Chandrakanth Are, MBBS, MBA, FRCS, FACS
THE INTRODUCTION of the electronic health record (EHR) was supposed to lead us to a utopian world for health-care delivery in America. The Patient Protection and Affordable Care Act, signed into law on March 23, 2010, promoted its implementation by providing financial incentives.1 The Centers for Disease Control and Prevention noted that nearly 53.9% of office-based physicians use a basic electronic health system, and approximately 86.9% of office-based physicians have some form of electronic health record.2 This rapid implementation has not been without its own hurdles, and these hurdles have contributed to large swaths of diverse opinions on every side of the issue.
To clarify, there is a difference between the electronic medical record (EMR) and the electronic health record. Electronic medical records are computerized or digital versions of the paper-based patients’ charts or health records obtained from one location or one provider’s practice.3 Electronic medical records contain information such as, but not limited to, patients’ demographics, diagnosis, prognosis, patient-physician communications, investigations undertaken, drug treatments, operations performed, and follow-up details. Electronic health records do all the tasks performed by EMRs but also go a lot further than EMRs and are much more comprehensive.1 Electronic health records collect and coordinate information obtained from more than one provider location; they are real-time patient-centered records and provide an electronic platform for accessing patient information anytime and from any place by any authorized provider. In addition to covering the clinical information, electronic health records focus on the total health of the patient.
“It is not uncommon for us to have to pore through screens and screens of data just to find one vital bit of information—whether the patient with pancreatic cancer has jaundice or not.”— Chandrakanth Are, MBBS, MBA, FRCS, FACS
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Benefits of Electronic Health Records
THERE ARE many benefits to electronic health records. To begin, they start with the famed handwriting abilities of physicians and their legibility or more precisely illegibility. We all recall several humorous occasions when we would be embarrassed by our inability to read our own handwriting the very next day. Or there were serious occasions where illegible handwriting made it nearly impossible to decipher the dose of a life-threating drug. We recall those pages from a bedside nurse to clarify the dose of a drug in the wee hours of the morning.
By virtue of their interoperability and remote connectivity, the electronic health record can significantly improve health-care delivery across the nation, particularly when transferring or referring patients from one facility to another. In the days gone by, beyond the phone call and fax, there was no system for an accepting hospital to review the details of a patient in detail. Whereas in the present day due to connectivity, we can know just about as much of the patient’s details even before he or she arrives at our doorstep.
In the right format, the electronic health record can also be a super weapon to conduct large-scale research studies of significant value to the entire population. The terabyte, petabyte, exabyte, zettabyte, and yottabytes of data that are being collected are a vast treasure trove that can make any researcher, health-policy advocate, or economist salivate. All of this can translate to great societal benefits of monumental proportions. If done right, it may also help to chip away at the $3.3 trillion we spend on health care, accounting for nearly 17.9% of our gross domestic product in 2016.4
What is surprising is that for a profession so sophisticated and at the cutting edge in everything else, we have been glued to our paper longer than we should have. The paradox was there for all of us to see. Here we would perform the most sophisticated surgical procedure using the state-of-the art technology and then promptly revert to our paper to document the findings. We probably should have done this transformation years ago, which could have prevented the rushed and shoddy implementation of these electronic records.
Drawbacks of Electronic Health Records
ALTHOUGH IT is easy for the supporters to gloat over the benefits, electronic health records are not without their own major faults and drawbacks. To begin, even at their best on the brightest day, they are cumbersome. It is said that some of the current versions were developed initially to help with billing and to build administrative efficiencies. It is also clear that some versions are more suitable for nonsurgical specialties, and the “one-size-fits-all” approach does not make it user-friendly for all specialties.
“The amount of documentation required to satisfy the growing requirements from the regulatory bodies has converted highly trained physicians into the most expensive scribes in the world.”— Chandrakanth Are, MBBS, MBA, FRCS, FACS
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Electronic health records can also pose major patient safety risks due to faulty documentation. As oncologists, we often receive consults about patients after they have been seen by multiple other services in the hospital. An example would be of a patient with pancreatic cancer. The initial “presumed” diagnosis of stage IV pancreatic cancer is propagated through serial progress notes and in the consultation notes of every subsequent consultant until we as oncologists have the benefit of the complete workup to clarify that the patient does not have stage IV pancreatic cancer. It is not possible for us to correct all the electronic notes retroactively, and this could lead to serious errors in patient care and safety.
Paper notes were sometimes criticized for their brevity. Lo and behold, we now have the exact opposite problem with electronic health records: electronic diarrhea, or “datarrhea.” The ability to enter information freely into the computer by anyone in the health-care delivery chain has its many benefits, but it has also simultaneously led to megabytes of data accumulation (of variable importance) for each patient. These data include not only the most crucial medical details, but also information about every other trivial detail about patient care. It is not uncommon to see a crucial note about the patient’s history or code status “discussions” completely buried in a sea of notes or e-mails about the preference for the pharmacy location. The application of filters helps but can be cumbersome.
Electronic health records have become a glaring example of a “cesspool of irrelevant minutiae.” It is not uncommon for us to have to pore through screens and screens of data just to find one vital bit of information—whether the patient with pancreatic cancer has jaundice or not.
