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Will EHRs Cure Healthcare?

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Will EHRs Cure Healthcare?
Physician-Friendly EHR Documentation

Implementing an electronic health record (EHR) costs tens of thousands of dollars for each physician.  Soon, taxpayers will be footing the bill.  That would be fine if we’re certain it will make our healthcare costs go down.  But how can we be certain of that?  There is no question that there will be some benefits resulting from the operational efficiencies and clinical alerts of EHRs.  But do we really believe these systems will make healthcare all that it can be?  
     
Until we are totally confident we know how to design and deploy EHRs in a manner that will dramatically improve healthcare, why would we want to proliferate these systems?  The thinking is that EHR interoperability will solve healthcare's crisis.  But ask yourself:  Whenever you've received inadequate care, what was the root cause?  Was it (1) because your doctor couldn't access a medical record that was in some other doctor's office?  Was it (2) because your doctor did not have access to the clinical knowledge that would have led to accurate diagnosis and/or effective treatment?  Or was it (3) because medical science, itself, just does not know enough?
   
Of those 3 causes for suboptimal healthcare, I believe the first one (lack of EHR interoperability) is actually the least impacting.  For most clinical episodes, the treating physician is not truly handicapped by not being able to see what’s in some other physician’s record of your prior care.  The second one seems to be considerably more instrumental.  No physician can learn all s/he needs to learn, remember all that was learned, and apply it effectively during a brief clinical encounter.  So we should clearly enable access to whatever is currently known by medical science, by providing computer-retrievable knowledge at the point of care.  Not to do so is just plain foolish…or professionally arrogant.
       
The third cause, in my opinion, is actually the most significant deficiency in healthcare.  Medical science just does not know enough.  The reason for this is that healthcare does not learn from its own experiences.  No one is retrospectively analyzing all the clinical encounters every day, to determine the early signs of what eventually become definitive diagnoses.  No one is evaluating what treatments actually work best for various conditions, and under what circumstances.  Medical science only moves forward via controlled clinical studies, which are too targeted and expensive to be our only strategy for advancing the science.  We need to mine the data on real-life clinical encounters – nationwide.  If you doubt this assertion, think about hormone-replacement therapy.  The message here is that data interoperability, attained through a standardized clinical vocabulary, is more critical than operational interoperability.
       
Once we have determined, through data analyses (while controlling for potentially confounding variables), how to diagnose and treat more effectively, we must convert that learning into a "clinical guidance system", operational at the point of care.  We would monitor outcomes, assuming we can figure out how to measure them, so that the system can be empirically enhanced – thereby establishing continuous quality improvement (CQI) for healthcare.  That, along with systematization of healthcare delivery, via processes like triage and rational incentives, is the only way that we can prevent the current crisis from turning into an apocalypse.
        
We need to conduct pilots of alternative EHR approaches, rigorously analyzing both the financial and clinical outcomes – so that we can learn what truly works best.  The point-and-click documentation requirement of most existing EHRs has ironically been demonstrated to decrease the productivity of physicians.  That is the last thing we need…particularly if there are no offsetting benefits derived from improved quality and value.  Let’s figure out how to do it right:  How to make data entry physician-friendly and highly efficient.  Let’s bring the best minds together to design and evaluate these systems, which will determine the future of our nation’s healthcare.  Let's not throw money at this devastating problem until we know for sure it will buy the cure.
               
           
Joe Weber
 
CEO, Narratek 
                 
joeweber@alum.mit.edu