How can we utilize technology in a way that supports the relationship between patient and practitioner and enhances the care of patients?

Adoption - Financial incentives provided through the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 have greatly accelerated the adoption of technology supporting electronic medical records. According to the annual report to Congress on the progress of HITECH, “as of June 2014, 75 percent (403,000+) of the nation’s eligible professionals and 92 percent (4,500+) of eligible hospitals and Critical Access Hospitals had received incentive payments”(1). Yet, despite this rapid implementation and the popular belief that electronic medical records will contribute to more efficient, coordinated, and quality care, the true impact of this technology has not yet been fully understood. Moreover, significant work efforts must be taken to integrate this new technology into every day practice for members of the patient care team so that this technology supports their work, rather than hindering it.

A 2011 report by the Institute of Medicine (IOM) cautions that there is very little evidence that health IT will increase patient safety (2). In actuality, the technology may lead to an increase in adverse events, which there is no standardized way to track currently. Moreover, monitoring this would need to be balanced with making sure that members of the patient care team engage with this technology, rather than resisting it so that there is uptake of the technology. According to the IOM report:

"Poorly designed, implemented, or applied, health IT can create new hazards in the already complex delivery of healthcare, requiring healthcare professionals to work around brittle software, adding steps needed to accomplish tasks, or presenting data in a non-intuitive format that can introduce risks that may lead to harm... Examples of health IT–induced harm that can result in serious injury and death include dosing errors, failing to detect fatal illnesses, and delaying treatment due to poor human–computer interactions or loss of data" (3).

This suggests that future implementation of new technology must be more user-friendly than it is in its current incarnation. As the IOM report stresses, there are numerous factors that contribute to creating safe patient environments; thus, we believe that finding a way to mitigate any additional challenge that the patient care team faces in utilizing this technology is of the utmost importance.

To this end, it is clear that future research must evaluate how computer software can operate most effectively and impactfully within this large, complex system as:

“Safety is an emergent property of a larger system that takes into account not just the software but also how it is used by clinicians. The larger system...includes technology (e.g., software, hardware), people (e.g., clinicians, patients), processes (e.g., workflow), organization (e.g., capacity, decisions about how health IT is applied, incentives), and the external environment (e.g., regulations, public opinion)...Comprehensive safety analyses consider these factors taken as a whole and how they affect each other in an attempt to reduce the likelihood of an adverse event, rather than focusing on eliminating one “root cause” and ignoring other possible contributing factors”  (4).

Understanding how to best utilize these technologies, will allow for a significant improvement in the way in which healthcare delivery occurs from the perspective of both patients and practitioners.

Meaningful Use - The focus of EMR research has shifted away from merely exploring obstacles preventing acquisition (such as cost or employee resistance, among others) to investigations around performance, or what has been termed “meaningful-use” of health IT, within this larger context. For example, a 2011 study by Vanderbilt University School of Medicine identified a number of barriers preventing physicians’ effective use of EMR systems. In addition to barriers resulting from the design of the software itself, the research identified a number of environmental factors undermining the potential usefulness of these EMR systems. The researchers ultimately concluded that some of these “barriers included cluttered workspaces, insufficient space for a paper chart when using EHR, not enough private rooms for computer use, computer stations ill-suited to tall users, and physicians not being physically located at a computer station (e.g., when commuting)”(5). Unless these barriers are reduced, it will make the uptake of EMR by members of the patient care team especially challenging. 

The impact of electronic medical records on clinical workstations becomes immediately apparent when touring healthcare facilities across the country. Even brand new facilities are struggling to contain the clutter that results from numerous computers, printers, ancillary equipment, and electrical cords necessary to support health IT initiatives. Furthermore, this technology has not fully replaced the use of paper, requiring workstations to continue to provide a number of paper filing and storage solutions.

In fact, even as computer hardware becomes more streamlined and reductive (tablets versus desktop computing) and wireless requiring less work-surface real estate, the prevalence of paper will continue unless the software becomes more intuitive and better aligned with how physicians arrive at a diagnosis and how other members of the patient care team, including nurses and medical assistants, record vital patient information.

The prevalence of paper will continue unless the software becomes more intuitive and better aligned with how physicians arrive at a diagnosis and how other members of the patient care team record vital patient information.

