Thursday, March 14, 2013

JAMA: "Improving the Electronic Health Record—Are Clinicians Getting What They Wished For?" - No, But Utopia Arrives Soon

At a new JAMA piece "Improving the Electronic Health Record—Are Clinicians Getting What They Wished For?", former Columbia U. and now NIH medical informaticist James J. Cimino, MD points out issues with the documentation that results from health IT systems.

A preview of the first page of this short Viewpoint piece is available free at this link.  It includes the observation that:

... There is no question that computerization has made patients’ records more available and legible. With respect to completeness, however, there are now complaints that the record is too complete: electronic notes are deemed by many clinicians as being full of extraneous details and obscuring important aspects of a patient’s condition

Dr. Cimino goes on to state that:

Empirical observational studies of clinicians have shown ways to improve EHR functionality ... Similar research on clinical documentation processes is needed to advance this crucial EHR component.

These are excellent observations.

The issue I have with the piece is - and I am finding this true of many articles critical of today's health IT - the ending, which I'm finding to often be PR.  Or, perhaps it would be more accurate to call the endings of late a "salvage operation-style" attempt to save face for the informatics community, who let this domain be overrun by the corporate IT sector and terrible products that violate many of the precepts of design of good health IT learned during five decades of research.

Cimino concludes an otherwise constructive piece with this statement:

... Rather than complain about the challenges [a euphemism if ever I saw one - ed.] they have introduced, clinicians should recognize that current EHRs are illuminating the opportunities for the next generation of systems that will support clinicians as active partners across the spectrum of health care settings and tasks. The resulting improvements in documentation will, in turn, support patients, administrators, and researchers as we move towards a true learning health system.

I note this assertion is at complete odds with the dictum I was taught from my earliest medical mentors, and that no amount of wishful thinking will banish:

"Critical thinking always, or your patient's dead." (Cardiothoracic surgery pioneer Victor P. Satinsly, M.D., Hahnemann Medical College, Philadelphia, early 1970s.)

Translating the statement into plainer English, it seems to me that Cimino is saying this:

"Doctors, shut up, stop complaining about the chaos and patient/professional risk today's bad health IT is causing, take the medicine your betters have prescribed for you, and don't be uncompromising patient advocates as patients are secondary in this quest to reach IT-based Healthcare Utopia - which we will reach come version 2.0."

(This comes, ironically, at a time when physicians are starting to get a voice, e.g., Twitter's #EHRbacklash.)

It appears articles with even a faint tinge of anti-health IT sentiment - in addition to the traditional methods, results, limitations etc. sections - have an "appeasement" section as well.  Perhaps this it what it takes to get past peer review and/or industry ire.

In my view, this salvage mentality sprinkled with euphemisms and Utopian rhetoric spoils an otherwise constructive piece.  This type of language and utopian predictions about HIT have also appeared in other major medical publications by informatics and healthcare leaders (including top governmental office holders), as for example here.

Now, I know Jim Cimino and he is a good scientist.  However, I truly wish the non-scientific, "wait for version 2.0", utopian P.R. would stopAs a member of the Medical Informatics profession myself, it's actually become embarrassing.

-- SS


Anonymous said...

Records may not be more available as he states:

The unavailability is unknown, actually.

The word "challenges" ought to be replaced with "impediments to safe care".

Without a robust search function, the list of "positives" he lists are ho humm features. I have yet to find a CDS pop-up that provided any useful support, but they all waste time.

The new transition of care documents are particularly onerous.

Overall, these are medical devices that have been sold without accountability, integrity, or transparency for safety.

Quite an experiment, and Cimino wants doctors to shut up. Hello???

Afraid said...

Maybe the editors put in the PR as a hat tip to their supporters and advertisers.

Unknown said...

I am certainly not asking doctors to "shut up" - this was meant as a call for additional informatics research - now that we have what we wished for (at least, what we told the vendors we wanted), we can better articulate what we really need. There was a lot more I could have said, but not in 1200 words. For example, I had to drop my horseless-carriage analogy.

Regarding availability of records, my own observations are that no electronic records .1% of the time is better than no paper record 50% of the time. But that is just anecdotal. Your performance may vary.

--Jim Cimino