by wayne persky
Founder and President of the Microscopic Colitis Foundation
According to an online article titled The History of Electronic Health Records (EHRs), electronic health records date back to the mid-1960s, when Lockheed developed an electronic system known as a clinical information system (Rajaee, 2022, June 4).1 This inspired other technology and engineering companies to begin developing electronic health record systems for hospitals and universities. During the 1970s, the federal government began using EHR in the Department of Veterans affairs.
Since the time of Hippocrates,
all medical records have been maintained manually in paper filing systems (prior to the advent of EHRs), but during the 1960s, the Mayo Clinic in Rochester, Minnesota became one of the first large health systems to begin using EHRs. Back then, the technology was so expensive that it was used exclusively by the government, in collaboration with health organizations. By the 1980s, EHRs were being adopted by more medical facilities.
Paper records have poor searchability.
Government regulatory agencies tend to be "information hogs". The Office of the National Coordinator (ONC) of Health Information Technology was created in 2004, and soon after that, EHRs were added, in accordance with the provisions of the Health Information Technology for Economic and Clinical Health Act (HI TEC H). As inducement to providers for using EHRs, the act provided higher payments to health care providers who met certain "meaningful use" criteria.
Men have become the tools of their tools.
The system reflects a general perception that it works well. But there are dissenters. For example, the Indian Journal of ophthalmology contains an article published in 2020 titled "Electronic medical records — The good, the bad, and the ugly" (Honavar, 2020).2 The article begins with an 1854 quote by Henry David Thoreau, "Men have become the tools of their tools". The author of the Journal article writes, "The interaction of physicians with electronic medical records (EMR) is the most relevant example of how our inventions have enslaved us. The focus is often on creating a perfect record on EMR, while patient interaction is relegated to the hazy periphery."
The article points out that despite several decades of evolution, the EHR system continues to grossly miss the intended mark, namely, efficient and personalized patient care. In fact, as the article points out, the system was so unpopular (mostly due to the high cost), that until Barack Obama spearheaded the American Recovery and Reinvestment Act in 2009, utilization of EMR was relatively low.
The article points out that despite several decades of evolution, the EHR system continues to grossly miss the intended mark, namely, efficient and personalized patient care. In fact, as the article points out, the system was so unpopular (mostly due to the high cost), that until Barack Obama spearheaded the American Recovery and Reinvestment Act in 2009, utilization of EMR was relatively low.
As noted by the article, the good points include:
Improvements in patient care:
Accuracy of patient information
Clinical decision-making
Continuity of care
Improvements in operational planning:
Health care statistics for improved planning and management of healthcare services
User (provider) benefits in coding, billing, regulatory compliance, prevention of medical errors, optimized workflow, and various other advantages
And the bad points include:
The EMR system has " undermined personalized face-to-face patient care and the vital doctor-patient interaction - the very soul of medicine - into a new check box-based doctor-computer-patient interaction"
Doctors and nurses spend, on the average, approximately 50% of their workday staring at a monitor screen, and entering data, rather than treating patients, and this is a primary contributing factor to clinician burnout (National Academies of Sciences, Engineering, and Medicine, 2019).3
A 2013 article in the American Journal of Emergency Medicine pointed out that a study of emergency rooms doctors found that a doctor needed to make (Hill, Sears, and Melanson, 2013):4
6 mouse clicks to order an aspirin
8 mouse clicks to order a chest x-ray
15 mouse clicks to provide a prescription
4,000 mouse clicks during a typical 10 hour emergency room shift
A former editor-in-chief of the New England Journal of Medicine (and a physician with six decades of experience), Arnold Relman, noted that the description of his own medical progress, and his complaints and state of mind when he, himself, was a patient, was incoherent in the EMR system (Ober, and Applegate, 2015).5
But despite dissenting opinions, in general, the system seems to operate relatively smoothly, with reasonably accurate information (as determined by the quality of information entered by providers), and there has been no reason to doubt its integrity — until now.
The EMR system sometimes fails to report deaths.
ReferenceaResearchers at the University of California, Los Angeles, discovered that approximately 20% of patients listed in the EMR as having a serious illness, were actually deceased, according to California data (University of California, Los Angeles, 2023, December 4).6 While that discrepancy can hardly be considered to be irrelevant, the reason this problem occurs lies outside the system itself.
This frustrating problem occurs because of a California law that makes full death data available only to law enforcement agencies and financial institutions. The National Association for Public Health Statistics and Information Services maintains a real-time death database, but this information is unavailable to health organizations. The researchers found that the problem exists for almost all California hospitals and hospitals in some other states. Obviously, the problem could be easily corrected, and the fact that it has existed this long (without even being reported, previously) is somewhat amazing.
This frustrating problem occurs because of a California law that makes full death data available only to law enforcement agencies and financial institutions. The National Association for Public Health Statistics and Information Services maintains a real-time death database, but this information is unavailable to health organizations. The researchers found that the problem exists for almost all California hospitals and hospitals in some other states. Obviously, the problem could be easily corrected, and the fact that it has existed this long (without even being reported, previously) is somewhat amazing.
References
1. Rajaee, L. (2022, June 4). The history of electronic health records (EHRs). Elation Health, Retrieved from https://www.elationhealth.com/resources/blogs/the-history-of-electronic-health-records-ehrs
2. Honavar, S. G. (2020). Electronic medical records – The good, the bad and the ugly. Indian Journal of Ophthalmology, 68(3), 417–418. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7043175/
3. National Academies of Sciences, Engineering, and Medicine. (2019). Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington, DC: The National Academies Press, retrieved from https://books.google.com/books?hl=en&lr=&id=cnHJDwAAQBAJ&oi=fnd&pg=PR1&ots=_5K3TBvFhc&sig=cdjAZ7wHJA0H45XjiMLASycwQWQ#v=onepage&q&f=false
4. Hill, R. G., Jr, Sears, L.M., and Melanson, S. W. (2013). 4000 clicks: a productivity analysis of electronic medical records in a community hospital ED. The American Journal of Emergency Medicine, 31(11), pp 1591-1594. Retrieved from https://pubmed.ncbi.nlm.nih.gov/24060331/
5. Ober, K. P., and Applegate, W. B. (2015).The electronic health record. Are we the tools of our tools? The Pharos Alpha Omega Alpha Honor Medical Society, Alpha Omega Alpha, 78(1), pp 8–14. Retrieved from https://pubmed.ncbi.nlm.nih.gov/25796660/
6. University of California, Los Angeles. (2023, December 4). Patients listed as alive in their electronic health records were actually deceased, according to data. Medical Xpress, Retrieved from https://medicalxpress.com/news/2023-12-patients-alive-electronic-health-deceased.html?utm_source=nwletter&utm_medium=email&utm_campaign=daily-nwletter
