Don't get me wrong, EMRs could be great, maybe even better than the WWW.
When I lived in the Bay Area in the late 90's, I was struck by the fact that everyone said the Internet and specifically the WWW was earth shattering, game-changing, and would make us forget all that preceded it (in 1998!). The point being that in the 90's, we could imagine the tremendous potential of the internet age, but the realities were still a far cry from that. A decade later we have come a very long way, but still more left on the journey.
Keep in mind that I'm a CIO who just went live with many EMR components in the past 2 months so I may be a bit more deluded than usual. I take tremendous pride with what our organization has done and how much better life truly is as a result of the system implementation. However, there is a part of me, that feels like some CEOs/CIOs in 1998 that read the press, spent the money, and built a fancy website for their company, and said "Now What?"
Just putting up the website didn't change the world. 1998 was the beginning: putting up a website or paying someone a lot of money to put up the website didn't change the game. However, everyone accepting that they were going to use the Internet over the period of a decade did change the world.
The healthcare industry accepting that we are going to use EMRs and President-Elect Obama affirming this direction will change the world. Here are 10 reasons why it hasn't changed yet. If you're glass is half-full, here are 10 things that will change in the next decade:
1. Can't Get Information Out. We've spent way too much time thinking about how we are going to get all that paper in the healthcare world into the EMR. We need to spend more time figuring out how we're going to get the information out in a cogent, actionable manner for the many clinicians that want to use it. We can't surf EMRs the way we surf the web. We need better data aggregation, handoff reports from one provider to the next, and a standard way of looking at a lifetime record.
2. Computers Don't Change People. An EMR does not in and of itself develop better communication between members of a care team. It gives them access to the same information, but it doesn't answer questions about what clinical processes and roles and responsibilities should be in a hospital. Even after an EMR, there will be clinical lapses: missed meds, empty handoffs, etc. Even worse, just like the e-mail age, the EMR will facilitate people talking less to one another (as an unintended consequence).
3. Not Enough Patient Participation. We can't type all of this stuff ourselves. We need more help from patients (who usually are pretty knowledgeable) to contribute to the information that we are collecting. Not all patients can type but a lot more have questions and are accustomed to using their PCs to live their lives. It's time that we tap into that potential in a responsible way and start interacting with our patients over the web channel.
4. The Data is Ugly. Anything that isn't billing data in the healthcare industry is ugly. There are inadequate nomenclature and data standards that are applied to content across all medical specialties. My apologies to the hard workings souls that are tackling these beasts across the industry (we need you), but we're not close enough yet. On top of that, even if we standardize the nomenclature, any 10 of my doctors will document the same clinical characteristic in 10 different locations in our EMR.
5. We Don't Know How To Drive. Our little auto industry (EMR industry) still doesn't build cars that look the same, and most of our drivers (doctors, nurses, etc.) have never seen a car before. The net effect of this is that many of our drivers drive in second gear all day, or take 3 right turns instead of taking a left turn. Vendors need to get more intuitive user interfaces, and healthcare organizations need to get better at driver ed.
6. It Doesn't Know Me & Can't Listen. If I'm a doctor that sees patients, my EMR better know who I am when I walk up to the terminal (through proximity badge or some other technology) and better listen to what I have to say (voice recognition or similar technology). Typing takes too long, and we need more innovative user technologies (the real killer Internet app for consumers is integration with your cell.phone ---what will be the killer app for users in the EMR space?)
7. They Don't Help You Drive Clinical Quality - Theoretically, if all of your patient information is in there, you should be able to figure out how well you perform certain interventions or how effective are your outcomes. However, EMRs place their current emphasis on getting stuff into the system: the goal is to be able to write any order the patient might need. The functionality is not developed to help you write the correct order for the patient. Lots of industry lip service to this goal, we need more technical innovation.
8. It's too expensive. Yes, I said it. Hospitals have very tight margins, and doing the right thing by EMR investments is just plain too expensive. Now I know that I probably could improve my cost management skills, but the stuff costs too much upfront, takes too many people to configure in the first place, and entirely too many people to take care of the system after the fact. Most healthcare IT shops are staffed liked they were developing the software themselves, not like they are managing a packaged application. Something has got to give sooner rather than later.
9. We need new staff. From what I can tell, to really use an EMR appropriately, you need a lot more nurses, pharmacists, and physicians to help with system development and support in the IT department. Last time I checked, these people were hard enough to come by, let alone be hired away by an IT organization or vendor. We need a new breed of healthcare IT worker that can be trained with the appropriate, relevant technical and clinical information to support a CPOE system without being a doctor.
10. EMRs don't make money. There is no positive correlation between using an EMR and profitability. That's because they are not intended to make your hospital more money. You can't spend this kind of money in healthcare and not get a dollar for it. An EMR won't allow you to have fewer nurses or doctors per patient. A payer doesn't pay you more for using an EMR (yet). They do pay you for managing your patients better and accurately capturing all of the services you provided them. It would be nice if the system did this for you (some systems do this some of the time - all the time would be nice).
11. Clinical Research. It's almost assumed that if you put this much patient care information in one place that you should be able to naturally and easily perform analytics against it. In our industry, incentives are not aligned for this purpose. In the banking, airline or manufacturing business, these analytics were lifeblood for competitive advantage. In the healthcare industry, research organizations (except at research universities) have been separate and are not used to this large availability of data. That world is just beginning to change, and normalizing this data and making it available as large datasets to researchers is not an easy process. Hopefully, soon this will change.
Unlike the Internet, there has not been a critical mass of investment in this sector to drive the innovation to revolutionize the EMR space. It remains to be seen if this innovation will come from Epic, Siemens, GE, McKesson, Meditech, etc. or from some other source. Signs point to this investment changing, but as of today, I contend the EMR is overrated. I installed my EMR, and life feels the same. However, I can see some things changing down the road....
