The Electronic Health Record and The Golden Spike
By Frank D. Byrne, MD
On May 10, 1869, at a ceremony in Utah, Leland Stanford drove the final spike to join the first transcontinental railroad across the US. Considered one of the great technological feats of the 19th century, the railroad would become a revolutionary transportation network that changed the young country.
For the past few years, the healthcare industry and the patients in its care have experienced a similar “Golden Spike Era” through the deployment of the electronic health record (EHR). Others have used this analogy, including author Robert Wachter, MD at a recent excellent presentation at the American College of Healthcare Executives 2016 Congress on Healthcare Leadership.
Why is this comparison relevant? While the Utah ceremony marked the completion of a transcontinental railroad, it did not actually mark the completion of a seamless coast-to-coast rail network. Key gaps remained and a true coast-to-coast rail link was not achieved until more than a year later and required ongoing further improvements.
Similarly, while a recent study indicated that 96 percent of hospitals possessed a certified EHR technology and 84 percent had adopted at least a basic EHR system in 2015, there is still much more needed to achieve optimized deployment of the EHR to make healthcare better, safer, more efficient, and to improve the health of our communities.
Nonetheless, the EHR is one of the major advances in healthcare in my professional lifetime. It is an essential tool in progress toward the Institute for Healthcare Improvement’s “Triple Aim for Healthcare”– better patient experience, lower per-capita cost, and improved population health. We cannot achieve those laudable goals without mining and analyzing the data imbedded in the EHR to generate useful information to guide our actions. Advances in data science are enabling the development of meaningful predictive analytics, clinical decision support, and other tools that will advance quality, safety, and efficiency.
But there is much work to do. Christine Sinsky, MD, vice president of professional satisfaction for the American Medical Association, and others have written with concern about dissatisfied physicians, nurses, and other clinicians who feel the EHR is distracting them from patients care and meaningful interactions with their patients.
“Contemporary medical records are used for purposes that extend beyond supporting patient and caregiver … the primary purpose, i.e. the support of cognition and thoughtful, concise communication, has been crowded out,” Sinsky and co-author Stephen Martin, MD note in a recent article.
Perhaps you’ve also seen the sobering drawing by a seven-year-old girl depicting a doctor focused on the computer screen with his back to her, his patient.
Some of the EHR’s shortcomings may be the result of lack of end user input prior to implementation, possibly due to the implementing organization not incorporating the extensive research gathered by the EHR providers. Further, even if one gets end-user input prior to implementation, there’s always challenges prior to go-live, and it seems to me that optimization after implementation has been under-resourced. And let’s not look at temporary ”fixes” as the best and final answer. I was dismayed recently to see “hiring medical scribes” listed as one of the top 10 best practices in a recent Modern Healthcare poll.
Don’t get me wrong, to have a long game, you must have a successful plan to get through today, and if hiring scribes can mitigate physician dissatisfaction until the systems are improved, so be it. But scribes are a temporary work-around, not a system solution.
As an advisor to an early-stage venture capital fund, I’ve enjoyed listening to many interesting and inspiring pitches for new technology solutions. Initially, my algorithm used to rate these ideas was:
- Is it a novel idea?
- Will enough people or organizations pay for it?
- Do they have the right customer?
- Do they have the right revenue model?
Thanks to the input of physicians, nurses, therapists, and other clinicians, and the work of Dr. Sinsky and others, I quickly added a fifth, very important vital sign: Will it make the lives of those providing care better? Similarly, author, speaker and investor Dave Chase added a fourth element to the Triple Aim, caregiver experience, making it the Quadruple Aim.
When I was in training, we carried the “Washington Manual” and “Sanford’s Antimicrobial Guide” in the pockets of our white coats as references and thought we had most of the resources we needed to provide exceptional care. Now, caregivers suffer from information overload of both clinical data and academic knowledge. Some query Google right in front of their patients to find answers.
In healthcare today, we work within a community of diverse skills and backgrounds, including clinicians, non-clinicians, computer scientists, EHR providers, administrators, and others. To achieve our goal of improving health and healthcare for individuals and communities, we must work together to organize, structure, mine, and present the massive amounts of data accumulated in the EHR. To me, the concept of population health is meaningless unless you are improving health and outcomes for my family, my friends and me. Just as the placement of “The Golden Spike” was only the beginning of railroad transportation becoming a transformational force in American life, the fact that 96 percent of U.S. hospitals possess a certified EHR is just the beginning.
I have been accused of being a relentless optimist, but I firmly believe we can use the EHR to improve the caregiver and patient experience (I believe patients will and should have access to their entire medical record, for example), and fulfill the other necessary functions that Sinsky and Martin describe as distractions from the medical records’ primary purpose: “quality evaluations, practitioner monitoring, billing justification, audit defense, disability determinations, health insurance risk assessments, legal actions, and research.”
Lastly, there is one more similarity to “The Golden Spike.” In 1904 a new railroad route was built bypassing the Utah track segment that included that historic spot. It shortened the distance traveled by 43 miles and avoided curves and grades, rendering the segment obsolete. Already, many EHR tools, applications and companies have come and gone. Many of the tools we use now remain rudimentary compared with what we really need. We must use what we have to learn and continuously improve, and frankly, we need to pick up the pace. The patients, families and communities depending on us deserve no less.
Frank D. Byrne, MD is the former president of St. Mary’s Hospital and Parkview Hospital and a senior executive advisor to HealthX Ventures.