By Dr. Chris Tonozzi, MD, Director of Data Quality
Mountain Family Health Centers did a major upgrade to our Electronic Health Record (EHR) system last month. We spent two half-days in training and slowed our schedules for two weeks so that we had time to adapt to the changes that the upgrade will bring. There are significant impacts that caused me to think of the overall impact of electronic health records on the practice of medicine.
EHRs were rapidly
adopted early this decade after President Obama’s 2009 stimulus package
included the HITECH act. This act incentivized the adoption of EHRs, first with
rewards, but with penalties after a period. $27 billion was spent on these
There was significant excitement around the potential for
EHRs to improve the quality, safety and efficiency of medicine. It seemed intuitive, as there are few modern
processes that haven’t been improved with computerization. But, we had no firm
evidence to this effect. Additionally, we knew that computerization would be
costly, but it was thought that the costs of implementation would be offset by
the efficiencies gained by the system over time.
Two additional significant concerns have developed since
2009. The first is that health care providers have had to do significantly more
work to complete their notes in the EHR. The second is that there have been
safety errors created by the EHRs.
It is felt that now, compared to the era of paper charts,
health care providers are increasingly relied on as data entry technicians, and
this contributes significantly to provider burnout. Besides turning the healing
profession into a data entry profession, the data entry can stand between the
patient and the health care provider. It is distracting during an office visit.
Providers may spend more time looking at their computer screens than at the
Safety concerns are becoming an increasing concern related to EHRs. Keep in mind that there were many errors that went unnoticed in the era of paper charts, but some EHR software is so prone to errors, there are cases where errors have gone unaddressed for significant periods of time. In the best-known case, a major EHR vendor (one of the top 5 in the nation) ultimately paid a $155 million settlement to the government related to a suit in which “code was so buggy that when one glitch got fixed, another would develop.”
In addition to being Mountain Family’s “Data Doctor,” I also have the job title of “Director of Data Quality.” What could be more central in managing Mountain Family’s data than a reliable EHR? Most health care providers will agree that EHRs are a necessary evil. Society is clearly going to increasingly computerized systems. So, our goals at Mountain Family have been to minimize the burden of the EHR and to improve the efficiency of the system whenever possible. Here are some of our efforts:
We make active efforts to make good use of the
data that is generated from the EHR. For example, most of our quality
improvement goals are based on data from the EHR, including our hypertension
control rates, our diabetes control rates and our tobacco cessation counseling
We regularly coach clinical staff on the
connection between their EHR data input and the desired quality outcomes. We
continue with a series of “Lunch and Learns” in which we review the outcomes,
and how to best document the care related to these outcomes in the EHR.
During the EHR upgrade this summer we’ve had a
team of very dedicated providers, nurses, medical assistants, office staff and
IT staff configuring, training and testing. The upgrade happened with a minimum
We make time for clinicians and other users to write
their notes and orders in the EHR. Our staffing patterns and clinic schedules
account for much of the time needed to document in the EHR.
We consider our EHR to be a “necessary evil” but we’re also optimistic that we can manage the risks; we also believe EHRs will evolve over time to be safer and more efficient. A futuristic outlook on the topic is provided in a new book by Eric Topol: “Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again.” It’s on my reading list!