Wednesday, March 21, 2012

Electronic Health Records, Cue Destruction, Reordering of Habits and Medical Quality: A Look at Charles Duhigg's Book on "The Power of Habit"

Habit destruction
While the peer-reviewed medical literature on the electronic health record (EHR) continues to be populated with lukewarm articles like this, the Disease Management Care Blog has been reading Charles Duhigg's interesting book on "habits."

According to Mr. Duhigg, it's the basal ganglia that warehouse the complex behaviors that allow the DMCB to brush its teeth, back a car out of the garage and nod at the DMCB spouse without really "thinking" about it. All it takes is a "cue" that signals that a behavioral sequence can begin that, when it is completed, results in a "reward."

The DMCB thinks of it as a labor-saving device for its grey matter. It "outsources" activity that would otherwise take a lot of effort, like figuring out every time it time it encounters a door that the secret to managing that nob involves firmly grasping it and then rotating it.

Such "habits" can be either good or bad.  Cues (such as walking in the door at 5 PM) can prompt humans to unthinkingly respond by donning jogging sneakers or opening a can of Pringles that in turn lead to either to endorphin rush or resolution of the munchies.  And it is this link between seemingly innocuous cues and habits the forms the central theme of Mr. Duhigg's book:

If you, your spouse, or your employer wants to alter your behaviors, the answer may lie in finding those underlying cues and replacing them.

Which brings the DMCB back to the EHR. Talk to any physician who has made the transition from a paper record to an electronic record and he or she will tell you that it is an ordeal. Patient throughputs decline, clinic work flows are reordered and doctor-patient interactions have to adapt to the intrusion of a keyboard and monitor.

In other words, it is a perfect environment for upsetting the baseline "cue" applecart that drives a clinic's good and bad habits. Silent but all important prompts that lead to and guide previously established clinical "routines" like medication list reviews, assessing allergies, performing a physical exam or ordering imaging studies are blown away and replaced with a new equilibrium. Providers, aware that they need to increase quality, develop new cues and habits in response to the chaos of an EHR installation.  It's not the EHR itself.

The DMCB wonders if the "cue destruction" may be one explanation for some of the EHR's successes. As noted here, a "successful" EHR install involves a "redesign of clinical processes" that likely forces providers to relearn countless hidden habits.  Since cue destruction is not an explicit and conscious part of the typical transition from paper to computer, EHR installs are likely to vary in terms of their impact. Some are easier and less intrusive than others.

Two conclusions:

1.While the EHR itself with its reminder prompts, decision support and quality improvement routines may lead to increases in quality, another basis for its success may be in its ability to force "cue" replacement and the alteration of old physician habits.That's not necessarily bad, but it is very unintentional. This could explain why the EHR's impact on clinical quality performance has been decidedly spotty.

2. This may warrant additional research. While a prospective randomized clinical trial examining the impact on quality or habits would be daunting, the design could include an EHR install in one arm and a totally rearranged paper record in the other. Alternatively, regression analytics could be used to assess whether the level of chaos associated with a new EHR purchase is an independent predictor of downstream quality.

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