Even When an EHR is Customizable, Few Make the Effort

September 30, 2013
Daniel Essin, MA, MD

The ideal EHR is highly customizable, but rather than dedicate the time and effort to do this, most practices buy a system pre-configured that causes problems.

For a moment let's assume that there is no better source of knowledge and wisdom about EHR than an EHR vendor? What could possibly prevent them from providing the most timely, scientific, and authoritative information?

I recently saw an advertisement from a vendor touting the 22 different flavors of their product in an effort to avoid a cookie-cutter approach to EHR systems in an effort to better adapt to the solutions and work flow needed by physicians.

But wait, there are not simply 22 specialties, there are more than 130 recognized physician specialties and subspecialties. The term allied health (or health-related professions, at some institutions) is used to identify a number of health professions, encompassing as many as 200 health careers. The detailed nature of the work that one performs in pursuing one of these careers undoubtedly differs from the others and may differ from institution to institution.

A question comes to mind: What about the other specialties, disciplines, and centers of excellence that do things these 22 specialties do not do? What about any practice that has unusual patients, unusual goals, or non-standard relationships with their community? If a cookie-cutter approach is bad, and I agree that it is, how does one prevent themselves being cut into a cookie by an EHR that only available in one, two, five or 22 flavors? I have found only one answer to this question - an answer that poses its own challenges.

The answer is that the EHR must be totally content-neutral, that is it must not allow or provide content and predefined data elements that cannot be overridden or suppressed and it must allow the adopter to add as much new content and define as many new data elements as they feel is necessary. Furthermore it must lock the adopter into rigid work flow sequences (whether predefined or user-defined) without having an "escape" mechanism that allows a practitioner to document, request any treatment or supply, and perform any unanticipated task without the system presenting an insurmountable obstacle.

If there are any EHRs available today that fully embrace this kind of content neutrality and practitioner-directed control over the work flow, they are not the big, expensive, market-leading ones. What's a practitioner to do if they don't practice one of the blessed 22 major specialties? More importantly, what's a large organization that offers a wider variety of services provided by "esoteric" specialties?

The common response to inadequate content-neutrality and customizability is to surround the EHR with a brood (a group of recently hatched ducklings) of specialized, single-purpose systems. Inevitably some or all of these prove difficult to integrate in the hoped-for "integrated" medical record. This leads to "lost" patient information, frustrated practitioners and sub-par care because practitioners "fly blind" when they are unaware of important results or if they are too difficult to locate.

If you look around you will find that this situation is pervasive; it is a rare organization that arrives at an elegant solution.

I mentioned that if you are fortunate enough to find and choose a content-neutral, highly customizable product, it presents its own challenge. The challenge is someone has to do the customizing and if that someone is not you, it still requires your intense involvement. I find that many practitioners are so put off by the thought of this effort that, instead of diving in, they opt for something they can buy pre-configured, even if it is outrageously expensive and ends up making them miserable every time they use it.

In athletics they say: "No pain, no gain." Unfortunately with EHR the pain is unavoidable but somehow, many EHRs make it easy to lose out on the gain.