Why Is the Transition to Electronic Medical Records Going So Badly?

It seems so obvious: the need to reduce health care costs, patients and doctors demanding better information, the availability of data. You have all the essential elements for a successful business: need, demand, raw material, desire and funding.  

And yet.

The problem, as the following article explains, appears to be one part expectation and one part experience.

Expectations are driven by the not-unreasonable perception that smartphones have solved arguably more complicated data delivery challenges that hospitals and insurance companies can not.

Experience is what should drive design, but as in so many failed tech implementation scenarios, theory triumphs over pragmatism. The notion of actually observing those using the technology and the data it generates in order to perfect systems remains an elusive goal, despite numerous analyses documenting its importance in optimizing tech adaptation its impact on desired outcomes. JL

Robert Wachter comments in the New York Times:

User-centered design has been woefully lacking in health care software design.Our iPhones and their digital brethren have made computerization look easy, which makes our experience with health care technology doubly disappointing.

LAST year, I saw an ad recruiting physicians to a Phoenix-area hospital. It promoted state-of-the-art operating rooms, dazzling radiology equipment and a lovely suburban location. But only one line was printed in bold: “No E.M.R.”

In today’s digital era, a modern hospital deemed the absence of an electronic medical record system to be a premier selling point.

That hospital is not alone. A 2013 RAND survey of physicians found mixed reactions to electronic health record systems, including widespread dissatisfaction. Many respondents cited poor usability, time-consuming data entry, needless alerts and poor work flows.

If the only negative effect of health care computerization were grumpy doctors, we could muddle through. But there’s more. A friend of mine, a physician in his late 60s, recently described a visit to his primary care doctor. “I had seen him a few years ago and I liked him,” he told me. “But this time was different.” A computer had entered the exam room. “He asks me a question, and as soon as I begin to answer, his head is down in his laptop. Tap-tap-tap-tap-tap. He looks up at me to ask another question. As soon as I speak, again it’s tap-tap-tap-tap.”

“What did you do?” I asked.

“I found another doctor.”

Even in preventing medical mistakes — a central rationale for computerization — technology has let us down. A recent study of more than one million medication errors reported to a national database between 2003 and 2010 found that 6 percent were related to the computerized prescribing system.

At my own hospital, in 2013 we gave a teenager a 39-fold overdose of a common antibiotic. The initial glitch was innocent enough: A doctor failed to recognize that a screen was set on “milligrams per kilogram” rather than just “milligrams.” But the jaw-dropping part of the error involved alerts that were ignored by both physician and pharmacist. The error caused a grand mal seizure that sent the boy to the I.C.U. and nearly killed him.

How could they do such a thing? It’s because providers receive tens of thousands of such alerts each month, a vast majority of them false alarms. In one month, the electronic monitors in our five intensive care units, which track things like heart rate and oxygen level, produced more than 2.5 million alerts. It’s little wonder that health care providers have grown numb to them.

The unanticipated consequences of health information technology are of particular interest today. In the past five years about $30 billion of federal incentive payments have succeeded in rapidly raising the adoption rate of electronic health records. This computerization of health care has been like a car whose spinning tires have finally gained purchase. We were so accustomed to staying still that we were utterly unprepared for that first lurch forward.

Whopping errors and maddening changes in work flow have even led some physicians to argue that we should exhume our three-ring binders and return to a world of pen and paper.

This argument is utterly unpersuasive. Health care, our most information-intensive industry, is plagued by demonstrably spotty quality, millions of errors and backbreaking costs. We will never make fundamental improvements in our system without the thoughtful use of technology. Even today, despite the problems, the evidence shows that care is better and safer with computers than without them.

Moreover, the digitization of health care promises, eventually, to be transformative. Patients who today sit in hospital beds will one day receive telemedicine-enabled care in their homes and workplaces. Big-data techniques will guide the treatment of individual patients, as well as the best ways to organize our systems of care. (Of course, we need to keep such data out of the hands of hackers, a problem that we have clearly not yet licked.) New apps will make it easier for patients to choose the best hospitals and doctors for specific problems — and even help them decide whether they need to see a doctor at all.

Some improvements will come with refinement of the software. Today’s health care technology has that Version 1.0 feel, and it is sure to get better.

But it’s more than the code that needs to improve. In the 1990s, Erik Brynjolfsson, a management professor at M.I.T., described “the productivity paradox” of information technology, the lag between the adoption of technology and the realization of productivity gains. Unleashing the power of computerization depends on two keys, like a safe-deposit box: the technology itself, but also changes in the work force and culture.

In health care, changes in the way we organize our work will most likely be the key to improvement. This means training students and physicians to focus on the patient despite the demands of the computers. It means creating new ways to build teamwork once doctors and nurses are no longer yoked to the nurse’s station by a single paper record. It means federal policies that promote the seamless sharing of data between different systems in different settings.

We also need far better collaboration between academic researchers and software developers to weed out bugs and reimagine how our work can be accomplished in a digital environment.

I interviewed Boeing’s top cockpit designers, who wouldn’t dream of green-lighting a new plane until they had spent thousands of hours watching pilots in simulators and on test flights. This principle of user-centered design is part of aviation’s DNA, yet has been woefully lacking in health care software design.

Our iPhones and their digital brethren have made computerization look easy, which makes our experience with health care technology doubly disappointing. An important step is admitting that there is a problem, toning down the hype, and welcoming thoughtful criticism, rather than branding critics as Luddites.

In my research, I found humility in a surprising place: the headquarters of I.B.M.’s Watson team, the people who built the computer that trounced the “Jeopardy!” champions. I asked the lead engineer of Watson’s health team, Eric Brown, what the equivalent of the “Jeopardy!” victory would be in medicine. I expected him to describe some kind of holographic physician, like the doctor on “Star Trek Voyager,” with Watson serving as the cognitive engine. His answer, however, reflected his deep respect for the unique challenges of health care. “It’ll be when we have a technology that physicians suddenly can’t live without,” he said.

And that was it. Just an essential tool. Nothing more, and nothing less.