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- Robert Shor, MD, FACC, Chair, ACC Board of Governors∗ ()
- ↵∗Address correspondence to:
Dr. Robert Shor, American College of Cardiology, 2400 N Street NW, Washington, DC 20037.
Do you have an electronic health record (EHR/EMR)? Does your office EHR talk to your hospital EHR? Does it communicate with a referring physician? Has your EHR made your life easier, or has its presence made your work more challenging? Do you think it has enhanced your ability to care for your patients? Although a few EHRs dominate the market, the 2013 “best government estimates are that 729 companies offer certified electronic health record (EHR) systems targeting medical providers” (1). Has your EHR met its mission or promise?
An extensive conversation played out among the American College of Cardiology (ACC) Board of Governors this spring in response to a March 21, 2015, The New York Times opinion piece by Robert M. Wachter titled “Why Health Care Tech Is Still So Bad” (2). The paper outlined some of the most glaring and common issues that both patients and physicians have with EHRs, many of which our very own ACC leaders echoed.
In the Board of Governors discussion, the Governor of ACC’s Washington State Chapter, Tim Dewhurst, MD, FACC, laid out a pro/con list for what EHRs can and cannot do. Sitting squarely in the pro camp, according to Dewhurst, are positives such as real-time communication, more efficient and excellent care, clear discharge or post-appointment instructions, real-time laboratory results, efficient record keeping and tracking, and virtual care. Dewhurst outlined some of the common frustrations of EHRs, including the expense of acquisition and maintenance, lack of interoperability standards, suboptimal user interfaces, lack of artificial intelligence, lack of friendliness to specialties in general systems, and excess time wasted completing notes versus the time to complete standard dictation.
With many years of experience in using an EHR, John Hirschfield, MD, FACC, Governor of the ACC’s Pennsylvania Chapter, resounded the many frustrations of the other governors in the discussion, particularly highlighting the pain points of “poor interface design, inadequate rollout support, and additional time demands required to ‘feed’ the record.” However, like Dewhurst and many others, he sees substantial benefit in EHRs. “Yes, the current generations of EHRs are primitive. Yes, we have been frustrated by an immature technology. Yes, many institutions have furnished inadequate support effectively shifting clerical work onto physicians,” he wrote. “However, I think they are here to stay, and hopefully the above deficiencies will resolve over time.”
Edward Fry, MD, FACC, Governor of the ACC’s Indiana Chapter agreed. “EHRs are here to stay,” he said. “Despite all their ‘warts,’ they are far better than paper. Portability, record keeping, potential data mining, coordination of information within a given system, and legibility are all attractive features. The genie is not going back in the bottle.”
Aside from these pros and cons, there is a deeper issue that Dewhurst illuminates. “One of the biggest issues blamed on EHRs, but is not at all the EHRs fault, is what I call the ‘Emperor Has No Clothes’ issue,” he wrote. “EHRs are largely built to satisfy arcane documentation requirements based on insane Centers for Medicare and Medicaid (CMS) requirements. In our crazy current fee-for-service system, we have blindly gone the path of wasting time by documenting a complete review of systems, comprehensive physical exam, and detailed family history so we get paid less than our office expenses for that visit. We do this to get paid, protect ourselves from legal issues (both malpractice and administrative). It does not add anything to patient care.”
But, what can we do about the issues with EHRs? As leaders of the ACC, what action can we take to make a change? Dewhurst said that we have 2 options. We can “work with Congress and the U.S. Department of Health and Human Services to demand complete interoperability of EHRs, at the vendor’s cost; and we lead the charge to a value-based reimbursement system that does not require insane documentation requirements.” He added that “if the people taking care of the patient can understand the assessment and plan in a note, then that is all that should be required. We need to continue to work with the public and policy makers to shed the light on these useless documentation requirements.”
But, as The New York Times piece concluded, what we really need here is simplification. The field of medicine merely needs “an essential tool” as Wachter wrote (2). We need a tool that we cannot live without. Until then, there is work to be done and patients for whom we need to care, whether we do so on paper or screen.
- 2015 American College of Cardiology Foundation
- ↵Verdon DR. Top 100 EHRs: why understanding a company’s financial performance today may influence purchasing decisions tomorrow. Medical Economics. Available at: http://medicaleconomics.modernmedicine.com/medical-economics/content/tags/ehr/top-100-ehrs-why-understanding-company-s-financial-performance-to. Accessed May 4, 2015.
- ↵Wachter RM. Why health care tech is still so bad. The New York Times. Available at: http://www.nytimes.com/2015/03/22/opinion/sunday/why-health-care-tech-is-still-so-bad.html?hp&action=click&pgtype=Homepage&module=c-column-top-span-region®ion=c-column-top-span-region&WT.nav=c-column-top-span-region&_r=2. Accessed May 4, 2015.