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Commentary Author: Donna M. Zulman, MD, MS, Division of General Medical Disciplines, Stanford University School of Medicine Last Updated: Sep 7, 2017 - 10:06:33 PM

Evolutionary Pressures on the Electronic Health Record

By Donna M. Zulman, MD, MS, Division of General Medical Disciplines, Stanford University School of Medicine
Aug 15, 2016 - 2:40:05 PM

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( - Frances Peabody's timeless lecture to Harvard Medical School students, published in JAMA almost 90 years ago,1 spoke of the complex and deeply human experience of illness, as epitomized by the powerful observation "for the secret of the care of the patient is in caring for the patient."

Peabody emphasized how caring meant understanding for each patient how particular personal and emotional circumstances influenced his or her health. Today, clinicians encounter a level of complexity-co-occurring chronic and rare diseases, organ transplantation, artificial devices-that has completely altered the practice of medicine, while the personal experience of illness and the social context are as important as ever.

Escalating clinical complexity has increased the dependence on technology for diagnosis, illness monitoring, and treatment, and most physicians experience this dependence daily in interactions with the electronic health record (EHR). The EHR has many virtues: It supports arduous and time-intensive tasks such as order entry and medical history review, and most systems routinely alert clinicians if they prescribe medication combinations that might cause harm. These features and others have the potential to prevent medication errors and decrease duplicative tests, contributing to the safety and value of care.2

But the evolution of EHRs has not kept pace with technology widely used to track, synthesize, and visualize information in many other domains of modern life. While clinicians can calculate a patient's likelihood of future myocardial infarction, risk of osteoporotic fracture, and odds of developing certain cancers, most systems do not integrate these tools in a way that supports tailored treatment decisions based on an individual's unique characteristics. Similarly, some algorithms (many developed by insurers) can identify patients at high risk for hospitalization,3 but evidence lags when it comes to using predictive analytics to deliver preventive care and services to targeted individuals. Existing EHRs also have yet to seize one of the greatest opportunities of comprehensive record systems-learning from what happened to similar patients and summarizing that experience for the treating physician and the patient.4 For instance, when a 55-year-old woman of Asian heritage presents to her physician with asthma and new-onset moderate hypertension, it would be helpful for an EHR system to find a personalized cohort of patients (based on key similarities or by using population data weighted by specific patient characteristics) to suggest a course of action based on how those patients responded to certain antihypertensive medication classes, thus providing practice-based evidence when randomized trial evidence is lacking.

Bloated records, devoid of meaning and full of cut-and-paste content, are leading some to call for adopting a "less is more" strategy that prioritizes relevant information.5 For patients with multiple active health issues, EHRs can generate an overwhelming number of reminders, resulting in dangerous alert fatigue. Outside of health care, other sectors have found suitable solutions for this type of challenge: the airline industry limits pilots' audible alerts to critical and life-threatening events, and financial software enables users to set investment goals without inundating their inbox at every price fluctuation. Better triage of EHR alerts and fewer workflow interruptions are needed so the physician can maintain situational awareness without being distracted.

A clear mechanism for addressing information overload is through enhanced graphic representation. Advances in personal computing and the entertainment industry suggest immense possibilities for more thoughtful and valuable ways of depicting information. When caring for a patient with a prolonged illness, such as a cancer that requires many cycles of chemotherapy and radiation, a single graphic could capture the clinical course, illustrating physiologic changes corresponding to new medications or acute events. The ability to visualize a patient's clinical course in this manner could substantially improve physicians' ability to rapidly synthesize historical events, communicate information to patients and families, and guide clinical decisions.

Perhaps the most important shortcoming of the EHR is the absence of social and behavioral factors fundamental to a patient's treatment response and health outcomes. In this world of patient portals and electronic tablets, it should be possible to collect from individuals key information about their environment and unique stressors-at home or in the workplace-in the medical record. What is the story of the individual? The most sophisticated computerized algorithms, if limited to medical data, may underestimate a patient's risk (eg, through ignorance about neighborhood dangers contributing to sedentary behavior and poor nutrition) or recommend suboptimal treatment (eg, escalating asthma medications for symptoms triggered by second-hand smoke). Recognizing this void, the National Academy of Medicine has called for systematic integration of social determinants of health into the EHR.6 Advances in this area could provide clinical teams with information to more holistically approach patients' needs.

At present, the spectacular effects of computers in science and in the secular world are not reflected in the EHR, which for physicians remains burdensome, all-consuming, and far from intuitive; this is not surprising, when the dominant EHRs are designed for billing and not primarily for ease of use by those who provide care. In fact, a measure of successful EHR evolution may be that physicians spend much less time with the EHR than they do now. Deimplementing the EHR could actively enhance care in many clinical scenarios. Simply listening to the history and carefully examining the patient who presents with a focused concern is an important means of avoiding diagnostic error.7 Many phenotypic observations (the outline of a cigarette packet in a shirt pocket, or spotting neurofibroma, fasciculation, or rash) change the diagnostic algorithm and are easy to miss when work revolves around the computer and not the patient.

There is building resentment against the shackles of the present EHR; every additional click inflicts a nick on physicians' morale. Current records miss opportunities to harness available data and predictive analytics to individualize treatment. Meanwhile, sophisticated advances in technology are going untapped. Better medical record systems are needed that are dissociated from billing, intuitive and helpful, and allow physicians to be fully present with their patients.


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