Wednesday, July 24, 2013

Electronic siloing: An unintended consequence of the electronic health record - Cleveland Clinic Journal of Medicine

EHR systems have largely been designed by those of a manufacturing, mercantile, and management computing background, largely due to abdication of responsibility and acquiescence by medical professionals, and political impotence of organized medicine and medical informatics organizations.

The results were predictable - a toxic effect on healthcare.  One such toxic effect is an impairment of essential communications between caregiving personnel - exactly the opposite effect the hundreds of billions of dollars spent on today's health IT was intended to improve.

From the Cleveland Clinic Journal of Medicine:

Electronic siloing: An unintended consequence of the electronic health record
July 2013
Chair, Education Institute; Staff, Department of Pulmonary, Allergy, and Critical Care Medicine, Cleveland Clinic; Jean Wall Bennett Professor of Medicine, Cleveland Clinic Lerner College of Medicine, Cleveland, OH

For all the purported benefits of the electronic health record (EHR), an unintended adverse effect is “electronic siloing.”

I define electronic siloing as the isolating effect of the EHR on clinical workflow that drives caregivers to work in silos, ie, alone at their workstations, thereby discouraging spontaneous interaction. To the extent that increasing evidence supports the importance of interaction among clinical colleagues and of teamwork to optimize clinical outcomes, electronic siloing threatens optimal practice and quality.

Not only does it "threaten" optimal quality, it causes that quality to deteriorate to the point where a recent volunteer study at 36 hospitals by the renowned ECRI Institute ( found more than 170 health IT-related mishaps in a mere 9 weeks, 8 of those incidents resulting in patient harm and 3 possibly contributory towards patient death.

... THE EHR BRINGS CHANGES, GOOD AND BAD [the latter especially from bad health IT - ed.]

The EHR represents a major change in health care, with reported benefits that include standardized ordering, reduced medical errors, embedded protocols for guideline-based care, data access to analyze clinical practice patterns and outcomes, and enhanced communication among colleagues who are geographically separated (eg, virtual consults). On the basis of these benefits and the federal Medicare and Medicaid financial incentives associated with “meaningful use,” the EHR is being increasingly adopted.

The literature supporting those benefits is scarce, of poor quality, and refuted by other literature by credible authors - not the optimal environment to justify spending hundreds of billions of dollars (e.g., see

Yet for all these benefits and the promise that technology can enhance interaction among health care providers, unintended risks of the EHR paradoxically threaten optimal clinical care.6Recognized risks include the threat to care should the EHR fail, the time and inefficiency costs of typing and multiple log-ons, and the perpetuation of errors in the medical record caused by the cutting and pasting of clinical notes.

To name just a few, all covered on this blog in various posts.

... Niazkhani et al noted that computerized ordering can change communication channels and collaboration mechanisms. More specifically, they point out that these systems can “replace interpersonal contacts that may result in fewer opportunities for team-wide negotiations."

This is, in fact, obvious to any practicing physician or nurse and requires no academic "proof."

Similarly, Ash et al cited the unintended consequences of patient care information systems, especially increased overreliance on the system to communicate, which can undermine direct communication between healthcare providers ... Taken together, these observations suggest that the EHR and computerized order entry in particular can disrupt interaction between physicians and other health care providers, such as nurses and pharmacists.

Similarly, that this needs to be stated in 2013 is akin to stating that it's a good idea to use sterile technique in surgery.

...  the EHR can inadvertently lessen spontaneous interaction between physicians as they care for outpatients. I have proposed the term electronic siloing to reflect the isolating impact of the EHR on clinical workflow that drives caregivers to work alone at their workstations, thereby discouraging spontaneous interaction between colleagues (eg, between primary care physicians and subspecialists, and between subspecialists in different disciplines). Because spontaneous face-to-face encounters and conversations among clinicians can encourage clinical insights that benefit patient care, electronic siloing can undermine optimal care. My thesis here is that the EHR predisposes to electronic siloing and that the solution is to first recognize and then to design care to prevent this effect.

The solution is first to force the industry and its pundits to admit the problem is poor design and hyper-enthusiasm that resulted in a premature national program for health IT diffusion, and abandon claims that clinicians are "Luddites" (see "Doctors and EHRs: Reframing the 'Modernists v. Luddites' Canard to The Accurate 'Ardent Technophiles vs. Pragmatists' Reality" at

Defenders of the EHR will point out that the EHR does not preclude such face-to-face encounters.

"Defenders of the EHR" will frequently default to fictitious and often ad hominem "blame the user" canards, since their scientific rationale for the proliferation of today's very poor systems is very weak.

While technically this is correct, it is also equally true that such encounters are less likely because they no longer flow naturally from the workflow of writing a note side-by-side with colleagues with the films displayed nearby. Pressured for time, clinicians learn efficiency of motion and are simply less likely to leave their workstations to seek another colleague who, in turn, may be tethered to a workstation and absorbed in keyboarding and monitor-watching. The net effect is that such spontaneous face-to-face encounters are clearly less common in the EHR era.

Again, this thinking will be countered by the hyper-enthusiasts by blaming users.  My response is that good health IT never depends on users to compensate for poor design or implementation, and there's nothing else to debate on that point.

... So, given the many clear benefits of the EHR and its current wave of adoption in health care, how can we maximize the benefits of the EHR while minimizing the adverse effects of electronic siloing?

Reasonable suggestions follow; see the article at the link above. 

The problem is that the reasonable suggestions are being proffered in an unreasonable, industry-dominated environment.

The first step is political action and activism by clinicians to take charge of the clinical information technology playing field.  Until and unless that occurs, even thoughtful articles from Cleveland Clinic, Harvard, Yale etc. will simply be shelved.

-- SS

1 comment:

Anonymous said...

So not only is there the siloing of data rendering not immediately available without searching. The clinicians are working in silos, isolated from eachother, despite the proclamations that communication is enhanced by EHR systems.

Interesting charade.