Electronic Health Record (EHR) systems hold great promise. However, like many new technologies, the difficulty of achieving EHRs’ promise has been vastly underestimated, as have the risks. The current national initiatives pushing for widespread EHR implementation may be leading us into an unmapped minefield.Message for the thoughtful: The national mood on EHRs
In the course of its EHR function research and educational endeavors, my organization, Advocates for Documentation Integrity and Compliance
(ADIC), has demonstrated the necessity for due diligence when purchasing and using EHR systems, aggravated by the limited uptake of EHR standards and the low thresholds for current EHR certifi cation. In the course of our work, we have also provided responses to various national publications’ suggestions that clinician stubbornness, not rational market behavior, is the primary cause for the slow uptake of EHRs in the US. We have also provided referenced documentation refuting statements that EHRs necessarily improve care quality measurement or reduce medical legal risk as based on unsound information. However, given the current national enthusiasm for an EHR silver bullet, suggesting a rational, critical, analytic approach to EHR uptake is like suggesting due diligence on dotcom companies pre-crash, like suggesting that relieving mortgage sellers from risk is a bad idea, or like suggesting that the puddle in a New Orleans yard is levee water leaking. These national enthusiasms, however well-meaning and sincere, blind us to readily apparent contrary information. America is enthralled with the future of EHRs and partying like its 2014, and we’re “mission accomplished” per President Bush’s 2004 EHR decree. In the hope that not everyone is at that party, ADIC welcomes each opportunity to speak to the thoughtful in hopes of lessening the effects of the looming EHR bust.The EAR party now underway
Dr. Don Simborg, co-founder of the standards development organization Health Level 7, presented on the subject of intra-Beltway “irrational exuberance” for EHRs at the Th ird Annual Leadership Summit on the Road to Interoperability, held in Boston the week of July 23rd. Following up on earlier published statements, he described in his keynote address “EHRs and the National Agenda: Changing the Focus” the current national policy as “EHR adoption regardless (aka EAR).” He then projected the coming EAR-ache that will result unless we change the message that any EHR is better than no EHR.2 By way of illustration, Simborg pointed to the Offi ce of the National Coordinator’s (ONC) failure to act on recommendations in an ONC-commissioned report he co-wrote, designed to avoid the EHR-caused increase in healthcare fraud predicted by an earlier ONCcommissioned report.Where the rubber (painfully) meets the road
The EAR-ache problem is acute and concrete. ADIC receives calls for information and for help from clinical facilities, payers, and the occasional conscientious EHR firm about repairing EHR systems that cannot meet basic requirements for assuring medical–legal validity. Th e truth is that many EHR systems were not designed to meet the well-established requirements for valid, admissible legal records. Furthermore, we fi nd that EHR users rarely test to make sure their own institutional requirements for valid medical records are met. Very few purchasers and users of EHRs who have identifi ed gaps in their systems proceed to develop means of mitigation to support basic validity requirements.
The United States faces a vast and growing, but unmeasured, medical-legal risk cost due to EHRs’ likelihood of being impeached or otherwise determined to be unreliable when used to support a legal action, such as defense against allegations of malpractice, billing fraud, employment discrimination, or any of the host of legal cases in which medical records form an important body of information and evidence. However, because of the way the risk projection and the risk insurance marketplace work, until there are many actual losses, there is no way to estimate that risk. Even more troubling is that these same functional requirement gaps have corollary data quality implications insofar as the same integrity requirements are also protections against falsifi cation, misuse, or innocent errors in medical records. Minimizing these data quality, integrity, and reliability functions also risks making them less trustworthy as clinical records.
We have had a “coalmine canary” event thanks to one brave institution, which published its fi ndings about its own problematic EHR that was a signifi cant contributor to both a family’s distress and that institution’s loss.Why ROI?