Electronic health records offer speed and ease. But what about the human relationships that are so crucial in health care? And what about nuances that describe patients who don’t quite fit in box A or box B? What about the fragility of electronic data and the potential for theft? Finally, what about all the aspects of coping, social context and mental health so critical for effective care but missed by EHRs?
Providers are people. Patients are people. With many EHRs, the patient is likely to see more of the top of their doc’s head than his or her face. The time pressure the providers face means they may see more of the input screen than they see of their patient. This demeans the relationship for both.
Studies have shown that healthcare providers who interact in a warm, relational way with patients are less likely to be sued. Patients are even more likely to forgive mistakes when the patient-provider relationship is strong. Studies also show that when providers focus on the one-eyed monitor, perceptions of customer service decline.
By focusing on the objective measurements of speed and efficiency offered by EHRs, healthcare systems and providers may lose the subjective – but no less important! – aspect of patient satisfaction that leads to better relationships, and down the line to better outcomes for both provider and patient.
First let’s look at the constraints of EHRs. What happens when the drop-down menu doesn’t contain a phrase that fit the doctor’s observations? What if the patient’s description or symptoms don’t fit? Does a fifteen-minute visit promote entering off-the-form data entry.. or settling for the closest dropdown? Then, do the options on an EHR in fact influence doctors’ observations – like GPS devices that reduce the ability to navigate via the world around us, do the defined fields of EHRs limit the possibilities that doctors allow themselves to consider?
Then what about factors related to behavioral healthcare? You get pulse, blood pressure, temperature, height and weight, but what about a patient’s history of early childhood adversity shown by the ACEs study to contribute to physical health even 50 years later? EHRs seldom if ever screen for overwhelming events, and, if they do, they are usually confined to abuse and neglect (only two of many types of traumatic events!). Further, the information is gathered with a behavioral health care referral in mind rather than as a matter of simple fact.
This is a cultural issue as much as a software issue. Society is not ready to incorporate the well-known consequences of overwhelming events—especially early in childhood—in the cost-benefit ratios or the underlying beliefs that drive the design of our medical model. Binary codes that trigger acceptance or rejection of payment collide with the rich complexity of the human experience. What we gain with speedy and inflexible systems that focus only on pathologies is magnification of what’s wrong.
Does the baby need to be tossed with the bathwater? Is it possible to create person-centric or maybe trauma-responsive EHRs? In an ideal world, electronic health records would humanize providers as well as patients, and connect to insurance systems that reward health improvements and resilience as well as cover medical care.
I suspect the checkboxes are here to stay – they’re needed for industrialized medicine. But also needed is a way to incorporate information about important but sometimes subtle improvements – a health curve rather than a disease snapshot. Also required is a way to screen for events that rendered the person unable to cope, reflecting the evidence-based knowledge we now have about the impact of overwhelming events on long term physical and mental health.
In short, EHRs should reflect what research shows to be most helpful for patients, providers, and payers: humanization to strengthen relationships between patients and providers, and rewards for to all parties for health improvements as well as coverage medical problems. Let’s hear it for truly meaningful use of software in the service of better health.