EHR: Tool or Task?

A group of us meets periodically for what we call the "journal club" although it has been some years since we reviewed journal articles. We still discuss cases, recent research, and our clinical experiences, which increasingly include EHR war stories. Among the group are users of Cerner, Epic, and a few others.

At a recent get-together a member of the group was commenting on how difficult it was to use their system in real-time because if he begins an EHR session at the beginning of a visit, by the time he is ready to finish up, the system has logged him off, occasionally losing work he has already done.

It occurred to me the his organization views computer charting as just one on a long list of tasks it expects him to complete along with coding the visit (all the docs have been trained and are "certified" coders), asking about guns in the home, and a myriad of others that stem from top-down policy decisions. How different, I thought, from my view that an EHR should be a tool that is at the physician's disposal to help him achieve those goals they consider most important.

The first EHR I built in 1982 had two simple goals: to help my wife, in her new practice, finish all of the day's charting before she left for the night, and, equally important, to get all that work done and get home in time for dinner. Even in 1982, people who had never used a computerized record imagined all sorts of functions a system should perform and which might prove beneficial. I chose instead to concentrate on creating tool that would deliver a few real benefits, not to conduct an experiment at the practitioner's expense.

The result was an application that made it possible to create a detailed note containing the pertinent positives and negatives in 60 seconds to 90 seconds. There were problem lists and allergy lists and the output integrated easily into the paper record - not bad for 1982. The movement of the paper chart went from being two-way (pull to read the old records, push to insert new material) to one-way (push new notes into the file). The computerized record could be read without needing to physically locate. Since charts were pulled infrequently, fewer were lost.

In 1982, there were no obstacles to maintaining a razor-sharp focus on making the computer a tool for the physician. There were no outside "authorities" telling me what a computer system "should" do or how to do it. In fact, there were no authorities at all except for maybe a dozen or so of us who were trying to figure this out. No definition of "meaningful use" came down from on high - the physician/user decided if the use was meaningful. If it was not, they didn't use it. There were no penalties or incentives to cloud one's judgment about what made sense to a particular practitioner. And finally, there were no huge costs. The first incarnation of our EHR cost about $5,000 (an IBM-XT, a $500 software toolkit, and a dot-matrix printer), not the enormous sums (reported to be as high as $250,000 per doctor) that are common these days.

As healthcare reform proceeds, it is anticipated that the number of patients able to access care will increase faster than the number of practitioners that are able (and willing) to see them. If the available physicians are going absorb the additional load, they will need better tools and fewer tasks:

• Better tools to help them practice efficiently and avoid losing track of important items requiring follow-up.

• Fewer tasks that exist only to satisfy the demands of those who are not part of the process of delivering care (i.e. government programs and mandates). Only things that practitioners actually find useful should survive. There is no place for policies and procedures based on someone's pet ideas or vague notions of social engineering.

Unnecessary tasks that interfere with cost effectiveness, efficiency, patient safety and practitioner sanity need to be eliminated or the dream of quality healthcare for everyone (and maybe Medicare as well) is doomed.

It might be preferable to forgo the incentives and accept the penalties of ignoring meaningful use if, in doing so, one can avoid the pain caused by using an EHR that adds non-productive tasks to the obligatory work of direct patient care.

Of course, one must find a way to compensate for the reductions in Medicare reimbursement. Possibilities include:

• Increasing volume through enhanced efficiency (including the use of efficiency-enhancing but uncertified computer apps)

• Leaving fee-for-service private practice - become an employee but be sure to get compensated fairly for your time, whether it's spent caring for patients or spoon-feeding the employer's computer system

• Setting up a concierge practice - compensate for reduced reimbursement by direct payments from patients