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Inbox: The EHR of the Future


In our recurring blog "Inbox" we share comments from physicians and practice administrators telling us what keeps them awake at night.

Editor's note: We work hard to write about issues that will help physicians run their practices in a manner that is both prosperous and efficient, while still delivering quality patient care. And we are delighted when our readers let us know what they are thinking. This month we are excerpting two Q&As written by managing editor Gabriel Perna speculating on the evolution of EHRs, and associate editor Erica Sprey on the reasons behind physician stress. The article has been edited for space and is followed by comments made by readers at PhysiciansPractice.com.


Will EHR usability ever get better? Physicians Practice asked two leading physician experts to look into the future. The experts are Robert Wachter, physician, professor, and interim chairman of the Department of Medicine at the University of California, San Francisco (UCSF), as well as the author of "The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age," and John Halamka, professor of medicine at Harvard Medical School and chief information officer of Beth Israel Deaconess Medical Center in Boston. Along with those credentials, both Halamka and Wachter were recently called upon by Jeremy Hunt, Secretary of State for Health in the United Kingdom to review problems with the country's health IT systems.

In other words, these are doctors with their fingers on the pulse of digital healthcare. Where do they see EHR usability in five years? Here's what they said:

J. Halamka: I am very optimistic about EHR usability and here's why. The [major EHR vendors] are fine, but do you believe the best innovation within the EHR space will happen with those vendors or will it happen in the garages of 26-year-olds who are working for free for equity? It's probably the latter … This year, you've seen every [health IT] vendor open up their EHRs to third parties, so the hot ticket at the[Healthcare Information and Management Systems Society] conference five years from now will be app stores all over … There will be an ecosystem of apps [connected to EHRs]…

R. Wachter: In my book, I talk about the productivity paradox. It's the experience of almost any industry. They implement IT with grand hopes, several years go by and not much good happens and people are left scratching their heads. Then, usually in about year 10, it starts getting better, both because the systems get better and because people begin rethinking the work in fundamental ways. The uptick in EHR installations really began in 2010 through the distribution of [the Health Information Technology for Economic and Clinical Health Act] money and was completed last year with an adoption rate of 80 percent to 90 percent. In that sense, we are really in year three to five in our journey. That means we should have five years to figure it out. I think healthcare is more complicated than other industries, therefore we are 10 years away…

Ken writes: It is definitely possible for us as providers to affect change and make EHRs far better than they are today! After years of experiencing the hassles of EHRs that didn't "think" the way I did, and wasting time on phone tag and the challenges of running my private practice, I decided to do something about it and created … a new user-friendly EHR and practice management platform for mental health providers. It was also inspired by my patients, who for years told me about how painful the process of getting in for an evaluation, therapy or medication was; how providers would not return calls nor be accepting new patients; and how upsetting it was that insurance company listings were out of date. So, I set out to improve my own practice systems and to modernize the process of connecting patients and providers, so that the real work of relieving suffering and optimizing psychological health could be accomplished.

To design our EHR, we started from scratch. We put mental health clinicians, designers, and programmers in a room together and said, let's build something that isn't just a box checker, but that is efficient, intuitive, and graceful. The key is to think of creating EHRs not as software development, but as building relationships between the physician, their practice, their patients, and their professional community.

David says: One of many problems with existing EHRs is that they don't follow the way providers think, document, and treat. Many present EHRs are designed to capture data, even if it is irrelevant, to satisfy insatiable demands from the government, insurers, pharma, manufacturers - all in the name of creating and monetizing data bases. There is a definite process flow in documenting healthcare. And meeting a number of elements may justify an E&M code, but doesn't translate to better care.

K comments: We should at least have the same EHR in every hospital, if not every doctor's office, so we can at least exchange information easily. That was a HUGE mistake in the beginning of this whole process. This would not have been such a fiasco if it had not been so profit driven.

James says: Make no mistake, it's still profit driven, and the competition between hospital systems is also a barrier to "exchanging information easily." If doctors want true interoperability and the free exchange of clinical information, they're going to need to demand and fight for it.

K writes: "Doctors," "demand," "fight," and all in the same sentence! Now that is a pipe dream. How do you think we got in the situation we are? We are so powerless that there is no fight inside of us. But it is nice to have this site to vent.

Anonymous says: Until these programmers learn the difference between data and useful information nothing will change.

What are your hopes for the development of EHRs? Tell us what you think; join the conversation at bit.ly/EHR5years.


Physicians Practice spoke with San Francisco-based internal medicine physician Alan Rosenstein about the impact of stress and burnout on physician behaviors and strategies that smaller practices can deploy to support their team members. (Click here for part one of the interview.) The following is part two of this interview:

Physicians Practice: If a physician belongs to a smaller practice without the resources that a large health system can bring, what other approaches are there to find support or to find a mentor?

Alan Rosenstein: ... The first thing with the private practitioner is someone to talk to them and say, "We really appreciate what you do; you are a precious resource." So what you are doing is showing empathy and showing them respect. When people keep on blocking you and telling you what to do, it pushes down your ego. And that is not necessarily a good thing, because healthcare is about relationships. Then the second thing ... you could do this with a friend, a peer. It doesn't necessarily have to be a trained coach. [A friend, a department member, a family member, a chairman of the department.] There are resources out there. One of the best online resources comes from the AMA. There are specific resources on stress and burnout, and physician resiliency. (You don't need to be a member.) It is an online program that can help them achieve what they want to achieve…

Anonymous writes: All very interesting but basically missing the point. The problem is not the physician but the system which has turned docs into members of the "team" and has them spending their time entering irrelevant, repetitive, and, in many cases, fraudulent data into electronic medical systems whose main purpose is to increase remuneration and do nothing to increase quality.

Melissa Stewart, PhD, says: Excellent interview outlining some of the numerous challenges physicians, particularly those of the baby boom generation, are facing. I appreciate and concur with Dr. Rosenstein's conclusions. As a physician coach I've shadowed physicians as they interact with patients who are less receptive to the authoritative approach and more apt to ask for what they want. Your reference to antibiotics is something that primary-care providers have shared with me on several occasions. My advice has been to avoid saying "no" but rather say, "Yes, you may need antibiotics but let's see if we can avoid that. If your symptoms are not gone by (date) call my office - no need to come in - and I'll call in a prescription to your pharmacy for you. In the meantime, here are some OTC medications that will relieve your discomfort." Doctors have shared with me that they've had some success with that approach.

Pierre Ghassibi, MD, comments: Again, everybody is targeting the physicians. The problem is society and the system. Many docs resent being told all the time what to do to avoid burnout when the issues are elsewhere. Some say that this is life, docs should go with the flow, adapt. True to a certain extent, but soon we will face a dangerous level of physician shortage, mostly a primary-care physician shortage and the country will be in a crisis. Let's be honest: lawyers and insurance companies hurt the country a lot.

How do you feel about mitigating physician stress? Tell us what you think; join the conversation at bit.ly/reasons-doc-stress.

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