therefore wanted to put everyone’s medical records in a government database. He saw this as a threat to privacy. He got a rider added to HHS’s budget forbidding it to implement the ID system or even discuss one.
The ban’s remained in succeeding budgets. The rider has created a national medical data firewall for each of us, which hinders all of us. Paul’s gone from Congress, but Congress continues the ban. As Forbes’ Dan Munroe wrote about Paul’s ban:
The health data chaos we have today doesn’t allow for interoperability, portability or mobility. It’s why fax machines remain the ‘lingua franca” of U.S. healthcare. Every healthcare entity in the U.S. sees each patient, event and location as unique to them. For lack of a single identifier, there’s no easy or cost-effective way to coordinate patient care. Emphasis added.
While the lack of a patient ID is not EHRs fault, it noticeably reduces their ability to interchange information. State or other HIE’s are, in effect, workarounds for lack of a uniform ID. This situation adds to the perception of EHRs as unresponsive technology.
Onerous Agreements. As many an EHR buyer has found, vendors see EHRs as a sellers’ market. They use this to write onerous license agreements exempting their products from adhering to standards such as MU or from responsibility for costly errors or omissions.
These agreements not only limit liability, but often silence a buyer’s adverse comments. The effect is to cut buyers from any meaningful recourse. This shortsighted practice adds one more layer to the EHR industry’s image as unresponsive, self serving and defensive.
Whither the Brand?
The question then is are things so bad that EHR needs rebranding? If so, how should this be done by calling EHRs something else, advocating for a different technology, or yet another alternative?
For some brands, a new name along with some smart PR will do. That’s how Coca Cola reversed its New Coke fiasco. EHRs have a tougher problem. EHRs are not a one vendor product. They are a program class. Reforming EHR’s brand will take more than effective PR. It will take pervasive technical and policy changes.
Change From Where?
Change in a major technical field, as in public policy, requires either overcoming or going around inertia, habit, and complacency. EHRs are no exception. Here are some ways change could happen.
External Events. The most likely source of change is a crisis that brings public pressure on both the industry and government. There is noting like a tragedy to grab public attention and move decision makers off the dime. I don’t want it to occur this way, but nothing like a tragedy makes events go into fast forward and move issues from obscure to inevitable. Given EHRs many patient safety problems, this is all too likely an outcome.
ONC Initiative. ONC could step in and help right matters. For example, as I have advocated, ONC could run NIST’s usability protocols for all systems seeking MU certification. It could then publish the test results giving users a needed, common benchmark. This, in turn, could be a major push to get vendors to regard usability, etc., as an important feature.
ONC is not inclined to do this. Instead, it asks vendors to pick one of several versions of user centric technology. As Bennett Lauber, Chief Experience officer of The Usability People recently told HIEWatch:
“Usability certification for meaningful use really isn’t a test the way the rest of the certification process is. (Testers) go out and observe users, and report back to the certifiers,” Lauber reports. “There seem to be different sets of evaluation criteria because ONC has not really defined usability yet….” Emphasis Added.
Recently appointed ONC Coordinator, Dr. Karen Desalvo, unlike her predecessors, has been frank about changing ONC’s course. She’s revamped her advisory committee structure and spoken about going beyond meaningful use to big data.Notably, she understands the need for and the problems of interoperability. However, she’s not offered any changes in standards. ONC is in the best position to implement real standards, but for both political reasons; it’s unlikely to do so.
To chill things politically, vendors only have to find a few Congressmen who’ll, for a well placed contribution, will send ONC vendor drafted letters threatening its appropriation, committee reviews, etc. It can happen otherwise, but as Damon Runyon has said, “The race is not always to the swift, nor the battle to the strong, but that’s the way to bet.”
User Revolt. The most notable user push back to the status quo has involved unilateral EHR vendor agreements.
As Katie Bo Williams of Healthcare Drive (edited by Hospital EMR and EHR’s Anne Zieger) has notably described, major lawsuits are costing some vendors dearly. The industry, however, has yet to set buyer agreement standards that could aid its and EHRs’ reputation.
These lawsuits might chastise vendors, but users will need to become bolder if they want change. EHR vendors have an association to protect their interests. So do hospitals, physicians, practice managers, etc. Users are the one group that’s not represented.
You may belong to this or that product’s user group, but there is no one group that looks after EHR user’s interest. If there were a well organized and led EHR user group that lobbied for better usability, workflow tools and universal data exchange etc., then these issues would become more visible. More importantly, users would be able to demand a place at the table when ONC, etc., makes policy.
Those interested in patient safety, too, are taking some new directions. Recently, ECRI convened the Partnership for Promoting Health IT Patient Safety to promote changes, within “a non punitive environment,” that is, in a collaborative setting among vendors, practioners, safety organizations, etc. While the group has not issued any reports, it offers two hopeful signs.
The group’s advisory panel includes experts, such as, MIT’s Dr. Nancy Leveson, who works in aeronautic and ballistic missile safety systems. The other factor is that the group has consciously sought to give vendors a place where they see the impact their products have on patient safety without the threat of litigation. Whether the group can bring this off and influence the market remains to be seen.
Technical Fix. It’s possible users may decide to fix EHR’s problems themselves. For example, the University of Pittsburgh Medical Center (UPMC) uses a combination of EPIC, Cerner and its own clinical systems. It wanted to pull patient information into one, comprehensive, easily used profile. To do this, the Center developed a new, tablet front end that overcomes a variety of common EHR problems.
Once a major actor, such as Pitt, shows there is a market, others will explore it. You’ll know it’s a real trend, when a major vendor buys a front end start up and brands it as its own.
Natural Turnover. Finally, John recently raised the question of EHRs’ future in What Software Will Replace EHR? He thinks that change will come organically as more technically robust software pushes out the old.
Slowly replacing current EHRs with new tools is the most likely path. However, a slow path may be the worst outcome. Slow turnover would give us a mixture of even more incompatible systems. This would make the XP installed base problem look simple.
The EHR brand reminds me of a politician with both high positives and negatives. It may be liked by many, however, it also has a lot of baggage. As with a candidate in that position, something will have to change those negatives or it will find itself just an also ran.