Lisa Rosenbaum, M.D., N Engl J Med 2015; 373:1585-1588 October 22, 2015
A decade ago, a primary care physician I admired seemed to come undone. His efficiency had derived not from rushing between patients but from knowing them so well that his charting was effortless and fast. But suddenly he became distracted, losing his grip on the details of his patients’ lives. He slumped around, shirt half-untucked, perpetually pulling a yellowed handkerchief from his pocket to wipe his perspiring forehead. Everyone worried he was sick. His problem, however, turned out to be the electronic health record (EHR).
Ten years and nearly $30 billion of government stimulus later, the mandate to implement EHRs has spawned many similar stories, some of which Robert Wachter catalogues in The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, which explores the tension between the push to digitize medicine and the sanctity of the doctor–patient relationship.1 Wachter centers his EHR analysis around the story of an 18-year-old given a 39-fold overdose of Bactrim (sulfamethoxazole–trimethoprim) — a near-fatal error partially caused by an EHR. Investigating the root causes, Wachter discovers design flaws, such as defaulting to certain units for medication dosing and alerts rendered meaningless by their sheer number. But he concludes that the mistake stemmed less from the EHR itself than from its effects on our collective psychology. “I realized,” he writes, “that my beloved profession was being turned upside down by technology…”
First, such aspirational narratives beget complacency — and a tendency to dismiss contradictory evidence. The EHR is touted as a cost-saving, quality-promoting tool, though cost-saving projections have been debunked and data on quality are mixed.4,5 Koppel notes that “a seldom voiced barrier” to health IT’s achievement of its promise is our refusal to acknowledge its problems and learn from them: “Researchers and data that do not support the syllogism of health IT equals patient safety, and more health IT equals more patient safety” are ruthlessly attacked.2 Although we’ve made progress in patient safety only by carefully examining our errors, somehow the dangers posed by technology are expected to right themselves…
Second, letting the market shape usability assumes that clinicians are the target users. But EHRs were designed to optimize not workflow or communication but billing — which is increasingly predicated on an ability to document quality…
Which brings us to the third problem: many clinicians know what they want — but haven’t been asked. Wachter describes Boeing’s engineers iteratively improving aviation safety: their industry, committed to “user-centered design,” has pilots test any system changes. Why, Wachter asks, do we do nothing similar in health care? After noting challenges such as the diversity of practice settings and users, he observes, “In the aviation industry, there is an abiding respect, even reverence, for the wisdom of the frontline workers.” Our biggest mistake lies not in adopting clunky systems but in dismissing the concerns of the people who must use them…
In a moving passage, Wachter speaks with a renowned surgeon who once spent his evenings before surgery reading his notes on the next day’s patients. He might have eight hernia repairs scheduled, but one detail — the patient found the hernia bothersome when he played tennis, for instance — would distinguish one case from the next, the patient from the problem. No longer. His notes have been rendered uselessly homogeneous by the tyranny of clicks and auto-populated fields. When he shows up to operate on patients, he says, “It’s like I never saw them before. I can’t even picture their faces.”
What this surgeon and the rest of us need are patient records that communicate meaning and foster understanding of the particular patient in question. The blanks on our screens can be filled with words, but the process of understanding cannot be auto-populated. Perhaps life without the EHR will soon be unimaginable. But the technology will support and improve medical care only if it evolves in ways that help, rather than hinder, us in synthesizing, analyzing, thinking critically, and telling the stories of our patients.
(Edited by me)