A routine visit to your primary care doctor more than likely exposes these IT warts and workarounds. Hunched doctors predominately positioned with their backs to the patient as they furiously enter data on a desktop computer, doctors precariously balancing laptops on their knees during a consultation, and nurses pushing clunky mobile workstations from room to room are all too common scenarios. With an electronic medical record in the room, it is as if a wall has been erected between patient and caregiver distracting physicians from making eye contact, posing open-ended questions, and discouraging physical touch (6). Most doctors choose the profession for these very human interactions and not surprisingly find the technology barrier frustrating. Indeed, electronic medical records are a major contributor to physician dissatisfaction (7).

Some physicians overcome these obstacles by memorizing patient information and documenting at the end of each day. A growing number of physicians have hired medical scribes to assist with electronic documentation, freeing them to focus on patient care rather than clerical activities.

Interviews with practicing physicians reveal some of the unintended consequences of electronic medical records. For example, in the New York Times article, “The Ups and Downs of Electronic Medical Records,” Dr. Scott A. Monteith, a psychiatrist and health I.T. consultant in Michigan admits that “the electronic systems were ‘disrupting traditional medical records and, beyond that, how we think’ — the process of arriving at a diagnosis. For example, the diagnosing process can include ‘looking at six pieces of paper,’ he said. ‘We cannot do that on a monitor.  It really affects how we think.’” In order to address this shift, electronic medical records will need to be better designed and supported by other technologies that put the users’ needs first.

Another example of the way in which the electronic medical record impacts the way in which care happens within the healthcare environment was illustrated by a study exploring paper usage following the adoption of the Computerized Physician Order Entry and the Electronic Medical Record (EMR/CPOE) that analyzed data collected from fourteen hospitals across the United States. The methodology is relatively simple: hospitals recognized by a panel of experts as the gold standard—leaders for EMR implementation—were sought for the study and included Massachusetts General, Brigham and Women’s, and Kaiser Permanente Northwest. In analyzing the results of the study, the investigators concluded that “like the paperless business office, the paperless hospital or medical office is currently a myth [with] persistent paper [as an] unintended consequence of EMR/CPOE implementation”(8).

However, figuring out a better way to integrate man and machine within the healthcare environment has to be imminent hence positively impacting both patients and practitioners. Solutions abound as entrepreneurs, engineers, and businesspeople try to enter this space. One interesting example of this is Dedo Graphium, which is a company that has created a new tool to replace clunky, difficult to use EMR systems. This new system is portable and integrated with tablets that doctors and other healthcare practitioners can easily take with them as they go about their work and meet with patients. Solutions such as Dedo Graphium, among others, illustrate that the healthcare space is one of interest to entrepreneurs and private businesses as well as government entities and engaged members of the public.

References

1. The Office of the National Coordinator for Health Information Technology (ONC) Office of the Secretary, United States Department of Health and Human Services. (2014). Update on the adoption of health information technology and related use and exchange of health information. Report to Congress, October 2014, 9.
2. Institute of Medicine. (2012). Health IT and patient safety: Building safer systems for better care. Washington, DC: National Academies Press.
3. Institute of Medicine. (2012). Health IT and patient safety: Building safer systems for better care. Washington, DC: National Academies Press.
4. Institute of Medicine. (2012). Health IT and patient safety: Building safer systems for better care. Washington, DC: National Academies Press.
5. Holden, R.J. (2011) What stands in the way of technology-mediated patient safety improvements? A study of facilitators and barriers to physicians’ use of electronic health records. J Patient Saf. 2011 December ; 7(4): 193–203. doi:10.1097/PTS.0b013e3182388cfa
6. Montague, E. et al. (2013). Dynamic modeling of patient and physician eye gaze to understand the effects of electronic health records on doctor–patient communication and attention. International Journal of Medical Informatics, Volume 83, Issue 3, 225 - 234
7. Friedberg,M.W., Chen, P.G., Van Busum,K.R., Aunon,F., Pham, C., Caloyeras, J., Mattke, S., Pitchforth, E., Quigley, D.D., Brook, R.H., Crosson, F.J., Tutty, M. (2013). Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Washington, DC: National Academies Press. RAND Health.
8. Dykstra, R. H., Ash, J. S., Campbell, E., Sittig, D. F., Guappone, K., Carpenter, J., … McMullen, C. (2009). Persistent paper: The myth of “going paperless.” AMIA Annual Symposium Proceedings, 2009, 158–162.