Thinking Out Loud: Electronic Health Records

By Chuck Dinerstein, MD, MBA — May 21, 2024
Electronic Health Records (EHRs) were once hailed as the solution to streamlining healthcare processes, but their implementation has brought forth a host of challenges. From increased work burden and clinician burnout to facilitated medical errors, the journey of EHRs has been tumultuous. With billions of dollars invested and a staggering increase in adoption rates, we find ourselves retrofitting the system. But this isn't just about optimizing technology; it's about preserving the heart of healthcare.
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“The implementation of EHR technology may be the root cause of some of these issues, [increased work burden, negative clinician emotions, burnout, and facilitated medical errors] beginning with developers designing a product based upon an organizational strategic vision, which routinely desires regulation compliance, billing productivity, and organizational growth.”

Now, after 15 years, $27 billion in “incentives,” and an 11-fold increase in electronic health record (EHR) implementations, we are left to fix “the plane as it continues to fly.” A new study looks at how one health system tried to optimize their EHR usability. In conjunction with the health systems IT group, a family medicine department created teams to look at daily workflow, including care coordination, communications, reception, medication, notes, nursing, order and referrals, and revenue. The study looks at what changes were made and how the metrics improved.

Those metrics tell the entire story. The included

“Monthly departmental measurements of productivity (number of departmental visits, charges, and payments).”

While the researchers' concerns do include increased work burden, which can be measured by productivity, none of these measures, all of which serve revenue, address burnout, negative clinical emotions or facilitated medical error. The problem with EHRs, primarily billing algorithms with a side effect of documentation, remains a feature, not a bug.

Changes included:

  • 34% were accommodations – workflow adjustments made to human workflows for the EHR’s design
  • 10% were creations – new workflows added by IT
  • 43% were discovery – workflows already present but previously unknown to the department
  • 11% were modifications – workflow adjustments made to the EHR for human needs

The workgroups made three times as many changes to how healthcare workers did their work to meet the needs of the EHR than to how the EHR worked to meet human needs. As the researcher conclude

“Sadly, the second largest proportion of optimizations (35%) were accommodations by the department adjusting workflow issues outside of the EHR. … Accepting the limitations within the EHR and working around them …”

As to the changes the EHR has made to human behavior,

“The IT-remedied interventions [Modifications] were surprisingly few in number …changes were predominately compiling department-specific order entry preference lists (i.e., medications … and orders) based on the most utilized departmental options … [ameliorating] the fundamental issue of clinicians having an overabundance of options, which resulted in orders being abandoned.”

It makes you wonder who the tool is.

The other significant change was in the discovery of workflow that was already present and previously unknown to the system users. The researchers described this as a “disconnect,”  a “well-established problem” that continually occurs. The value of the EHR as a new tool comes from its full implementation. That this is a “well-established problem” speaks to the failure of the companies feeding from that $27 billion to provide a usable product.

But all is not lost; all three revenue-related outcomes, visits, charges, and payments ultimately increased. The fundamental role of the EHR, a documentation and billing system, remains undeterred.

I would like to mention my conflict of interest in these issues. I was part of the workgroups attempting to implement an EHR in my hospital. None of these user issues were unknown at the time, now well over a decade ago. It is dispiriting but unsurprising that they remain uncorrected. The headlong rush to AI is another chapter in this IT transformation of health care. Silicon Valley is known for “Move fast and break things,” that is what it has done to health care in implementing EHRs. It is what they are doing now as they rush AI into any number of interfaces between physicians, nurses, and patients. It is breaking the canaries in the healthcare mines, so burnout has increasingly become a concern for physicians and nurses. The IT companies that, in conjunction with the government, have imposed these ill-designed, poorly implemented systems upon us need to be held accountable. Unfortunately, like Boeing, they are too influential to fail.


Source: Optimization of Electronic Health Record Usability Through a Department-Led Quality Improvement Process Annals of Family Medicine DOI: 0.1370/afm.3073


Chuck Dinerstein, MD, MBA

Director of Medicine

Dr. Charles Dinerstein, M.D., MBA, FACS is Director of Medicine at the American Council on Science and Health. He has over 25 years of experience as a vascular surgeon.

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