E-H-R, where are you?

It’s 2011. Why isn’t every single doctor in this country on electronic health records?

You’ve probably wondered that at some point. When you’ve gone to the doctor and wondered why, as she flips through a manila folder, she doesn’t just get a computer system. Or why her information can’t easily be sent to another doctor and no one knows what anyone else is doing and it is so, so frustrating.

Or maybe you’ve read articles in the news or even posts here on tumblr, questioning and arguing and demanding the healthcare system get off its duff and get digitized. Some of the people who’ve written about it are policy people, some are in health care, some are doctors themselves. Many argue vehemently about how much we need EHR and how ridiculous it is that we don’t yet have it. 

Last year, Generic asked me what I thought of this Ezra Klein column in The Washington Post. In it, Klein writes:

In part, you’re dealing with the fractured incentives in the system: It’s good for patients and good for insurers if doctor’s offices spend money setting up computer systems, but it’s not necessarily going to make doctors any money, and the doctors themselves are frequently older and don’t want to learn a new system. That’s one reason why systems where the insurer and the provider are the same — think Veteran’s Affairs or Kaiser Permanente — tend to be ahead of the curve on electronic medical records.

It’s true. EHR systems are prohibitively expensive. Purchasing the software, installing it, training all the users, taking a huge hit in income due to a massive decrease in efficiency as you learn the new system. Let’s not forget transferring data over if you don’t have a legacy system. It’s not just the making money—it’s making money back. Now, under ARRA, there’s money to help smaller practices without deep pockets install these systems.

It’s also true that EHR is good for patients and good for insurers. We like things that are good for patients, and we should. We should support those. But keep that “good for insurers” part in mind. And note: There’s no “it’s good for doctors.” Can something that’s possibly not good for doctors ultimately be good for patients?  

But when Klein says that doctors are older and don’t want to learn a new system - when you read something like this, stop for a minute and think. Me, I ask this question: Are you making an assumption? Are you stereotyping doctors? Is that reallythe reason they don’t want to change? Or “part” of the reason? Maybe it is, but it would help us to know if that’s real data, or just an opinion. I’m not being a pedantic annoying academic - I’m thinking about this in terms of a real, applied, fixable problem. What if the issue isn’t that doctors are old and don’t like learning a new system? What if it’s something else, and something we can’t just dismiss outright but a problem we can try and solve?

Hey, we might be able to do something with that. 

As for Kaiser Permanente - it’s not just the fact that it’s provider and insurer all in one. It’s also the fact that KP is totally vertically integrated. Everything occurs within the KP system. How much easier is that problem to solve, systems design-wise and organizationally speaking, than a multi-site network scattered across urban/suburban locations where patients use external labs, scanning facilities, and pharmacies? And even with vertical integration and centralized medical centers, I don’t think KP would say their road to electronic records has been “easy.”

Klein also notes that it’s ridiculous the medical system isn’t digitized, while banking is. Here’s where it gets really interesting, especially if you like to think about how systems and organizations work.

Take the banking system. Set aside for a moment the fact that the banking system started on the road to computerization ago. I’m not in any way an expert on banking. In fact, I welcome anyone to explain the banking system to me, as well as most anything on financial institutions. But even as relatively not-knowledgeable as I am, I know this: The banking industry is fairly transaction-oriented, right? Transactions that move data from one spot to another, tracking and monitoring it, and sometimes moving it back. That’s something you can build a computer system around.

Think about it. What does Ezra Klein mention? He specifically mentions only that you want to go in and make a transaction. He doesn’t say that when you walk in to the bank, the teller tracks your entrance, makes a note that she spoke with you, looks up your name, logs the result, and so on. There’s basically one action she performs. 

A medical record - that big fat manila chart - is a totally different beast. Do you have any idea how it gets created? How it gets maintained? How things are sorted and filed? Then, say, if a patient needs a prescription refill, or a referral, or some kind of insurance form, or help with something regarding the nursing home, or a Medicare form, or a letter sent to an employer. Who does what? How do different people in an office communicate? What are the tasks? What are the resources? Hell, does anyone even know what a workflow actually is? 

I’m not being flip, I’m being deadly serious.So much of the conversation about EHR and why the healthcare industry doesn’t have its act together rests on issues of “the technology” or “do you know how much money they cost” or “doctors are so resistant.” These are all massively important. But does anyone know why they’re important? Why they happen? How they relate? Not really. Only sort of.

Even at the very basic level, it’s shocking to see how little people seem to know about the workflows clinicians perform now, with the charting systems they already have. Or even what a workflow is. 

Transitioning an office to an electronic medical record system is a fairly monumental task. There are different definitions for success. Me? I do not define success as “We got the technology installed and people are using it. For the most part.” I’m still working on my definition of success but I know it involves things like: implementing system that addresses pre-existing problems, tries to solve them without replicating them or worsening them, and, if it does make some tasks more difficult, provides support where necessary. 

So here’s a challenge for all you UX people out there: If you really care about UX as much as I know you do, dedicate some time to working on the user experience for something that really, really matters: the electronic health record. So many people bitch about healthcare and the state its in, but it’s not really a sexy fun industry. If doctors don’t have EHRs they can use that won’t drive them crazy - I’m talking Windows 3.0 based stuff here, folks - how do you think they’re going to implement a system that will replace this “insane paper system” that you find so ridiculous?

You want a better system? Then help me create one. I’m being serious. I’m not just talking about the computer program itself. I’m talking about the larger system. The organization in which an EHR is embedded. The healthcare system in which the medical organization is embedded. The society in which the healthcare system is embedded.

Systems. Organizations. Society. 

Call to arms. Let’s do this thing.