The amount of documentation required to satisfy the growing requirements from the regulatory bodies has converted highly trained physicians into the most expensive scribes in the world. It is not uncommon to see multiple house officers seated at rows of computers along long corridors in the hospital wards typing away frantically in preparation for morning rounds. For every patient, a larger proportion of the house officer’s or physician’s time is spent at the computer outside the patient’s room rather than with the patient. It is frequently said that residents spend 45 minutes on the computer and 15 minutes with the patient. The most important reason why most of us choose medicine is to build relationships with patients by spending time with them in intimate face-to-face encounters. Electronic health records have now parasitized larger amounts of time than we ever wish to spend staring at the computer screen. This, in turn, has led to a dramatic decrease in the amount of time we spend with patients, which can affect professional satisfaction and wellness.
The seminal iCOMPARE study noted that house officers spend just 13% of their time in direct patient care and just 7.3% with education. Nearly 67.9% is spent on indirect patient care, of which interacting with electronic charts takes the pie.5 The inability to spend time with patients and the proliferation of electronic clerical tasks are thought by many to adversely affect wellness—not only of physicians but also their families.
Dangers of Health-Care Hacking
CYBERCRIME IS pervasive in every other industry, and it is gradually making its foray into health care. The information about a patient in the electronic health record is the most comprehensive record that consists of vital information, ranging from social security numbers, credit card details, and other crucial identifiable information. Another important aspect is that most of the identifiable information, such as date of birth and social security number, is not modifiable, unlike credit card numbers. It is for this reason that electronic health record data fetch a larger value in the black market (thousands of dollars) when compared with pennies for credit card numbers.6 It is not surprising that health-care hacking has reached epidemic proportions over the past few years.7
Moving Forward With ‘Digital Natives’
SOME PROPONENTS wish for more time to heal all the drawbacks associated with electronic health records by relying on the principle of attrition. They believe that as time progresses, the older generation of physicians (those not so good at typing or not so digitally savvy) will dwindle in numbers. These older physicians are considered to belong to the generation of “digital immigrants,” as they did not grow up with the Internet or digital technology. In contrast, the current generation of physicians are considered to be “digital natives.” The digital natives grew up with the Internet, and most of them cannot recall a world without it. It is their hope that as the “digital immigrants” reluctantly fade into the horizon, somehow all the issues with electronic health records will no longer be an issue with the “digital natives.”
“Let us do what we can to improve wellness by curbing electronic diarrhea: How about 45 minutes with the patient and 15 minutes with the computer?”— Chandrakanth Are, MBBS, MBA, FRCS, FACS
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Shifting Focus From Computer to Patient
IT IS EVIDENT that electronic health records are here to stay and thankfully so. They provide innumerable benefits that are just waiting to be tapped. If done right, they can indeed alleviate some problems associated with health-care delivery in America. It is also clear that there is much work to be done to improve them. A recent study conducted by Stanford Medicine noted that 59% of physicians believe electronic health records need a major overhaul.8 Many physicians consider them more of a storage tool than a clinical tool, and 90% of the physicians believe they should be more intuitive, patient-centered, and responsive.
As the debate continues about the pros and cons of electronic health records, we should place some immediate emphasis of their effect on the wellness of our physician workforce. If the electronic diarrhea on these records continues, it may be difficult to improve physician wellness. So, in the interim, let us do what we can to improve wellness by curbing electronic diarrhea: How about 45 minutes with the patient and 15 minutes with the computer? ■
Dr. Are is Jerald L & Carolynn J. Varner Professor of Surgical Oncology & Global Health; Associate Dean for Graduate Medical Education (DIO); and Vice Chair of Education Department of Surgery, University of Nebraska Medical Center, Omaha.
DISCLOSURE: Dr. Are reported no conflicts of interest.
1. Authenticated U.S. Government Information: Public Law 111-148, Mar 23, 2010. Available at www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf. Accessed November 7, 2018.
2. Centers for Disease Control and Prevention: Electronic medical records/electronic health records (EMRs/EHRs). Available at www.cdc.gov/nchs/fastats/ electronic-medical-records.htm. Accessed November 7, 2018.
3. HealthIT.gov: Health IT and health information exchange basics. Available at http://www.healthit.gov/providers-professionals/learn-ehr-basics. Accessed November 7, 2018.
4. Centers for Medicare & Medicaid: National health expenditures 2016 highlights. Available at www.cms.gov/Research-Statistics-Data-and-Systems/ Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/highlights.pdf. Accessed November 7, 2018.
5. Desai SV, Asch DA, Bellini LM, et al: Education outcomes in a duty-hour flexibility trial in internal medicine. N Engl J Med 378:1494-1508, 2018.
6. Forbes: Your electronic medical records could be worth $1000 to hackers. Available at www.forbes.com/sites/mariyayao/2017/04/14/your-electronic-medical-records-can-be-worth-1000-to-hackers/#6a2a449350cf. Accessed November 7, 2018.
7. PBS News Hours: Has health care hacking become an epidemic? Available at www.pbs.org/newshour/science/has-health-care-hacking-become-an-epidemic. Accessed November 7, 2018.
8. Doctors call for overhaul of electronic health records. CISION PR Newswire. Available at www.prnewswire.com/news-releases/doctors-call-for-overhaul-of-electronic-health-records-300659100.html. Accessed November 9, 2018.