Paper Chart Thinking in an EHR World

March 5, 2013
Marion K. Jenkins, PhD, FHIMSS

Using an EHR to simply replace the paper patient chart is not worth it.

There have been dozens of articles and online "discussions" about the pros and cons of healthcare IT in general, and EHRs in particular. Many of them have degenerated into downright arguments, with pro-technology advocates saying that physicians and other clinical and business office users are simply not giving their systems a chance, and anti-technology adherents saying that technology slows them down too much and doesn’t belong in healthcare.

Recently, I was involved in one of these online discussions and it ultimately lead to the following post, presumably from a practicing physician: "Unless and until EHRs work like a paper chart, I refuse to use them."

My first thought was, to post a comment like, "Really? You want a computerized system where the information is only viewable by one person at a time (whoever happens to have the chart in his/her possession)? You want information organized in a typically haphazard format, using whatever layout you have developed over the last nearly 20 years, and be in an analog form, which means it cannot be searched, sorted or analyzed? You want a system where the data is hidden away in some filing cabinet, storage room or sitting on someone’s desk, and at any given time it has about a 10 percent chance of not being where it needs to be at a critical time, such as a patient visit or when trying to connect new content from a lab test or imaging session to the rest of the record?"

I decided that that approach would not add to the usefulness of the discussion, so I chose not to. But it has been on my mind ever since. In fact there is a similar polarized discussion going on right now on a healthcare IT group on LinkedIn, with both sides flaming away on their keyboards with nearly a dozen self-cancelling posts every day.

There is no question that EHRs and other health IT systems need to continue to improve. The biggest issues seem to be around usability, fragmentation and lack of interoperability of the systems themselves. On the user-device front, tablets, slates, and smartphones have come a long way, but they still need a lot of work in such areas as battery life, survivability in the clinic environment, and ease of use.

Most healthcare facilities that we encounter seem to be intent on just getting systems installed and "up and running" in the shortest time possible. The impact of ARRA/HITECH and meaningful use, which is literally shipping out billions of dollars in checks, has unfortunately only focused on the initial step of just getting the data into the system.

So, I’m just going to say it: EHRs are not worth the investment.

If all you are focused on is replacing the paper patient record with the collection and storage aspects of an EHR, it is not worth the investment.

It is only when the vast amount of healthcare data is collected in digital form, and can be organized, searchable, and analyzed can it become a true clinical knowledge base, and become the Holy Grail of evidence-based, predictive, and preventive medicine.

Until then, with these self-cancelling and somewhat self-fulfilling online arguments, we are stuck at the starting line. (Unfortunately in healthcare we’ve been stuck here for nearly two decades, while virtually all other industries have eventually embraced digital technology and automation.)

To imagine the potential future value of digital healthcare, think of the evolution of online e-commerce sites. Their initial value proposition provided the ability to buy things at your convenience and without leaving your home or office. Next came more extensive and sophisticated catalogs, including the ability to zoom in on a product, and look at product features and even see reviews from experts as well as ordinary users. Next came the ability to select different products and have the system automatically compare them. And today, they have developed algorithms to take your searches and purchases and suggest other things you might like.

This is all based on the accumulated experience of millions of sites, hundreds of millions of users, and probably billions of engineer hours in developing and fine tuning the functionality and usability of these systems, and taking advantage of all that data. And along the way, improvements in hardware and software, plus constructive input from end-users, and considerable development in user interfaces and security, have led to the feature-rich systems we enjoy today. 

Think of the possibilities when all stakeholders - patients, providers, and payers - have reliable and accurate healthcare data actually available when and where we need it. If we can get past this painful startup phase, and stop thinking of EHRs as simply a replacement for paper charts, we can eventually get there.