Electronic health records (EHRs): If you've followed this column for any length of time, you should know that they're the heroes of this space.
Simply put, no. My paradigm didn't break down, and for one simple reason - customization. The kinds of EHRs that improve care require a level of functionality that allows the user to move through the clinical process as an individual. This functionality is called customization. It changes the doctor's role from a human liaison between a generic computerized note and the patient to a doctor reasoning with computerized assistance that adapts to their clinical flow. Now, to be clear, the authors of the study didn't use the words "lack of customization" when they reached their conclusions. That was my own reading of the evidence. However, follow my reasoning, and I think you'll see why customization as a benchmark of EHR quality explains why not all EHRs are the same, as well as why generic EHRs could be more of a problem than they are a solution.
The Strain of Medical Errors
Let's begin by giving some context to the study at hand. Many chiropractors take a kind of righteous pleasure in describing the failures of the American medical system; it's part of our collective chiropractic culture. What has fueled this practice since the late '90s is the landmark publication on iatrogenic death and physician errors from the Institute of Medicine (IOM) titled "To Err Is Human" (1999). The recognition of this problem is incredibly controversial. The IOM has suggested the problem might not be solved without the widespread adoption of EHR systems in order to improve the quality of medical care.2 It's a commonly held fact among many health care policy types that EHRs are going to offer a powerful solution when it comes to managing the increasing number of prescriptions and medical interventions for our aging population. They believe in the ability of EHRs to reduce redundancy of care and medical errors, and to increase the quality of health care.
What Does the Study Say?
According to the July study in the Archives of Internal Medicine, it can't be assumed that an adoption of the EHR system in medical institutions will actually improve quality of care.1 Their quality indicators were based on the physician's decision to prescribe drugs or antibiotics, order a routine medical exam and order preventative counseling. Institutions using EHRs were only shown to increase their quality on two out of 17 quality indicators. These findings surprised the authors, especially when compared with other studies that looked at four benchmark EHR institutions, which were able to show increases in care quality. What was the difference between the effective and ineffective EHRs?
What's Wrong With EHRs?
The authors explain that they aren't sure that the quality of each of the EHR systems was up to the task of improving care quality: "Unlike the EHRs at benchmark institutions, the types of EHRs that have been widely disseminated may be more rudimentary, lacking clinical decision support and not focused on quality improvement. A recent report from the NCHS found that only 40% of physicians who reported using an EHR in 2005 had all 4 of the minimally necessary features of a 'complete' EHR system."1
The authors of the study took considerable data from more than 50,000 records in thousands of medical offices over two years, but they didn't have specific information on EHR capabilities. The study says, "The clinics could report they are using an EHR simply for prescribing functionality or simply as a note-keeping function. ... We have no information on the number of EHRs in the present analysis that had clinical decision support that would be applicable to the quality indicators we examined."
In addition to the problem of knowing the functionality limitations, they say the outcomes may be limited because within the realm of medical practice, there are currently no economic rewards for improved standards of care.
Not All EHR Systems Are Equal
For me, the take-home message from this study is not that EHRs can't improve the quality of health care. The message is this: Not all EHR systems are created equal. Not even in medical practice. This corroborates an experience I had 12 years ago, when I first began investigating digital documentation systems and found that the functionality differences between some of the products were like night and day. It was like comparing apples to oranges.
Unfortunately, this study seems to show that health care providers have no clue there is any difference between the apples and oranges. This reality can lead to inconclusive findings when it comes time to evaluate EHR systems. It could be that the technology is too new and too diverse for health care providers to properly define an EHR as something more than just a digital note. Only the advanced EHR systems are defined by their ability to organize, integrate and evaluate the clinical decision-making process, which offers true efficiencies and improves quality. These systems are defined by more than the way they are stored (i.e., electronically on a computer). I have a solution that everyone from health care analysts to solo practitioners can use to evaluate the functionality of the EHR system in question - examine the customization.
Why Customization Matters
Between the lines of the EHR study, I believe there's an acknowledgement that customization matters. The authors state that EHRs were shown to improve outcomes at benchmark institutions that had developed their own EHR systems from the ground up. In other words, these systems were customized for the situation at hand, with input from the personnel using the system. This is as far from a generic digital note as you can get.
