With EHRs, There's Literacy and Then There's Literacy

Prior to federal EHR mandates and bribes, many physicians were reluctant to adopt EHR. Having taken the plunge, fully 23 percent of EHR adopters are unhappy with their choice and are looking replacements. Maybe the reluctant ones were onto something, but that is not the point of this article.

Reluctance has been attributed to unfamiliarity/uneasiness about technology. The reluctant are characterized as "old fogies," nearing retirement anyway; reluctance will wane as they are replaced by the next, computer-literate generation.

Literacy has two definitions with radically different meanings:

1.) the ability to read and write (Type I); and
2.) knowledge that relates to a specified subject (Type II)

In short, the ability to do something, on the one hand, and the understanding of what that something is and how it works on the other. With understanding comes the ability to respond to the unexpected (anything you don't currently know how to do) by applying relevant theory and knowledge.

As an example, I could never do calculus but I understand what calculus is about, why it works and can identify problems that can be expressed/solved using calculus. My wife, also a physician, breezed through solving calculus problems but never really developed a sense of how and when calculus should be applied. My son excels at both. All three of us can be said to be "calculus literate," depending on which definition you apply.

Just as there is calculus literacy there is microwave oven literacy. Some (most) people know how to read and write "microwave"; that is, they can enter a time or press the "popcorn button." Some understand how and why microwave ovens cook food and can reason about what can be cooked in a microwave and what should not. Both groups are microwave literate but recently some in the first group succumbed to a hoax that proclaimed: "Wave allows your iPhone to be charged wirelessly through microwave frequencies. Wave can be used to quickly charge your device's battery using any standard household microwave. "It takes only Type I literacy to initiate the charging cycle and incinerate both your phone and perhaps the oven; it takes Type II literacy to know that you shouldn't.

The sad fact, when it comes to EHR, is that very few posses Type II computer literacy. There is no body of widely disseminated theory and knowledge on the subject; few express interest in discovering or broadening fundamentals. The subject is not part of the medical school curriculum.

The computer literacy that most medical students and new physicians possess is of Type I. The know how to "read" and "write," conducting Internet searches and using Microsoft Word, Excel, Adobe Photoshop and the like. It's true that there are now fellowships and board certification in medical informatics, but they focus on expanding the trainee's body of Type I literacy to include healthcare.

They learn how to read and write through exposure to activities like:

• data modeling and database query;

• basic biostatistics;

• participating in committees and implementation teams;

• exploring the features of commercially available EHRs and how to use them;

• learning how to run reports to support business and quality improvements;

• being a middle-man (person) between management and physicians; and

• coaching physicians on the "proper use" of the EHRs and about its quirks.

The pathways by which someone might gain Type II literacy are:

• Study of an EHR's internals in detail.

• Developing applications for real clinicians to test/use.

• Studying the science of medical records and medical information.

These pathways are not available to most informatics trainees because:

• The internals of most EHRs are opaque and proprietary.

• There are few opportunities for trainees to develop software.

• Assuming that they are competent programmers and did develop applications, most EHRs are closed platforms. There is little opportunity for user-developed applications to be incorporated into the EHR. (If there was, most of the flaws in today's EHRs would have been resolved years ago; the flawed applications would have been replaced with ones that met the institution's and the users' needs.)

• Few books/resources exist that address this subject specifically.

• Most fellowships are too short to incorporate a significant component of relevant computer science course work.

As Cassius might have said, "The fault, dear Brutus, is not in our stars, but in the EHR... because we have allowed ourselves to become its underlings." The enthusiasm for existing EHRs is due in part to the assumption that the systems would perform as hoped if only the users were more capable (computer literate). If so, the computer-literate generation should be able to demonstrate that the reluctant were wrong - that the difficulties with EHR were in fact due to inept users, not poorly designed software.