Fixing What's Wrong with EHRs is Easier Done than Said

Immigration, drought, and EHR are all of great concern. We know people are concerned about immigration because of the daily news. The message is basically, "Solve the immigration crisis." In California, farmers are concerned about the drought as the "Solve the water crisis" billboards in the central valley attest.

It's obvious that physicians are concerned about EHRs. The concern is so great that the AMA convened an advisory committee and has spoken out. In September, they recommended overhauling (their word) the design of EHRs to improve usability and called on EHR vendors and the government, "To leverage the power of EHRs for enhancing patient care, improving productivity, and reducing administrative costs..." The AMA framework outlines a list of "usability priorities" - things they cannot specify precisely but are easily identified when you haven't got enough. The tip-off that these are "non-functional" requirements lie in the words of the AMA statement: enhance, support, promote, offer, reduce, promote, facilitate, and expedite. The first item on their list is, for example, "Enhance physicians' ability to provide high-quality patient care."

According to the AMA, "these priorities were developed with the support of an external advisory committee comprised of practicing physicians, as well as noted experts, researchers, and executives in the field of health information technology."

To me, their announcement essentially says no more than, "Somebody, please solve the EHR crisis." If this reformulation sounds critical, it is, and I'll explain why.

"Solve the ... crisis" statements do little to advance a solution; they merely express concern, dismay, and helplessness. They lack actionable suggestions for how to solve the crisis. They merely express the hope that someone who is smarter or more knowledgeable will be able to do what they cannot.

This is where the EHR crisis diverges. Immigration and drought are the result of forces beyond the control of policymakers, legislators, vendors, or individual organizations. They are truly complex problems. Immigration and drought cannot be solved, only mitigated or accommodated.

Turning to EHR, let's consider the AMA's priorities. What does it mean, for example, to "Enhance physicians' ability to provide high-quality patient care?" Is there a single enhancement that would work in every EHR? How do you enhance a computer system in a way that will result in predictably higher-quality care? The vendors already claim (or perhaps believe) that their systems are optimal, or at least adequate. Will they have any idea how to make their "practically perfect products" better? Similar questions can, and should, be asked about each of the AMA's eight challenges.

Taking a step back, several points are inescapable:

• The problems with EHR were smoldering for years, but only became a crisis when the federal mandate was imposed.

• The mandate effectively put a stop to the development of new EHRs since, in addition to implementing their new concept, they must replicate everything that is old to get certified or no one would buy them.

• Few comprehend the root causes of the EHR problems about which they complain. The few have an idea, either don't disseminate their knowledge, can't get it published because editors assume that ordinary physicians don't need to know that stuff, or the publications appear in obscure journals that no physician will ever discover. Thus, most physicians, probably including the committee members, have only vague notions of what it might mean for an EHR to be better. They can't have had much experience with one that is significantly better because if there were such a beast, people would be using it instead of complaining. Most notions of what would be better are based on daydreams, not evidence.

• The AMA's contention that EHR just needs a minor overhaul implies that they believe that today's EHRs are basically sound and well-designed. This assumption has no basis in fact. Just because EHRs are bought and used is not evidence that they are well designed, easy to use, or that they do what people expect.

Unlike drought and immigration, there is a solution to the EHR crisis.

It is to abandon mandates, abandon certification, and abandon penalties and incentives. Instead, efforts should be directed toward educating physicians about the information science behind medical records, be they paper or electronic.

The money that is currently being wasted on incentives and bureaucracy should be redirected to fund:

• Research that concentrates on basic science and is not tied to, or conducted using, an existing EHR; and
• Development of completely new EHRs that start with a blank slate and embrace design concepts that put the medical record, not data, at their core.