Throwing the EHR Under the Bus …

Given what is now known about how the case of Thomas Eric Duncan at Texas Health Presbyterian was handled, the attempt to blame the hospital’s electronic health record for the missed diagnosis sounds pretty lame.

But people are still doing it:

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Critics of electronic medical records have found a case they will be talking about for years.

Consider this argument from Ross Koppel and Suzanne Gordon:

While it is too early to determine what precisely happened in this case, it is not too early to consider the critical issues it highlights. One is our health care system’s reliance on computerized technology that is too often unfriendly to clinicians, especially those who work in stressful situations like a crowded emergency room. Then there are physicians’ long-standing failure to pay attention to nurses’ notes. Finally, there is the fact that hospitals often discourage nurses from assertively challenging physicians.

Long promised as the panacea for patient safety errors, electronic health records, in fact, have fragmented information, too often making critical data difficult to find. Often, doctors or nurses must log out of the system they are on and log into another system just to access data needed to treat their patients (with, of course, additional passwords required). Worse, data is frequently labeled in odd ways. For example, the results of a potassium test might be found under “potassium,” “serum potassium level,” “blood tests” or “lab reports.” Frequently, nurses and doctors will see different screen presentations of similar data, making it difficult to collaborate.

Another technological issue is the flatness of electronic records: Much of the information looks the same — a series of boxes to check and pre-formatted text that makes highlighting an urgent or important issue difficult. Electronic records, with their cut-and-paste functions, create what doctors call “chart bloat.” The announcement that Duncan’s electronic records totaled 1,400 pages illustrates this phenomenon. Poor record presentations may well have contributed to the hospital spokeswoman’s initial statement that Duncan’s temperature was only 100.1, when in fact the hospital’s records show it increased from that to 103 by the time Duncan was discharged four hours later.

A Textbook Case

This is the kind of the thing that overworked doctors and critics of electronic health records have been saying forever:  This stuff is great and everything, but there are problems and you’re ignoring them. And we need to do something about it.

On the other hand, if you’re one of the people who thinks that EHRs are the problem and not the solution,  consider this:

Clinical decision support could have stopped the current outbreak dead in its tracks. 

All it would have taken was a single electronic warning and Thomas Eric Duncan would most likely not have been sent back home. The CDC would have been notified.  Duncan would not have potentially infected scores of people in the Dallas area.  Amber Joy Vinson would never have boarded a Frontier Airlines flight to Cleveland.

And we’d all be talking about something else other than Ebola, most likely football and the ISIS crisis.

Risk and Opportunity

There’s no doubt that we’ll be hearing a lot about innovation in the weeks to come.  People will be building apps and inventing alogorithms and coming up with helpful new subscription based services designed to stop the global pandemic.

History teaches that most of these ideas will be stupid, a few will be smart and a few may even be game changers.

The game changers may not be ambitious services that use Big Data to categorize all people with 99.9 degree fevers and stomach aches and other Ebola-like symptoms into cohorts and index them using brilliant algorithms, although they could be.

They may be simple ideas that are easy to implement. One early example:

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Data Points :

Privacy: Much of the weird slowness of the CDC response to the outbreak has to do with the invisible electric boundary lines that divide the health care system into a thousand different units and sub-units.

If the agency seems tentative, it is.

That’s  because twenty years of political battles in Washington have made it so. We need to have a grown up conversation around privacy and transparency. Where do we stand on the rights of individuals versus the rights of society? And where are we on the rights of a business to put its own interests ahead of society, as appears to have happened in the early days at Presbyterian with potentially cataclysmic results?

Early Warning :  Critics have pointed out that the  healthcare system has been carefully designed to allow high risk patients carrying infectious diseases to penetrate as deeply as humanly possible with in it before they are detected.  Unlike the healthcare systems in places like Liberia and Sierra Leone where there are only a few healthcare workers, the U.S. healthcare system deploys a massive show of force to get things done. Front office staff. Nurses. Doctors. Nurses assistants. Lab techs. Physicians. Specialists. Sub specialists. Hospitalists. The mind boggles at the number of people involved.

In a case where things go South,  a potential Ebola paitent will have contact with six to ten people before anybody figures out that somebody needs to do something.  They’ll sit around a waiting room for ninety minutes and then enter the system, exposing God knows how many other people.

It shouldn’t take a a specialist in infectious diseases from Harvard to tell us that’s a big problem.

Why not screen patients before they reach the front lines?  Let’s figure out a way to do it remotely. Do intake electronically. Have people check in using their mobile devices.  This seems like common sense.

Protocols and Guidelines:  Officials have been shocked by the confusion among healthcare workers about which procedures and guidelines they should follow.  It’s hard to understand the scope of this problem until you study how many competing sources of information there are out there. As the CDC releases new guidelines, there is going to be complete confusion about which ones to follow.  The old ones? The newer ones? Version two? Version four?  The EHR is the most logical place to get updates to people.

EHRs traditionally have not been about pushing this kind of content.  After all, people have other sources of information: why should vendors worry about it?

They should worry about it because it’s their problem.

The focus group results are in. Faced with criticism about the quality of the information their systems generate, it’s been clear for some time that EHR companies need to evolve into content companies. They need to learn to help organize information and build tools that offer users context and allow them to sort and filter information.

In the end, building a smart EMR may be as much about the quality of the content you deliver as the interface you come up with.

/ john irvine