Dan Morhaim is a physician and, as a Democrat, represents Baltimore County in the Maryland House of Delegates.
Paul came to the clinic because he was feeling depressed. As the first physician to see him, I opened a new file in our electronic health record system.
After typing in “depression” as the presenting symptom, I was shown a menu of dozens of potential diagnoses, including “adjustment disorder with depressed mood,” “adjustment disorder mixed anxiety and depressed mood” and “atypical depressive disorder.” A competent clinician could easily choose one of several options and still be accurate. Once saved, unfortunately, these entries are difficult to change.
Electronic health records were once touted as a turning point in U.S. health care, expected to revolutionize recordkeeping on patient histories and reduce the potential for medical errors. I hope that someday they will. But as the Affordable Care Act launches and, presumably, more Americans seek treatment, there is no standard system nationwide, and entry errors and inconsistencies are becoming common.
Ironically, the most significant benefit of the expensive, multiyear effort to implement electronic health records may be legible medical notes.
Medical billing is a chronic war between those wanting to get paid (physicians, hospitals) and those not wanting to pay (insurance companies, government). While billing has long been computerized, the shift to electronic records among clinical practices is relatively recent. The 2009 stimulus legislation made billions in federal funds available for the transition to electronic health records, with more earmarked for the future. Hundreds of electronic systems now exist.
To greatly simplify, the dog-and-pony show goes something like this: A company hypes its system, emphasizing its compatibility with billing procedures. Administrators buy the systems, generally without input from the doctors, nurses and others who enter the data.
A June editorial in the Annals of Internal Medicine rightly called the universe of electronic health record systems a “Tower of Babel,” noting that a 2012 study found that only about 10 percent of U.S. physicians reported “meaningful use” of the systems.
These systems tend to be fantastically complex. One doesn’t have to be intimately familiar with, say, Hertz or Enterprise to rent a car online. But many electronic health record systems have pull-down screens listing each of the 68,000 possible diagnosis codes in the World Health Organization’s International Classification of Diseases and 87,000 possible procedure codes.
Or consider what happens when I write a prescription: Every potential drug interaction or side effect listed generates a warning prompt. Inevitably, recognizing that the warnings are generally inapplicable and take time to sort out, clinicians start to bypass the alerts. Sooner or later, ignoring one will lead to serious complications.
Compounding these issues is the fact that hospitals, clinics and offices have different systems. When these systems get overloaded or go down, even more work is generated, sparking delays in care.
Like many health-care providers, I work at more than one location. At one facility, the electronic health record system starts with 30 tabs, each representing a different chief complaint of patients. Each primary tab has multiple tabs behind it. At another facility, detailed diagnostic data must be entered before the next screen can be completed. Each program takes time to learn and requires continuing education.
Perhaps the most pernicious side effect is the erosion of the provider-patient relationship. When I first began working with electronic health records, I caught myself staring at the computer screen instead of engaging patients, who rightly felt ignored. Like many colleagues, I’ve reverted to the practice of talking with the patient and taking notes with pen and paper. After the evaluation is over and the patient has left, I type in the data. This takes much more time, but it is the only way to complete a proper history and exam.
The result is decreased productivity and frustrated providers — and a lack of meaningful data to manage patient care.
It’s hard not to think much confusion and duplication could have been avoided if policymakers had involved providers in every step of the transition.
The Veterans Affairs is often criticized, but one thing for which it deserves praise is its award-winning electronic health records system. Deployed throughout the VA system in the late 1990s, the Veterans Health Information Systems and Technology Architecture, known as VistA, is an integrated in-patient/out-patient, pharmacy and data management program. By some estimates, more than 60 percent of U.S. physicians have used VistA at some point during their training.
Had information technology companies been incentivized to make VistA compatible with billing systems, our country might have an efficient and robust clinical system that practitioners nationwide would know how to use. The only potential downside: Fewer government dollars for tech companies and their consultants.
The Office of the National Coordinator for Health Information Technology should declare a moratorium on implementation of electronic health records programs and review where things stand, with the goal of implementing a uniform, user-friendly system. Broad adoption of an upgraded version of VistA might do wonders.
Ideally, electronic health records would provide doctors with instant access to information and help patients track their medical histories. Such records should be a giant step forward in continuity and comprehensiveness of care. So far, the “cures” are worse than the disease.