With the passage of the HITECH Act in 2009, the Department of Health and Human Services successfully pushed the medical community to adopt electronic health records. Leading that effort was the Office of the National Coordinator for Health Information Technology (ONC).

After 10 years of use and billions of dollars of investment, electronic health records (EHRs) have not only failed to live up to their potential but have helped create a crisis in medicine.

To be sure, developing computer software to cover modern medical care is a daunting task. But what has been virtually ignored in the blame game is how designs mandated by ONC have virtually assured that electronic health records will be poorly designed and excessively complex.

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Current electronic health records have a number of usability issues. A 2018 survey of physicians across the U.S. by Stanford Medicine and the Harris Poll found that 59% of physicians users felt that their EHR needed a “complete overhaul.” Users estimated that 62% of their time was spent entering data into the EHR, leaving only 38% of their time to be spent directly with patients. That is just one of many studies linking the use of electronic health records to physician burnout. Critics complain of complex rigid user interfaces, interminable cascading check boxes, lack of clinical content, and a focus on business and regulatory issues instead of patient care.

Through a series of expert committees, ONC developed certification and testing criteria that electronic health records had to meet to become certified in 2011. By that time, my company, Codonix, had been providing clinical EHR systems for 15 years, first to hospital emergency departments and later to physician-owned clinics. It was clear to me from the beginning of the new ONC testing protocols that almost no clinical oversight had gone into their development.

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For example, the protocols required electronic health record companies to create test users who were then instructed by the testing proctor to place an order for two different medications and then go back and change the order without leaving any trace that the order had been modified — something that goes against best practices. An order should never be erased once they are entered. The clinical portion was rife with other errors: test protocols that included drugs that had been withdrawn from the U.S. market, incorrect laboratory values, and the like.

Another major cause of user frustration is ONC’s mandate that electronic health records force users to document to certain coding schemes. For example, providers are required to document a patient’s smoking history using the Systematized Nomenclature of Medicine — what everyone calls SNOMED — codes. There are nine different ways to “smoke” (or not), and these overlap in confusing ways.

A “never smoker” is an individual who has smoked fewer than 100 cigarettes in his or her lifetime. After making that determination, however, providers have to pick from eight different ways to smoke: every day smoker, some day smoker, heavy tobacco smoker, light tobacco smoker, and the like.

This kind of complexity and reliance on rigid coding systems permeated the ONC requirements. It affects how clinicians document a patient’s spoken language, allergies, ethnicity, diagnosis assigned, drugs administered, and so on. The list covers virtually every aspect of EHR documentation.

To add to the complexity, there was no uniformity in the design of the back-end data. For example, one set of diagnosis codes (ICD-10) was required for reimbursement, while another more complex set of diagnosis codes (SNOMED) was required to document patient care. The net effect is that a patient’s clinical issues are stored in two incompatible formats. This duplication and inconsistency affects all aspects of documentation, from medications dispensed to procedures performed.

These design criteria forced EHR developers to require clinical users to follow complex coding rules, virtually guaranteeing user dissatisfaction.

ONC also required electronic health record developers to support several complex and incompatible protocols used to communicate with different EHRs, with the patient, with state immunization records, and with the Department of Health and Human Services itself to report quality measures. A total of five different incompatible communication protocols are required. Because each of these require different data elements, EHR designers must force users to document encounters to meet the requirements of these various protocols. Submitting an influenza immunization message to a state registry, for example, requires users to enter the patient’s next of kin and mother’s maiden name. This level of complexity and inconsistency is not user friendly.

The mission of ONC has transformed over time from one of encouraging the adoption of electronic health records to one that purports to improve health care quality through the use of ONC-mandated systems.

Under the Merit-based Incentive Payment System (MIPS), users must report quality measures using a system that is so burdensome and confusing that a mini industry has sprouted up to coach and guide users on how to aggregate and submit data — if not game the system. These reporting requirements are mandated despite the overwhelming clinical consensus that this type of data submission is time consuming, probably counterproductive, and is becoming cost prohibitive.

Although studies have shown that electronic health records can lead to better reporting (by which I mean box-checking), there is almost no evidence that they lead to better outcomes for patients. In Stanford’s poll, 92% of respondents felt that their EHR had little to no value for clinical decision support. In a survey conducted by the Medical Group Management Association, 76% of respondents felt that MIPS reporting played no role in improving patients’ clinical outcomes.

The Department of Health and Human Services has a poor track record designing software — just think Healthcare.gov — and EHR software is several orders of magnitude more complex. As currently implemented and designed by committee, the existing ONC requirements are best described as spaghetti code.

Instead of simplifying and standardizing back-end data collection — which would be transparent to the doctor, nurse, or other user and would allow EHR designers to focus on clinical usability — ONC has instead opted to use electronic health records as a reporting tool instead of as clinical a clinical documentation tool, putting the design paradigm backwards.

Electronic health records should not be expected to support 28 different coding schemes and multiple communication protocols, each with their own limitations, which subtly or blatantly force users to follow certain rules. Instead, these potentially transformative systems should be designed with the provider and the patient at the center.

