It would be easy to shrug off a lot of the complaints from doctors and nurses as the same old change management story, where people complain about whatever they are unfamiliar with. Healthcare providers aren't the first workforce to complain about the shift from paper to computers and being asked to change their work habits to match workflow dictated by software. The logistics workers who complained about the advent of supply-chain automation have either adapted or found another line of work by now, and, once the bugs were worked out, the efficiencies delivered by the automation became impossible to argue with. Eventually, EHR may deliver on all its promises of efficiency and patient safety. But has it been a mistake to rush it?
Obama partisans might also be tempted to see an anti-Obama agenda in this criticism, since this is another element of his healthcare reforms, along with the changes in health insurance regulation. But the sentiment is too unanimous to be that alone.
On the phone, Denton reiterated that he sees "a huge potential for benefit" from health IT. The problem: "Some of it was pushed before it was ready for primetime because of meaningful use."
That is, before the federal government introduced its system of immediate incentives for EHR implementation, combined with eventual penalties for lack of use, his hospital was beginning to introduce the technology, but slowly. "It was happening slowly because the products weren't very usable," he added. The HITECH Act establishing the meaningful use goals was signed into law in 2009 as part of economic stimulus measures, although it can be seen as a companion to the Affordable Care Act healthcare reforms that followed in 2010. Suddenly, EHR implementation became something that had to move forward at a steady clip, whether the software was usable or not, he said.
If not for government intervention, the technology would have been phased in more slowly and carefully, with time for course corrections along the way, he believes.
Meanwhile, meaningful use "hijacked some of the development" going into making EHR products better, Denton said. Or that's part of his theory of how things have gone so wrong. Instead of working on user interface improvements, vendors diverted effort into satisfying the checklist of government requirements to get their products certified as supporting meaningful use, he suspects.
One of the justifications for implementing health IT is that it should reduce medical errors caused by sloppy paperwork and unreadable prescription slips. Again, Denton sees "the potential for that to exist in a well-designed system," but generic software that tries to address every population and medical specialty can actually have the opposite effect, he said. User interface tricks meant to improve productivity can introduce errors. Auto-complete search, where a blank on a form will be filled in with a suggested match when a physician types in the first few letters of the name of a drug, can make it easy to pick the next drug down on the list, after the one intended. As a result, he has seen cardiac drugs prescribed where a painkiller was intended, for example. "So it introduces new potential errors." Even where the software is trying to head off potential errors, for example by detecting potential drug interactions, it is "really easy to get fatigued by all the popups" and stop paying attention.
His hospital uses a McKesson product, Paradigm, and has sunk enough money into it that the choice is unlikely to change. So as head of an IT oversight committee, Denton's role is to seek ways of improving that product's implementation. Yet even though the EHR and related systems at the hospital are all supposed to be HL-7 compliant, they don't share data, and the hospital is still struggling to be able to produce the "continuity of care" documents that healthcare providers are supposed to be able to exchange online in the new world of digital IT.
"Even at our own clinic, we've felt stuck," Denton added. His pediatric practice had to junk the first cloud-based EHR it tried as simply unusable, he said. Adding insult to injury, he wound up paying $10,000 to break the contract and get an export of his own data. Part of the deal was a "gag order," so he can't name the cloud software firm, he said, although "it's not one of the bigger ones." Since then, he has moved to OfficePracticum, but doesn't sound too enthused about that, either.
One reason for his disappointment is that as a medical student interning at Intermountain Healthcare in the 1990s, he worked with an early electronic medical records system custom built for its hospitals and was favorably impressed. While it may not have had every feature of today's EHRs, "it worked in a way that allowed you to really do your job better," he said. "But it's unique to them, and they spent years and years developing it."
In contrast, commercial EHR software has to be generic enough to work in many hospitals and all specialties. The result is a compromised design that doesn't serve anyone's needs really well, Denton said.
Thus, Denton came into the Coursera informatics course wanting to study up on how all this technology is supposed to work. I had to ask if he thought our professor, Dr. Braunstein, was describing a different world of health IT than the one he was living in.
"I think his world exists," Denton said. There seem to be select places in the U.S., probably academic medical hospitals with the resources to invest in perfecting their IT, where positive results from EHR and health information exchange between providers is a reality. But the effect of meaningful use has been to spread the technology across the country into communities that lack those resources. "It's probably a matter of trying to do too much at once," he said.