EHR Initiative - Is it a Monkey on the Back

In an interesting post by Evan Steele in his EMR Straight Talk blog: "Government EHR Teetering on the Backs of Physicians" talked about the recent HIT Policy committee response to the CMS proposed Meaningful Use regulations and the disconnect between the regulatory requirements and the practicalities of introducing these technologies into the complex clinical environment.

All this was nicely summarized in this graphic

As Evan points out

The government continues to ignore the fundamental problem that has discouraged EHR adoption in the past, particularly for high-volume, community-based specialists—and that is the EHR products themselves. The government has created an unstable program, basing it on unproven, difficult-to-use, traditional EHRs, and then has imposed additional layers of complexity on top of these products.

Demanding direct data entry by the provider into a Computerized Physician Order Entry System (CPOE) is a sure fire way to limit adoption. Did we learn nothing from the Cedars-Sinai failed CPOE implementation back in 2003

Cedars-Sinai failed despite having a very strong track record and deep experience in informatics, strong leadership, and substantial resources. There were several reasons for this failure: many decision-support mechanisms were introduced at the outset, especially for drug-drug interactions; with the way the application was set up, alerts could not be overridden; and it was hard to achieve buy-in from the very large number of providers using the system (Ornstein C. Hospital heeds doctors, suspends use of software: Cedars-Sinai physicians entered prescriptions and other orders in it, but called it unsafe. Los Angeles Times, January 22, 2003: B1)

So despite deep experience they failed and had to suspend use of the system. Meanwhile we see the government meaningful use objectives mandate CPOE from the start. The impact on physicians is likely to be negative and the impact on the vendors and their products will likely create more challenges:

First, EHR vendors will have to rush to modify their products to meet HHS certification requirements, resulting in even more cumbersome EHR products. Then, over the next five years, they will have to constantly hustle to keep up with the continuously evolving meaningful use criteria, as well as implementing the Y2K-like conversion from ICD-9 to ICD-10. In the technology world, rushing development efforts to meet unrealistically aggressive timeframes typically results in unusable and clumsy software. Unfortunately for physicians, the government will expect them to use these more complex EHRs to meet onerous meaningful use requirements that become increasingly stringent from 2011 to 2013 and 2015.

Building on existing processes and systems and in particular clinical practice that collects information as a natural part of the clinical interaction with patients would seem to be a much more constructive approach that would garner support all round. The narrative has been the mainstay of clinical practice and to date the most efficient way of capturing that narrative has been dictation. Facilitating and including the narrative dictation and building on it to satisfy the data needs of EHR's and even CPOE systems is the bridge between these two opposing views and the Healthstory Initiative creates an open and widely accepted infrastructure of standardized implementation guides for the common note types. The project members have been submitting commentary on the Meaningful use specifications and continue to push for the inclusion of narrative in the specifications.

EHR's should be in our future but on terms we can accept and will work in the complex and demanding clinical environment - that requires inclusion of narrative in meaningful use and sensible standards that focus on flexibility and adaptability of technology to meet the needs of clinicians.