I’ve had reason to think about Electronic Health Records (EHRs) these past few weeks. There is a lot riding on their success or failure. There’s no question that EHRs will be the future of all documentation in healthcare, but I’m not convinced that healthcare is ready for the transition. At least not yet.
The potential advantages of EHRs are many. In theory they offer real-time information, integration of many systems across a single platform, the ability to store, access and manipulate massive amounts of data (“business intelligence”, analytics, “big data”, etc), they provide information that follows a patient regardless of where they go or who they see, the offer potential for patients to view, edit, use, and add to their own medical information, and so on.
These are all good things. If only the potential was reality. The current state of EHRs is far from their future potential.
I’ve witnessed some crazy things as a result of EHRs in acute care. No harm has come to me personally, but the issues have caused delays in my mother’s care. She has been battling some serious health issues for many years. Someday I may write about her experiences in both acute and ambulatory care in great detail, but for now I will share a few recent examples of bad experiences with EHRs.
- My mother’s medication regimen is complex, really complex. It has taken years to get her dialed in. We’ve worked with the UCSF liver transplant team, my mom’s internist, my mom’s neurologist, and her nephrologist to ensure things are right. The regimen is accessible via my mother’s MyPatientChart at UCSF; an electronic PHR. Two major problems: 1) upon a recent hospital admission the healthcare system couldn’t access the record so I had to give the ED personnel a physical copy, and 2) the person entering the regimen into the electronic medication reconciliation system – a scribe of some sort in the ED – got it wrong. Some of my mom’s medications are uncommon, and the person entering the data couldn’t find an exact med or two, so they just guessed. Seriously, they substituted the wrong med. The attending took the information at face value and ordered them via the EHR. It took me about 24 hours to discover the error. This would not have happened in a paper record because the pharmacist would have reviewed the paper I submitted. And for those of you that would disagree, remember I was an acute care pharmacist for the first 15 years of my career, i.e. pre-EHR. I reviewed hundreds of handwritten medication lists from family members.
- I spent more than one encounter with a nurse, physician, or resident speaking to the back of their head while they recorded information in the EHR. I could see my mother’s frustration with the lack of eye contact and communication. My mother is from a generation where you looked a person in the eye when you spoke with them. She made more than one comment about people constantly “looking at that stupid computer” instead of talking to her.
- I can’t tell you how many times I asked about my mom’s condition or progress and was met by someone logging into the EHR to read me her labs. What the heck do her labs have to do with her “condition”? Look at her. Examine her. Talk to her. Get her up. Walk her. Watch her eat. Talk to me about how she’s doing. The reliance on the EHR has led to an interesting lack of common sense, which is at least partly responsible for my mother enduring three separate hospitalizations in less than three weeks. Labs were good, but she was physically unable to function outside the hospital. Crazy.
- Speaking of three separate hospitalizations, my mother was discharged from the hospital on Saturday, and bounced back two days later on Monday. Unfortunately it was two different hospitals. None of the information from her discharge from hospital ‘A’ on Saturday was available at hospital ‘B’ on Monday. Why? Because the information wasn’t linked. A paper chart wouldn’t have helped, but what advantage did the EHR offer? None.
- Delayed discharge secondary to the EHR? Yep. I received a call from the hospital that my mom was ready for discharge so I went to pick her up. Nothing for a couple hours. I asked the nurse about the discharge repeatedly, and his response was always that the physician hadn’t written the orders. He kept pulling up my mom’s profile on the computer as proof. I also tried the case manager. Same response. Five hours later I finally insisted that the nurse call the physician. The physician arrived in my mom’s room with a bit of an attitude wanting to know why I wanted to speak with him. Was my mom getting discharged or not? He insisted that he had written the orders that morning. I asked the nurse to join us, and a bit of a discussion ensued. Apparently the physician had written the orders, electronically of course, but had failed to hit “SEND”. The orders were sitting in the physician’s queue waiting for a single click of a button. That wouldn’t have happened with a paper chart. The physician would have simply written “D/C patient home”. I’ve seen the order a thousand time. Simple, elegant, final.
All of this occurred in the span of about five days. I could go on, but there’s no reason.
I believe the benefits of an EHR are far off. From what I’ve observed we’re in a sort of gray area. We’re not really getting much benefit out of the EHR, but it’s certainly creating some new difficulties. At this point I believe things can go either way. One direction brings the promise of better healthcare through technology, the other brings worse healthcare through lack of communication and loss of human interaction. Don’t be too confident that it will be the former.