Author: James Miller, President, PharmaLeaders

Last month Atul Gawande, a noted surgeon, writer, and CEO of the new Amazon, Berkshire, Chase Health enterprise published a thought-provoking article in the New Yorker detailing both the promise and frustrations that electronic health records have caused for healthcare professionals. In particular, he shed light on his own experience at Partners HealthCare as 70,000 employees of the network – spread across 12 hospitals and hundreds of clinics in New England— adopted Epic software.

As Gawande describes, while the initial promise for digital health records has been high, the execution has been less than inspiring for many healthcare professionals:

“Three years later I’ve come to feel that a system that promised to increase my mastery over my work has, instead, increased my work’s mastery over me. I’m not the only one. A 2016 study found that physicians spent about two hours doing computer work for every hour spent face to face with a patient—whatever the brand of medical software. Something’s gone terribly wrong. Doctors are among the most technology-avid people in society; computerization has simplified tasks in many industries. Yet somehow, we’ve reached a point where people in the medical profession actively, viscerally, volubly hate their computers.”

Gawande details many of the issues that have led to this high level of frustration including:

• Systems that create pointless data gathering
• UX designs that are simply incredibly confusing
• Data overload in patient records that obscures key information
• Organizational infighting about which data needs to be collected
• After-hours work by physicians to complete their data entry
• Rules that restrict administrative roles from accessing patient records
• Lack of fluidity to make useful changes to the software
• Overloaded email “In Basket”

While systems such as Epic seem to be creating more stress than streamlining for healthcare providers, Gawande also examines the situation from a systems perspective, where these types of massive patient record systems do help overall patient outcomes.

Gawande met with Gregg Meyer, the chief clinical officer at Partners HealthCare, who supervised the Epic roll-out at Partners. Meyer explained:

“We think of this as a system for us (healthcare providers) and it’s not. It is for the patients.” While some 60,000 staff members use the system, almost 10 times as many patients log into it to look up their lab results, remind themselves of the medications they are supposed to take, read the office notes that their doctor wrote in order to better understand what they’ve been told. Today, patients are the fastest-growing user group for electronic medical records. Computerization also allows clinicians to help patients in ways that hadn’t been possible before. In one project, Partners is scanning records to identify people who have been on opioids for more than three months, in order to provide outreach and reduce the risk of overdose.”

Even as medical records help patients have better access to their information along with better outcomes, Gawande points out the potentially bitter irony of the situation, saying: “It’s perfectly possible to envisage a system that makes care ever better for those who receive it and ever more miserable for those who provide it.”

While the evolving need for electronic record keeping is certainly challenging, Gawande offers a glimpse into some possible solutions. For example, some healthcare systems have begun employing medical scribes whose primary role is to accompany physicians and complete the data entry so that the doctor can focus his time and attention on the particular patients they are meeting with. Some of this scribing work is even being offshored.

“Massachusetts General Hospital has been trying out a “virtual scribe” service, in which India-based doctors do the documentation based on digitally recorded patient visits. Compared with “live scribing,” this system is purportedly more accurate—since the scribes tend to be fully credentialed doctors, not aspiring med students—for the same price or cheaper.”

While this arrangement is not without problems, the doctors who have scribes working alongside them are reporting much higher rates of job satisfaction while seeing more patients.

Another point of hope is that physicians and healthcare systems are adapting and evolving on their own, forcing EHR providers like Epic to start opening their system APIs for a range of specialized apps, much like has been done for smartphones. Epic calls their app store the “App Orchard” and now has more than 100 different apps with more being added all the time.

However, as promising as this type of app-based approach might be, overall progress has been slow. In a recent survey, Matthew Holt of the Health Care Blog notes “a combination of government prodding (partly from ONC implementing the 21st Century Cures Act, partly in the continued growth of pay for value programs from CMS), fear of Apple/Google/Amazon, genuine internal sentiment changes at least at one vendor (Cerner), and maturity in dealing with smaller applications vendors from three others (Allscripts, Athenahealth, Epic), and the growth of third-party integration vendors like Redox and Sansoro, is making it easier for application vendors to integrate with EMRs. But it’s not yet in any way simple. We are a long way from the all-singing, all-dancing, plug-in interoperability we hoped for back in the day. But the survey suggests that we are inching closer. Of course, “inching” may not be the pace some of us were hoping to move at.”

Despite the many obstacles and challenges that Gawande encountered with the new EHR software, he ends his article on a somewhat optimistic note as he and a patient go through the EHR checklist together before an operation:

“Let’s go through these checks together,” I said.

I angled the screen toward the couple. Side by side, we confirmed that his medical history was up-to-date, that the correct surgical site was marked on his body, that I’d reviewed his medication allergies. His shoulders began to relax. His wife’s did, too.

“Are you ready?” I asked.

“I am,” he said.

So, here perhaps Gawande has given us a glimpse into the future of healthcare, one in which patients and providers are collaborating together in the care setting with a third participant – the data backed patient record screen. It remains to be seen just how much knowledge and authority these new bedside digital assistants will gain, but as health care becomes ever more complex and data-driven, there is no turning back.