Customization is the ability of the user to mold the documentation process to their own clinical workflow. As we know, no two doctors are ever going to work through a history and exam the exact same way. Forcing doctors into a prescribed way of thinking through a rigid note-taking process can do more harm than good. It creates an artificial standardization that is unrealistic and may not allow for the recognition of soft clinical clues, or ways to back out of rabbit trails that are created by complicated clinical presentations. Let me give you just one example.
We all learned in school that orthopedic exams were objective, standardized tests that created a reproducible clinical picture anyone reading our notes should understand. If we had a disc involvement, we'd see a positive SLR. It was as simple as that. Then we had our first patients in practice and found out that simplicity wasn't always involved. We learn that a positive SLR, from a documentation standpoint, actually reveals almost nothing. In order to make the test noteworthy, it became necessary to document the kind of pain and the angle of the leg with respect to the horizon (30, 45 or 90 degrees), some of which didn't necessarily indicate a disc problem. But you need to document what you think it does indicate, based on evidence, and if the test needed to be modified for some reason or another, based on the patient's antalgic position. A positive SLR became more than just a checkbox we marked on a sheet of paper; it was synthesis of several major clues to the patient's disability. However, your exam sheet doesn't allow you to document all of this, and most EHR systems don't document it, either (except for one that I know of).
Yet many EHR systems treat orthopedic exams and other areas of the patient examination, with the simple understanding of a student. You either place a mark in the checkbox or you don't. There isn't room for the physician's thought process, because there's no customization.
The doctor marks a yes or no res-ponse for the test and continues to navigate through pages of orthopedic exams, looking for the next appropriate test. There's no altering the sequence of exams. There's no immediate jump into another section of the exam based on the patient's pain level and presentation. And there's no red-flag warning to remind the doctor of the possible complications associated with disc involvement that may require more immediate attention.
In other words, there is no functionality that will inspire a greater quality of care. This is a problem. Technology should help us improve our quality, document it and show the outside world the competency our profession can deliver. The digital environment has led us to believe that we're safeguarding the clinical process and improving it. In reality, we're not improving anything, and we could even be making our outcomes worse because of the way the technology forces us to adapt to a system that interrupts the internal logic of our clinical thinking. You can see why customization is a powerful benchmark for evaluating the level of functionality and therefore, the clinical helpfulness of EHR systems. If EHRs are going to increase the quality of health care, be it in a CAM setting or within medicine, they require customization that empowers the provider.
Where We Stand
Perhaps in due time, we may be able to have our own studies to evaluate the long-term effects of adopting EHRs in chiropractic practice. I would like to think that such a study would show better outcomes for chiropractors than what was found in the Archives of Internal Medicine. That may just be my positive thinking, but I've got two reasons for suspecting why it's possible. The first is while medical practices don't yet have an economic incentive for proving the quality of their care, chiropractors have all the economic incentive in the world to prove that what we do is effective. (If you need evidence of this, I'll simply refer you to some of my other columns.) Secondly, because of the pressure to prove and improve the quality of our care, we're more likely to pay attention to EHRs and their quality benchmarks than the average MD in private practice.
That means we're going to have to know the difference between the apples and oranges if we want the benefits of customization, and any other benefit that can come with EHRs in the clinic of the future. There is absolutely no doubt that the quality and details of our documentation will improve with the right EHR. However, getting both the quality of documenting the outcomes of care along with improving the actual outcome with an EHR can only occur with the high-level customization that very few EHRs currently provide. Choose your EHR wisely and you'll not only sleep better by improving your documentation and quality of care, but you'll also elevate our profession.
References
- Linder JA, MA J, Bates DW, et al. Electronic health record use and the quality of ambulatory care in the United States. Arch Intern Med, 2007;167:1400-5.
- Preventing Medication Errors: Quality Chasm Series (prepublication copy), 2007. Board on Health Care Services, National Institute of Medicine. Available at http://darwin.nap.edu/books/0309101476/html/131.html. Accessed on Aug. 25, 2006.
Click here for previous articles by Steven Kraus, DC, DIBCN, CCSP, FASA, FICC.