Rather than designing clinical software, ONC should focus on analyzing, simplifying, and standardizing the huge amount of information stored in the background. Rigid, outdated, and incompatible coding and communication protocols need to be simplified and rationalized.

Physicians have long been trained to document patient encounters in organized and structured ways. A medical chart should be designed so clinicians can quickly scan and abstract all of the necessary information about a patient in a short period of time. At the same time, EHRs can transparently generate a huge amount of discrete data ranging from drug codes to diagnosis codes to procedure codes. In short, normal clinical records generated by a typical electronic health record system are a treasure trove of organized and coded information; there is no need to force them into cumbersome reporting structures.

Google can abstract an enormous amount of information from unstructured text. Imagine the power of similar algorithms when used to analyze health data that is not only already organized but also has a huge amount of attached discrete data. In this regard, the ONC and electronic health record makers can learn a lot from Google.

Andrew Muchmore, M.D., is the founder, chairman, and chief technology officer of Codonix.

  • I spent many years in Critical Care. Many things have changed of course, but MANY have been detrimental to patients. The electronic record has NOT been an improvement. Let’s be totally honest, the EMR was created for reimbursement, NOT improved outcomes. I have personally dealt with & assisted other “patients” regarding errors, omissions, “lost” information, staff unfamiliar with systems, records split into different patient IDs, inability of patients to have errors corrected. As we are witnessing now, the records are not trustworthy for data collection that will be vital going forward. In the current environment, I am not hopeful for an improvement in many of these areas. Designing the record with the patient at the center is not impossible. It has been frequently suggested that I write a book to document some of these incredibly frustrating failures of the current healthcare system that I have witnessed & navigated. If we all somehow manage to survive COVID 19 it just might be worth it.

    • I was involved with an EHR project that used short character codes for various nursing patient assessment states (e.g., GoodNoc, etc.). Before the EHR went fully live hospital-wide it became apparent that all the mnemonic codes had been used up and non-intuitive codes had to be used as more conditions were documented! Nurses couldn’t figure out what had happened with their patients after 2 days away from them … I blew the whistle on this at the next Medical Executive Committee meeting and within days the project was cancelled and the CIO was gone. All the thousands of expensive man hours put into the project were rendered useless and the EHR project started all over again. This is, sadly, not a rare story.

  • Thanks. But I fear too little, too late. The veritable cat is out of the bag and we are forced to carry around million-dollar cash registers and that will never change. Is offensive it is wrong and I’m done with it

    • I sense your frustration but I also sense an incipient rebellion – providers have had enough, and it turns out that coupled with inherent inefficiencies, the people who bought these systems are having second thoughts as well. Decreasing physician efficiency, coupled with huge ongoing expenses, and the absence of what had been almost unlimited free government money to implement EHR systems, does not make the annual report look good.

  • See this: https://poets.org/poem/naming-cats

    Yes, this EHR mess is what happens when the rules are written by competing IT vendors and competing coding system vendors, each salivating at the prospect of a federally mandated increase in their sales. What should have been done is to set aside a large block of time to work out ON PAPER how the data flow would work — of course, that would thwart the ambition of politicians who want to crow about “incredibly quick progress towards an EHR.”

    • I meant to add the the above that the proposed data flow MUST include the flow from the MIND of the physician or other “provider” to the supplier of information (e.g., lab, medical imaging, etc.) and back to the MIND of the provider. Yes, and many times the information provider and the information consumer are the SAME person — we call those “progress notes”, which are frequently just “notes to myself” which IT frequently requires us to structure as formal letters to the patient’s entire medical care community, slowing down what should be a simple “jot” as a personal reminder.

  • Thanks for documenting what I(and thousands of others) have been saying aboutEHR’s since they were mandated by the Obama administration: they are cumbersome,user unfriendly,time wasting abominations that do not only not improve patient outcomes but are detrimental in their diversion of clinician time from observation of and listening to the patient into mindless data entry,at the expense of time which could be spent on reasoning,reflection and judgement.This,to say nothing of their ruinous expense.What would be necessary to bring about a reconsideration of the unquestioned underlying thesis- that IT must be the way in which medicine is practiced?

    • You ask the perfect question. “.. that IT must be the way medicine is practiced?” – in my mind the problem is not inherently the computer screen – it is that the work flow was designed by IT folks and as I discuss ONC fiat, these groups know nothing about clinical medicine or clinical work flows. This software should be designed by clinicians themselves, and by that I don’t mean non-practicing. Internists should not be designing neuro-surgical work flows and vice versa. The tools to do this are available.

  • Let’s all have standard basic exams and standard mini templates that include specific symptom exam and assessment with usual diagnosis built in. Let voice add proper complexity at any point. By standardized the usual then this with labs, tests and procedures billing codes could go to national data health cloud as structured data. Then patients docs and government can push and pull data. Let’s also include all the standard info we all collect on the patient and only update the new. By creating ehr interfaces to create standard data language we could keep same her.

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