Thursday, October 21, 2010

The "Water Water Everywhere, Nor Any Drop To Drink" Problem of Electronic Health Records (EHRs)

As further evidence of the growing mojo of the population health (née disease) management industry, go no further than the ability of the Care Continuum Alliance's Forum10 to attract speakers of national stature. Case in point was the October 13 appearance of National Health IT Coordinator David Blumenthal. This was the second time the Disease Management Care Blog saw him speak. He was just as measured, serene, confident and mistaken as he was the first time.

Listen to the rhetoric of Dr. Blumenthal and others like him, and it's easy to get the impression that the U.S. on the cusp of joining the rest of the civilized world in a new computer age of medical efficiency, englightenment and safety. If you believe them, it seems a major hurdle toward this era of electronic enchantment is being overcome by the enlightened application of meaningful use criteria coupled with provider financial incentives.

Yet, when the DMCB talks to physicians from smaller practices, it hears a recurrent and contrarian theme that matches news reports: they are actively shopping electronic health record (EHR) vendors but, so far, the offerings disappointingly fall short in ease of use, have marginal point-of-care decision support and don't generate significant patient value. While they stand to get some serious money, their calculus also includes the bitter past lessons of promises broken while struggling to keep their patients healthy and satisfied. As for the large medical groups, one read of Health Care Renewal's collection of depressing stories of endless HIT hubris, waste, mismanagement and patient harm should be enough to give any reasonable person pause.

Yet, before you think the DMCB is being an neo-Luddite weenie, let it be the first to agree that the fact that docs are now actively looking EHRs tells us something. It would appear that conversion away from paper records may be reaching a national tipping point. The DMCB thinks there are two reasons: 1) the drumbeat of Medicare money can't be ignored, and 2) the shift of some docs in some regions into larger physician practices is enabling those groups to accumulate sufficient capital for an investment in HIT.

Of course, as that happens, non-readers of the DMCB will make some painful discoveries. EHRs with or without "meaningful use" have little hope of controlling costs, don't necessarily increase quality, have little impact physician or patient behavior and trade new problems for the old ones.

But, says the DMCB, none of these are the Achilles heel of the metastasizing medicalinfotechnology complex. Rather, the biggest EHR vulnerability is its glut of data with little in the way of any real information.

The growing body of raw data contained in all those EHR servers, if it remains unorganized, will rapidly outstrip the ability of providers and patients to keep up. Drug lists are being cluttered with unimportant or discontinued medications. Past patient histories are becoming a logarithmically expanding mash of rule outs, billing codes and pay for performance buttons. Pop-up prompts, lists, tables and sidebars are diverting attention. Terrabytes of other pharmacy, insurance claims and personal data are being imported like spaghetti being thrown against a wall. Other than some flatfooted nods to organizing some of information into "lists," the emerging "meaningful use" criteria are failing to distinguish between being comprehensive and attaining comprehension. It's like the Rime of the Ancient Mariner: "Water water everywhere, nor any drop to drink" (which explains the graphic above).

Which brings the DMCB to an ironic punchline: this is a problem that will be solved. The change from a "capture all data" to a "assemble all insight" user-interface will enable providers to quickly drill through a patient's information set to find the right (not all) information at the right (not all the) time. When that happens, someone will deserve a Nobel. In addition, an up and coming electronic device that really has the greatest health information technology potential for market disruption will make current paradigm of a health-system dominated EHR obsolete.

That would be the cell-smart phone. More on that in a future post.

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