A recent post in the Wall Street Journal Health Blog noted that a study found electronic medical records don't improve outpatient quality. The authors of the Archives of Internal Medicine article, Electronic Health Records and Clinical Decision Support Systems, correctly points out that we should be skeptical and "doubt [the] argument that the use of EHRs is a "magic bullet" for health care quality improvement, as some advocates imply."This should surprise no one. Were we that naive to think that simply installing health information technology (HIT) in the medical field would generate significant improvement in outcomes? Does simply installing computers in our classrooms improve educational test scores?
Of course not.
The excellent commentary after the article makes some plausible reasons why the clinical decision support (CDS) didn't seem to improve outcomes on 20 quality indicators. First, it isn't clear that the CDS implemented across the various doctors' offices and emergency rooms actually addressed the indicators studied. Second, the data studied is already dated (from the 2005 to 2007 National Ambulatory Medical Care Survey), a long time in technology terms (iPhone first debuted in 2007). The authors of the original article also point out that there is some evidence that institution specific use of CDS actually improves quality. Whether this can be scaled to the national level is the question.
In other words, it isn't just that perhaps CDS failed, but rather the robustness of the system was inadequate, that doctors failed to use them, or just as importantly patients were unswayed by the doctors reminded by the CDS to do the right thing. One of the 20 quality indicators studied was in fact the appropriate antibiotic use in viral upper respiratory infections. As most people know already, there is not typically an appropriate antibiotic to use for a virus. It's a virus. It does, however, take good bedside manner to inform and educate an ill patient!
As someone who has had the benefit of a robust electronic health record since the spring of 2006, I know I'm incredibly lucky. In an April 2009 New England Journal of Medicine article, only 4 percent of doctors nationally have a fully comprehensive EHR that I take for granted daily. Only 1.5 percent of hospitals have a comprehensive EHR, which I also have access to. CDS is also an incredibly helpful tool and an excellent reminder to provide the right care every time. It is a safety net. Understandably some EHRs aren't that good, the CDS is clunky, and certainly the one I use is good, but not perfect.
The real issue isn't finding a perfect EHR, but rather how do we address the culture of the medical profession. There is something still heroic and mystical about a lone doctor, independent, smart, and getting the job done. Indeed, to get into medical school, one has to be self-motivated, persistent, and determined. Why on earth would we need a computer to help us?
Frankly, because it makes us better doctors. CDS frees up time and mental energy. I don't have to remember the latest guidelines on immunizations, repeating blood work, or treatment of illness like coronary artery disease, congestive heart failure, and hyperlipidemia. Most of these diseases are well understood and often under a protocol, something known as precision medicine, a term used by Harvard Business School professor Clayton Christensen.
Now I can focus on if the patient in front of me is an exception to the protocol as well as thoughtfully diagnose and treat their ailments which don't fit any protocol (cognitive medicine) because science hasn't evolved to that level of understanding. I'm a big believer in the history and physical exam and how the use of HIT can make care more personal. Having real-time access quickly and reliably to medical information and data 24/7 is important to make this happen. Instead of hunting for lab work in a paper chart or trying to find a specialist's consultation, I can access the information I need rapidly and focus on the patient in front of me.
Sadly, however, many doctors don't feel the same way. Perhaps it is a generational thing. Perhaps it is because their EHR is inadequate. It might also be, however, our training and tradition which limits us from improving. If anything, the medical profession needs to emulate ourselves after the aviation industry where technology is used to support decision making and make pilots and flying even safer and better. We are where our aviation colleagues were in 1935 as noted in Dr. Atul Gawande's New Yorker piece, the Checklist. Because, really, CDS is essentially a checklist.
In the situation where a patient doesn't fit CDS, then we get to do what we do best and that is use all of our training to get a patient better. HIT, EHR, and CDS are things the next generation of doctors must accept that will make the care we provide more personal than ever before. In the end, that is what patients really want.
This is why I love my EHR so much.
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