Failure of EMR to Give Expected Benefits in USA


I have just read an article about EMR from Scientific American entitled ‘Can AI Fix Electronic Medical Records?’

Below are my comments.

In the article, there are statements like

  1. “Digitization of patient charts”,
  2. “Medical records suck”.
  3. “EHR, one that is not simply a digital file folder and “to transition from paper charts to EHRs”

These reflect the confusion that arise from the use, in the USA, of the term EMR for the information system used in clinics and hospitals. In other places, people call the system the Healthcare Information System. In my hospital we call it the Total Hospital Information System. The latter name gives it a different perspective. It is a system to facilitate work just like systems in a shop, manufacturing plant or an airport.
Identification of case types, instances of care (visits, encounters and tasks) and role of the care provider allow the system to provide data entry forms and views of data appropriate to them. This is done through planning based on deep thinking.
The article mentions that systems “varied widely from site to site and even between sites using the same system”.
This is probably not the fault of the system developer but on the choice on how to implement them. A major problem in US is the lack of desire to streamline and to standardize. This is obvious from the statement: “Blood sugar from patients at one hospital …. there were literally thousands of different ways they were entered in the EHR”.
Strict clinical governance will alleviate many of these problems.
There was also a finding mentioned in the article that “To prescribe medications, a doctor has to locate them. a simple search for Tylenol brings up a list of more than 80 options. a simple task has taken precious minutes”.
As early as 1999, there are systems that can be customized for each doctor called the ‘favourite list’ and specific lists for departments containing selected drugs used in each of them.
Another surprising finding mentioned was “The physicians often made dosage mistakes. At one site the error rate reached 50 percent. We’ve seen patients being harmed and even patients dying because of errors or issues that arise from usability of the system”.
A good pharmacy system is integrated with a drug decision support system (like MIMS or Multum) which will check prescriptions and warn doctors about wrong dosage, drug interaction, contraindications due to allergy or pregnancy. Errors should be reduced in a computerized system not increased.

The article says ‘Physicians complain about clunky interfaces and time-consuming data entry. Polls suggest that they spend more time interacting with a patient’s file than with the actual patient”.
The reality is that when paper records were used, doctors and nurses also spend a lot of time writing notes or charting and flipping through the pages to read notes. The difference is, on paper, they can write whatever they choose and often after the interaction with the patient. In a computerized system, there is a need for data to be structured. If what the doctor is supposed to enter is anticipated and the GUI is made intuitive, data entry will be faster. Again, there is undue emphasis on the difficulty to record data but not placing importance to provision of information or guidance by the system. In my hospital care providers are very grateful that laboratory results, X-ray reports and vital signs are readily available without hassle.

The article suggests that

  1. “EHRs turned physicians into data-entry clerks”.
  2. “Doctors have to type up their narrative of the visit”,
  3. “.. but they also enter much of the same information when they order lab tests, prescribe medications and enter billing codes”.

This obviously stemmed from a failure to understand the use of a database (maligned in this article). It is a fundamental dictum that data is entered only once and used repeatedly for various purposes. It is also typical in USA to think that the system (as a result of misleadingly called EMR) is for doctors rather than for all stakeholders. In the USA, it was difficult to introduce Computerized Physician Order Entry because doctors (physicians) are reluctant to place orders for tests, procedures supplies, and so on themselves. This is because, previously entries were made by clerks. In other countries, this not an issue since doctors has always filled up the order forms themselves. If charge codes are attached to orders, there is no need for clinical care providers to worry about charging at all.

Another statement in the article is that “Information still does not flow easily between providers”.
In reality, most patients are managed at a single facility. Within the facility itself there is no reason at all for inability to share data. When they are transferred to another facility only a referral letter with a summary is sufficient to ensure continuity of care. Indeed, a good healthcare information system should be able to generate summaries automatically. Patients can carry summaries with them on their handphone, a thumb drive, a flash card or as a printed document. It is not about using the most advanced technology (example a shared common cloud-based database or AI) but about using the most appropriate technology.

In Malaysia, we run into the same problems in the past and will continue to dos so because we do to learn from our mistakes and successes.

First of all the attitude. I hear statements from people high up. “I don’t know much about IT in health but I think it’s no good”. People don’t want to learn let alone study in depth.
When we had the Telemedicine program together with Hospital / Clinic information systems the leadership cannot see their congruence. We cannot have one without the other. Until now we have a Telemedicine unit when we should have an integrated Health IT and Information management unit. The importance of Telemedicine and a central database for patient care is highly exaggerated.
We should concentrate first at where data is generated and its use for operations i.e. help workers to do work. At the beginning we had it right by calling it THIS. Last year, some smart alack has called it EMR (I suppose to follow the USA).
Yes, for managerial use of data we need a data warehouse. But why don’t we think first of where the data is to come from and how. I remembered attending workshops regarding National Lifetime health record (LHR) and Data warehouse where I asked: “What do you want to do with the data” The answer they give me was: “We just collect it, for people to use for whatever purpose.”
We still have a long way to go.

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