The Future of the EHR Has a Pair of Possible Paths

For the previous post in this series, click here.

The current ballyhoo over EHR has interrupted what would have otherwise been a gradual evolution of EHR with the most effective, easiest to use products winning out over time. A fork in the road has developed and two possible futures for EHR are now before us. 

The first follows the course already charted. The provisions of the HITECH Act coupled with the FDA's recent interest in regulating EHRs as medical devices make this future seem almost inevitable. In the other future, our legislators or the computing industry experience an epiphany; one that leads them to begin the basic research and development that will put EHR on a sound theoretical foundation analogous to that of genomics. How should we spend the $20 billion allocated to EHR? The current plan is to spend it to induce physicians to adopt those very EHRs that they have been slow to adopt in the past.

The alternative is to spend it on the research and development to achieve the technical advances that will enable the construction of EHRs that actually meet our expectations instead of frustrating them; systems that make our lives easier, "mind the store" when we are out so that things to not fall through the cracks, and "watch our backs" so that, to use the words of Dr. Gurly (a former JCAHO surveyor) "every patient gets what they need and needs what they get."

For a brief glimpse of the alternate future, let's assume the breakthroughs have occurred and fast-forward 10 years. The chart entries and documentation that constitute the EHR are no longer stored inside of the applications that you use to create them. You have the option to use separate applications that are optimized for the different settings in which you practice (such as the OR, the procedure room, or the ER) and when making rounds on your hospitalized patients. The records are stored in a separate module that is optimized for secure access and archival retention (we're talking a 50- to 100-year timeframe.) The stability of the archive makes it possible for you to change or add charting modules at any time to suit your immediate needs. Access to the records is controlled by the archive which has enough internal intelligence and knowledge of your organization (and the patients) to allow free access by those that common sense (or your policies) dictate should be permitted while keeping out those who have no business there. The separation of charting and archival storage means that when you are charting on hospital rounds your notes can be simultaneously sent to the hospital's archive and the one in your office.

Notes need to be signed before they are accepted by the archive but you use more than one charting module. How do you keep all those electronic signatures and passwords straight? You no longer need to. All documents that require signature are routed to a module that is the equivalent of an electronic notary public. That module verifies your identity (perhaps by using the camera built into your device to recognize you) and then applies a robust electronic signature to the note and forwards it to the archive. Vendors of charting modules no longer need to invent their own proprietary schemes that may vary year to year and vendor to vendor.

The notes and other documentation that you create have the same look and feel and the notes that you used to type or dictate but when you chart items such as vital signs and lab results or associate particular findings with codes such as ICD-10, the quantitative data is embedded within the note in much the same way that word processors embed formatting information in their documents. This allows you to search for chart entries based on their content, sort them, extract data to be used for graphs or calculations and eliminates the ambiguity inherent in free-text narrative. Some of the subtlety of a history can only be expressed in plain language and is not readily reducible to a code or a discrete value. Your notes now contain more of this descriptive content than they used to because you spent less effort recording the quantitative stuff and much of the coding is pre-assigned or automated. There is sufficient context and quantitative information embedded in the notes so that E&M codes and the like are calculated automatically, allowing you to devote your time to the patient.

When anything occurs in your practice that needs follow-up, whether you want to remember to look at a test result, recall the patient in a year for another prostate exam (actually that one was put in the reminder queue automatically, you only had to make the decision once, not once a year for each patient), it’s time to reorder supplies, or a patient called and needs a call back, the reminder will be sent to a reminder module, Like the archive, the reminder module accepts reminder items from any source. Reminders include information that the module can use to manage the queue. When it is time to remind, how should the reminder be delivered? Pop-up on your screen, a text message, a phone call, email, etc. Is it a reminder that needs to be acknowledged? If so, how soon? What should be done if there is no response? Try again, call someone else, etc.

The other core functions such as scheduling, drug interaction, and dose checking, etc. have also been reinvented to be more effective and easier to use. The important difference is that each function no longer has to be reinvented by each vendor. Individual modules are now produced by vendors that develop deep expertise in the function that they are providing. A little bit like ordering a combination platter from a take-out restaurant, your job is to choose a module from each group that suits your needs and situation and connect them. You may have elected to install some of the modules at your practice location while others are located in that “cloud” (what used to be called a Service Oriented Architecture [SOA]) that has become so popular. If the evolution of EHR follows this path, there will more exciting and useful developments to come.

While systems like this will definitely lower levels of aggravation and stress, they don't let you off the hook completely. You still have to decide what you need to do, how you want it done and then you, or someone you trust, must manage the whole thing - so what else is new? Some things never change.

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