Caring in the Age of EHR

I had the opportunity to read Dr. Rich Joseph’s opinion piece, inspired by his interaction with Dr. Bernard Lown (he of International Physicians for the Prevention of Nuclear War fame and the founder of the Lown Cardiovascular Group), in the February 24, 2018 edition of The New York Times. Dr. Joseph provides a compelling argument for returning to an emphasis on caring and not just treating in our medical profession. The article is brief and, of necessity, provides a narrow and simplified view of the issue, but the narrative is impactful and a cause for reflection.

I feel that I have a unique combination of qualifications to comment, having practiced primary care internal medicine for 16 years, been involved in and a leader of organized medicine my entire career, been on the vanguard of the hospitalist movement, led the second wave of physician practice acquisitions by hospital systems (the first being in the mid-1990s), having been a CMIO and CIO through Meaningful Use and the transition of my health system from the best-of-breed model to a single, integrated electronic health record (EHR), and, finally, as a seated Delegate in the House of Delegates of the AMA.

During my career, the exam room has gotten increasingly crowded. The Health Maintenance Organization (HMO) intrusion had already begun when I started practice, introducing the embryonic form of the future monsters we know as preauthorization and pharmacy benefit management (initially through formularies), followed in 1995, and again in 1997 by stringent coding guidelines (these play a key and more harmful role later). Time with, and focus on, patients was diverted while trying to remember what specialist could be referred to for which HMO and while ensuring enough bullet points in each dimension of care were captured and written down to qualify for the level of code to be submitted.

The crowd grew and increasingly pushed the patient back in the exam room as Preferred Provider Organizations (PPOs), with their ever-changing cast of characters and permissible sites of care, and narrow networks, pruned of many trusted colleagues, joined the party. Then, in 2004, President George W. Bush declared the goal of moving physicians and hospitals to EHRs and the crowd became a demanding, all-consuming mob. Now the figurative crowd was joined by the physical presence and distraction of the screen, keyboard, and mouse. Previously, even as the physician’s mind was diverted to the intrusions into the patient-physician relationship, eye contact with patients could be maintained, assuring them of care and caring. Now, the unblinking eye of the monitor demanded focus, and the fragile, reassuring connection of eye contact was repeatedly broken. As a result, the atmosphere of care became thinned and less capable of supporting the life of the patient-physician relationship.

The HITECH Act subsidized the acquisition of EHRs in hospitals and practices, but without addressing any of the glaring deficiencies of existing products and with the addition of further data points and workflows to comply with Meaningful Use requirements that have proven to be anything but meaningful to patients and physicians. The aforementioned coding guidelines now exerted their most harmful effect, as EHRs, which largely developed from billing tools and lab software, built workflows that focused on capturing bullets to support coding and revenue capture, rather than studying the real flow of care in medical offices and creating workflows that conformed to that reality. This process creates bloated, disjointed, and non-narrative records that impede rather than support care.

Meaningful Use only increased the arbitrary and non-intuitive structure of EHRs as developers raced to bolt on features to pass the certification process and stay in the high-stakes game. There was an opportunity to provide some relief and actually benefit patient care by requiring standard coding formats and field definitions to support interoperability, but ONC shied away from the complexities and, fearful of having the economic incentive dollars reclaimed by the administration and used for other infrastructure projects, chose the expediency of measures of use and kicked the interoperability can down the road, where it is still rattling along today.

I have not (and lack space or time to do so here) addressed the rapid advance of technology in diagnostic studies and treatment that also call physicians away from the patient and to images and lab results that disingenuously suggest that this represents the patient and is the path to better care.

So, Dr. Joseph and Dr. Lown, thank you for causing me to reflect. I would contend that our desire to care has not decreased over the years, and would point you to the personal statements of medical school applicants for proof of core motivations and altruistic intent. I think our caring has been crowded out by the mob in our exam rooms and at the bedside. We are distracted by regulations, preauthorizations, insurance payment denials and audits, bright and shiny, technologically advanced diagnostics, the non-intuitive workflows of our EHRs cum billing tools, and lack of interoperability.

There are solutions, but they require resolve and collaboration. My candidate for first target is interoperability. The technical pieces exist for interoperability that far exceeds our current state. What can be quickly done will not be a final solution, but it can be a leap forward in the evolution of interoperability. We have waited nine years for something better than cumbersome, bloated, and difficult-to-read Continuity of Care Documents (CCDs), and it is time to give specific timeframes to EHR developers. I am well aware of the speed with which the major EHR players can move when incentivized by financial gain or reputational protection. They can respond to this need timely and effectively but need the incentives of regulation and deadline.

When we have access to information already existent in other systems, in a manner that is ingestible by our system and presented in an efficient to review and assimilate manner, we will regain precious time for interacting with and caring for our patients.

Next, let’s talk about EHR structure and workflows.

[Currently working as a freelance consultant, David Bensema, MD, was previously both CIO and CMIO at Baptist Health Kentucky, where he led the implementation of an enterprise-wide EHR system. Bensema has served in various physician leadership roles and has a strong passion for advancing healthcare IT to improve patient care.]