Fixing the EHR Beast

Hello and welcome. I am Dr. George Lundberg, and this is At Large at Medscape. Can the US healthcare EMR, EHR, HIS, PHR mess be fixed? This is very difficult to talk about. I doubt that very many of you would disagree that it is one God-awful mess as of 2014. But the problems without EMRs (electronic medical records) are worse than the problems with them. As a society we depend so much on technology that it must be fixed.

I started working with computers in medicine in 1963. I have never been a "techie," but I got hooked on the potential of computer technology then and have never looked back. (Disclosure: I worked for MedicaLogic when it marketed Logician and for WebMD when it marketed Medical Manager, so I have been part of this evolving mess. I own no stock in either or in any other such company.) So, let us try to analyze simply what has been wrong about the US EMR effort, what has been right about it, and what needs to be done to fix it.

Old, Unfriendly, Decentralized, and Incompatible

First, what is wrong? Most current EMRs were developed by software engineers, primarily to serve the financial interests of healthcare facilities. Clinical usefulness for physicians and nurses was an afterthought. The hardware and software used for most EMRs are still old-style and legacy-based, and this is enterprise-wide. Our decentralized approach to EMR product development and the large amount of money available have resulted in hundreds of vendors, each seeking a competitive edge and striving for uniqueness, thus assuring incompatibility and little interoperability. Once the megabillions became available, lobbying forced the rapid adoption of old, unfriendly systems.

Errors in diagnosis and treatment may often be increased rather than decreased by EMRs. Fraudulent clinical data entry is encouraged by the quick and easy checkbox buttons. Copy and paste of repetitive information without serious thought has become a norm. There is massive disconnect in the marketplace, as evidenced again by the 2014 Medscape survey of physicians.^[1]

On the Other Hand...

What is right? After many decades of resistance to using EMRs, large and growing numbers of hospitals and physicians are now using increasingly clinically oriented EMRs. To motivate adoption of EMRs, the federal government has used both sugar (monetary incentives) and club (financial penalties for failure to implement). Large numbers of real physicians are now engaged and angry at the squandered opportunities.

Now that their attention has been caught, maybe those myriad smart docs will help to build new generations of the systems that will actually help them practice better medicine. Physicians now routinely access the Internet in a wide variety of ways for amazingly easy access to trustworthy and relevant clinical information. The handheld PDA, smartphone, mobile app revolution is roaring with giant promises made and delivered, and modern physicians are deeply into using the approaches.

Let's Fix This Sucker

What is needed? We need interoperability across facilities, healthcare groups, state lines, publically and privately owned systems, and patients. We need to enhance the ease of use at the get-go of planning and not as an afterthought. We need Cloud-based engineering as the dominant approach, portability of information access, patient-centered thinking to produce systems that enhance rather than impede empathetic patient-physician interaction, and rapid clinical records search capability. Think Google, Yahoo, and Bing for the medical records you need. Why not?

There must be a way to make these IT systems more helpful to patient safety than they now are. All of this, plus practical clinical decision support systems incorporating advanced, relevant data analytics.

To summarize, the immense promise of electronic health records has yet to be realized, and that is a good thing because the best is yet to come. The contrast between instant access, algorithmic mobile apps, lightning-fast search, and transmission as a useful dominant [and the current] data-overload, cumbersome, clunky systems in which I cannot seem to find what I need and, when I do, I don't believe the information because I know someone faked it. Standard EMRs would be funny if they were not so tragic. Did someone say something about privacy and security information? You have got to be kidding. There is none. Think about paper records; there is also little privacy and security there.

Let's all fix this sucker. It can be done. The future for EMRs is now, but, hey guys -- get modern. It's all about user experience.

That is my opinion. I am Dr. George Lundberg, at large at Medscape.

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