On the Other Side of the Quality Chasm
The acceleration of the movement toward electronic health record (EHR) implementation and adoption begun by the Institute of Medicine reports of the late 1990s and fueled by the American Reinvestment and Recovery Act of 2009 has propelled us away from the paper environment at a rate that would undoubtedly not have been present in their absence. It is now possible to conceive of a time when the majority of our healthcare institutions and professionals function entirely in an electronic environment.
Now that the other side of the quality chasm is in sight, it is worthwhile to consider what it may be like when we land there, and prepare for a vastly different environment.
A significant body of evidence has been building over the last decade reflecting medical errors that may occur because of electronic medical records. Examples include default acceptance of all orders in an order set when some may not be applicable to a specific patient, or an inaccurate weight entered manually for a newborn but used to automatically calculate medication doses. Any implementation should include attention to proactively averting such errors by responsible quality control processes.
The practice of medicine in real time and enhanced capabilities for granular auditing bring the considerable exposure to medical liability to the forefront. Standards of expectation should be established for reasonable response times to alerts, e-mails and data generated and delivered in real time. Clear policies, consistent with state law, should be established to define exactly what compromises a legal electronic medical record, what information must be produced in the event of litigation, and consideration of consistency in patient care considerations in implementing new features and functions. (Is a different level of care being delivered to a subsection of patients within a hospital if a new feature or function goes live on one service and not another?)
It will be very long time before most hospitals and practices cease to work in a part paper, part electronic environment, but the common goal is to eliminate as much paper as possible. It is therefore highly probable, if not certain, that a generation of clinicians will eventually evolve who have never worked on paper.
It is also certain that hospitals and practices will experience both planned and unplanned system down time. Downtime policies specify circumstances where documentation and order entry must revert to paper, but do not generally address the possibility that clinicians may not know how to work on paper. As part of disaster planning and down time policy determination, policies should be in place for clinicians to be trained at regular intervals in the use of order forms, progress notes, history and physical notes, medical administration forms, etc. that may be called to use in a disaster environment or system down time. After a few years using fully implemented EHRs, they may simply not know how to use paper.
Similarly, ward clerks, pharmacists, lab technicians, and other support personnel must know how to carry out their responsibilities on paper, and must periodically be retrained.
Paradoxically, we may have to be certifying people to work on paper in the future.
Several years ago, I began to consider the vulnerability of our massively growing medical databases. Even though security measures, redundancy, and backup processes are in place, much of the firewall technology is "off the shelf," which simply means to me that someone sitting in a distant country can find a way through it. Most hospital security and background checks on IT personnel consist of credit reports and other forms of superficial investigation, but are rarely in-depth security evaluations.
In spite of painful mass casualty attacks and natural disasters that we have experienced (the Oklahoma bombing, September 11, Hurricane Katrina), our emergency rooms remain woefully unprepared to handle a massive number of injured people or able to sustain care for a large population of injured individuals for anything other than a very short time. If one considers the potential chaos that could ensue from a combined mass casualty episode combined with an intentional attack on the same regions’ medical databases, the importance of this consideration becomes obvious. Organizations such as HITRUST are bringing the importance of protecting our databases to light. As we move further toward the universal use of EHRs, hospitals and database specialists will need to devote more time, energy and money to protecting our healthcare databases.
I have recently been an active participant in the debate over physician-patient communication by e-mail. The greater issue goes far beyond this particular debate. While the mechanics of physician-patient interactions may be brought into the 21st century by reduction to the 1s and 0s of the binary world, the art of medicine cannot be.
If one has ever engaged in online dating, cyber political debate, or an e-mail argument, they will appreciate that much is lost in the absence of face-to-face interaction. Things are said that would never be said when an immediate reaction can be anticipated with someone who is physically present in real time and not in an untouchable, invisible virtual space. In an electronic environment, as much attention needs to be paid to taking care of the emotions and reactions of patients as is paid to the convenience of the communication vehicle in use. This lesson must not be lost for the upcoming generation of texting / Facebooking / Twittering clinicians. Those of us with grey hair have a teaching responsibility in this arena
Let’s not cross a quality chasm and create an empathy chasm.
Samuel R. Bierstock, MD, BSEE is the founder and president of Champions in Healthcare, LLC, a strategic consulting firm specializing in clinical information system implementation and healthcare IT business strategies.