Wednesday, September 14, 2016

Electronic Health Records (EHR)

Electronic health records allow for a variety of improvements in medical practice and health care:

Communication between physicians can be improved.

Lab results can be coordinated and exchanged efficiently, with a reduction in the chance of results being overlooked.

Patients or clients of a health care service can become more directly involved in perusing their own health records, and therefore could have a more empowered, active role in their health care.

Some systems can also allow prescriptions, other treatments, and symptoms to be tracked efficiently over time.

Patients could also contribute information (such as providing a history, filling out questionnaires about symptoms, etc.) directly into the system, which could make the clinical time with a health care provider more efficient and more personal, less focused on "data gathering."

Problems with EHR

Yet, there are a variety of problems associated with the use of computerized health record systems.  

Impact on Rapport

I think the worst problem is the potential impact on rapport during a health care visit.  If your physician or therapist is fumbling with a keyboard, and staring at a screen, instead of paying attention to you, this is poor quality of care, and threatens the therapeutic relationship.  This is potentially harmful to clients or patients, and is also potentially harmful to the well-being of the physician or therapist.  

You could compare this to having an "appointment" with a friend...if your friend is busy checking a cell phone or typing on a computer keyboard during dinner, or during a forest walk, the technology will harm your friendship!  When such behaviour becomes more frequent, more of a norm, more trendy, people tend to simply go along with such things, rather than insist that the device or gadget be turned off.  I think it would be better to complain to your friend about it instead, and to insist on having a conversation, or to insist on just walking quietly through the forest together!  

In some of the meetings I have attended over the past few years, I have seen people enthusiastically talking about new apps and gadgets in therapeutic settings (such as collaborating with clients using an ipad), yet part of the irony of these meetings was that the presenters or audience members were themselves so engrossed with their laptops or with their other gadgets that they had very little eye contact or social connection with those around them, and perhaps not a lot of awareness that their gadget-preoccupation was even a bit of an annoyance to their neighbours.  

Corporate Influence: 20 Billion Dollars!

Another problem with electronic records has to do with economic factors.   The EHR market is worth about $15-20 billion dollars globally, and is growing rapidly! *   This is enough money to fund 400 000 therapists, each earning $50 000 per year.

The corporations producing EHR software and machinery profit financially from sales. Clinics or hospitals using EHR will need educational sessions with representatives of the tech companies.  This is a potential conflict of interest issue:  it is similar to having medical education sessions organized and led by pharmaceutical reps.  The educational sessions are marketing opportunities for representatives of the EHR software company to consolidate adherence to a product.  Much of this education is sincerely useful for staff and beneficial for clients or patients, and the educational sessions may come with sincerely positive intentions.   But there are biases favouring a continuing business relationship with the software corporation, separate from considerations of patient or client care.  

Literature Review of EHR Problems

What does the academic literature have to say about this?  We have a pertinent article just published:  Susan Hingle, in Annals of Internal Medicine (Sep 6, 2016, doi 10:7326/M16-1757), reviews the use of electronic health records. Here is a quote from this article: 

Sinsky and colleagues confirm what many practicing physicians have claimed: Electronic health records (EHRs), in their current state, occupy a lot of physicians' time and draw attention away from their direct interactions with patients and from their personal lives. Observers documented that for every hour of direct clinical time with patients, physicians spent 2 additional hours on EHR and desk work, and physicians reported spending up to an additional 1 to 2 hours of after-hours personal time completing documentation and EHR tasks. These observations have important implications for patient care and outcomes...A recent study found that physicians who use EHRs and computerized physician order entry have decreased satisfaction and a higher risk for professional burnout. Physicians who burn out are at a significantly greater risk for depression and suicidal ideation, and there is also concern that they are more likely than satisfied colleagues to provide lower-quality patient care and to leave clinical practice early, although this is difficult to fully measure...Now is the time to go beyond complaining about EHRs and other practice hassles and to make needed changes to the health care system that will redirect our focus from the computer screen to our patients and help us rediscover the joy of medicine.

Here is another article, expressing similar concerns, from the Washington Examiner, published in October 2014 by Richard Pollock:

Another critical article, from the point of view of nursing staff in a hospital:

Here's a good article published in 2016 by Suzanne Coven, in Stat:

Despite these concerns, I do acknowledge the potentially useful role of computers, electronic records systems, therapeutic apps, etc.  But I think this gadgetry must never be focused on at the expense of highly personalized care for each client or patient.  As I have said elsewhere, I think these innovations can be truly great advances, but they can be a bit like giving children gifts at Christmas or birthdays:  children may get excited about a new toy, and may even become conditioned to expect more and more expensive toys as time goes by.  The toys may be great toys!  They could even be "educational"!

But the "gift" that children (and all the rest of us) really want and need is care and attention from loved ones.  Without this, the toys are worthless, and may even cause the children to have a deteriorating, materialistic quality of life.  

The impact of gadgetry and computers in health care affects not only clients or patients, but also caregivers, clinicians, therapists, and office staff.  It is important to consider staff quality of life, and staff satisfaction with work, as essential components in choosing health care strategies.  "Efficiency" and "optimal data collection" may seem to be desirable goals, but such efficiency is insidiously negative if it does not allow for a healthy workplace environment.  This is similar to managing a nation's economy:  a bottom-line view of maximizing economic efficiency may lead to increased overall financial wealth in a society; this is easy to measure, and therefore could be irresistible for policy-makers to follow.   But such optimization of efficiency and wealth can often lead to a decline in the morale and well-being of the population, if it is not balanced by other factors.  A reduction in efficiency, if it means more time for family, and better care of the environment, can sometimes lead to far greater wealth than anything money can buy.  

So in order to move forward with this issue, I do not suggest that we abandon EHR technology.  It is a potentially useful and innovative tool.  But we must never let our tools or toys distract us from providing a caring, empathic, human interaction.  We must never let a pursuit of efficiency or the acquisition of data have a higher order of importance  than caring, empathic, personalized health care. And we must be wary of corporate influences on health care policy, especially when large amounts of money are involved.

If you are affected by this issue, I encourage you to offer constructive feedback to your health care provider.     

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