“The practice of medicine is an art based on science” – Sir William Osler
This was famously stated over 100 years ago by Dr. Osler, the father of modern medicine and the physician who laid the foundation for professionalism in healthcare. In this vein, a panel of experts from Boston-area hospitals and elsewhere recently convened to attack the question “What needs to change to get doctors back to the patients?” While the primary theme was identification of the obstacles preventing physicians in the 21st century from reaching the bedside, the undertone was undoubtedly built around the evolving utilization of health information technology, digital health, and clarifying health systems’ functionality.
If you attended, then I hope you gleaned some valuable insights into how health IT can transform our practices and the overall quality of healthcare while simultaneously uncoupling physicians from the burden of navigating the evolving health IT environment. In this two part series, I’ll explore some of the themes presented and look towards the challenges to be overcome as well as some proposed solutions.
We now have EHRs, but have our care processes – with respect to documentation – actually changed relative to the paper era?
Dr. Steven Stack, past president of the American Medical Association (AMA), commented on the migration to electronic health records (EHRs) and its effect on documentation. From templates and macros to the ability to go on epic dialogues within charts, a substantial number of clinicians, including those in training as I have witnessed, treat documenting in the EHR as a clean, white notepad upon which anything and everything can be written. Has this created fewer meaningful words and impaired our abilities to effectively care for patients? Although there’s no evidence to support this, the anecdotes from the panelists certainly speak to the palpable reality. Furthermore, the complexity of documentation that exists within some EHRs exponentially increases the time clinicians must spend at the computer, easily impeding their ability to spend time at their patients’ bedside.
So, what is the next evolutionary step? Dr. John Halamka, CIO of Beth Israel Deaconess Medical Center and co-chair of the National HIT Standards Committee, coined a term I strongly favor: clinical relevance. As our system evolves toward integrated care management, clinical documentation may transform into a more purposefully-designed tool that constructively contributes to the overall care of the patient. Clinical relevance – whether it be about the actions to be taken for the diabetic patient with rising blood glucose or the recently discharged heart failure patient whose home-monitoring alerts are approaching the red zone for weight gain – may prevail in the next phase of documentation design. This would counter the current methods of documentation, which are integrally organized into the reimbursement system, and that has an unclear impact on the quality of care.
Specific solutions might include collaborative note structures wherein multiple providers contribute to a note that intelligently structures quality metrics and disease templates. In turn, clinicians may be able to untie themselves from some of the elements of documentation and data filtering, allowing them to return to the bedside. Certainly, the ICD-10 challenges that providers will soon face, regardless of delay, may further shift the balance in clinically relevant documentation by providing one more hurdle for physicians to clear, aside from relevant care. Yet, such a transformation in clinical documentation would mean overhauling how we approach care entirely—is healthcare ready for this? Maybe what matters most is improving our ability to understand the data we currently feed into our EHRs.
The data is there, but how do we transform it into wisdom?
Healthcare data is growing at a remarkably rapid pace and multiple panel members supported this with anecdotes from their own institutions. One of our greatest challenges is now clarifying that data and using it in meaningful, real-time manners. As Dr. Halamka put it, “we are already overwhelmed with data, what we need is information, knowledge and wisdom.” The pronounced physician dissatisfaction with the EHR, based on a study from the AMA/Rand Corporation, should be weighted considerably when approaching the design and impact of health IT solutions to bring us this wisdom. The appropriate visualization of data is crucial to effective patient care in every setting. Communication is based on data and when that information is challenging to find or requires active searching, it leads to errors and has an adverse effect on care. Tools that improve our awareness and analysis of available data within the EHR at the point of care will undoubtedly improve our efficiency of the system. Though not elaborated on in the panel, areas such as predictive analytics and real-time data visualization need to be further explored to provide use cases and solutions.
Is it possible that once regulatory pressures ease in late 2014 that our field may finally have the breathing room to devote time and energy towards innovative health IT solutions, and, in turn, help us see the petabytes of data in a meaningful form? It may be, and examples such as the adoption of Google Glass in the Beth Israel Emergency Department demonstrate the resolve of health IT leaders to push forward with innovative agendas. With practicing clinicians pushing the envelope in the application of technology-driven solutions to the most pressing problems, such as those discussed by the panelists, we should start to see words put into action. Industry and academic leaders who creatively brainstorm interventions will serve as the futurists who are transforming our care.