I was recently in New Orleans and coincidently listened to an interview with Robert Wachter of the University of California, San Francsico talking about health IT and his new book on where the nation stands regarding electronic health records (EHRs).
Somehow, the temptations of the French Quarter and the problem of EHRs combined in my mind to produce the image of the nation’s health system out on the town, binging on HITECH Act ARRA money, blackout drunk, and waking up married to some very inappropriate electronic health record system.
This isn’t exactly how it happened, but most of the bloom does seem to be off the rose of the electronic medical record and we are in a phase of regret and disillusionment. Physicians have been complaining for years about the hours added to their days by the workflow disruption of digital data entry and the breach in the relationship with patients created by interacting with the computer, rather than the person. At the same time most of the anticipated fabulous features of EHRs are still in the anticipated stage.
This unfortunate situation seems to me to be mostly the result of clunky software, poorly designed facilities and workflow, and perhaps even some semi-conscious sabotage.
While no one is seriously arguing that we should return to paper records, new systems create new problems and we have yet to gain the real advantages promised from health IT.
Despite this morning-after period of realism, the federal government has not let up on its plans for a new third stage of “meaningful use” for electronic health records, including requirements for ambitious consumer use. The Office of the National Coordinator for Health Information Technology has recently released a report successfully embarrassing the industry into lowering some of the barriers preventing information sharing across providers. A new law just passed by Congress and signed by the president repeals the Sustainable Growth Rate and includes payment incentives for physicians to attain meaningful use standards. And the new Chronic Care Management payment for physician offices providing care coordination for beneficiaries with multiple chronic illnesses has one structural capacity requirement: 24/7 access to electronic health records.
At this difficult moment, Robert Wachter, MD, one of the leaders in the hospitalist movement, has published a thoughtful reflection on where the health care system stands on the hopes and fears for the electronic health record: The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age. I would summarize his view as one of reasoned self-criticism and cautious optimism. While no one is seriously arguing that we should return to paper records, new systems create new problems and we have yet to gain the real advantages promised from health IT.
So, now wiser because of our indiscretions, what should a sober America expect from electronic health records that would be important in the care of older adults?
Many of the features would be the same things that would be important for the entire population—electronic prescription drug orders and useful decision support around clinical issues, patient access, and secure messaging. But some things are especially important to older people. Easy flow of information between sites of care (such as hospitals and nursing homes) is good for all, but perhaps most important for older adults, which is the population segment most in need of care to be coordinated over settings and time.
But what features would be important to build into the EHR to be particularly attentive to the needs of older people? Here is my list:
- The EHR must prioritize and privilege patient goals of care. For the older adult with multiple chronic conditions and the potential for conflict among care plans, the EHR must help the care team reconcile plans and treatments under the overall organizational principle of meeting the patient’s own goals for his or her life. Person-centered care is important to our work. That’s why the John A. Hartford Foundation is supporting efforts by the National Center for Quality Assurance (NCQA) to incorporate person-centered goals into quality measures and is partnering with the Patient-Centered Outcomes Research Institute (PCORI) to fund the CaRe Align initiative led by longtime grantee Mary Tinetti, MD, which is seeking to develop a new model of care that could better meet the complex needs of older patients with multiple chronic conditions.
- Since those goals are almost certainly to be about ability to do various activities (activities of daily living) and fulfill social roles (spending time with friends and family), the EHR must also record and track functional and cognitive status. At its heart, the insight of geriatrics is to focus on mitigating the effects of disease on function, rather than exclusive focus on individual diseases.
- EHRs must support strong models of care while also enabling practices to fulfill regulatory and compliance standards and get paid for their work. For example, EHRs should facilitate the delivery of the Annual Wellness Visit, the Chronic Care Management benefit, and Care Transitions benefit. This would require EHRs to list all involved providers, including community-based organizations; to include a wide variety of geriatric assessments (e.g., depression and cognition); and to be remotely accessible by at least some members of the care team. Obviously, much if not all of the record should be accessible to the person and his or her designated family and informal caregivers.
- A major problem with current systems is “alert fatigue,” where the electronic system alarm is triggered so many times that users have little choice other than ignoring their warnings. Nonetheless, incorporating what is known about Potentially Inappropriate Medications and the Beers criteria would be very important in care of older adults. A recent study reviewing prescriptions suggested that use of potentially inappropriate medications occurs in as many as 30.9 percent of older adults.
- As a very basic test, the Electronic Health System (beyond an individual site’s record) must proactively inform professionals and other caregivers about changes in status, such as a hospital admission. For almost 20 years, I’ve heard about physicians and care managers being surprised about hospital admissions that they may not learn of until months later. I’ve even heard about how homegrown solutions to this problem have been washed away by the adoption of national EHRs, actually setting health systems back on this measure of connectivity.
Helping to create a solid infrastructure for high quality care of older adults is the aim of our new Tools and Measures portfolio of grants. So we really want to know: What other features do those of you who are the experts think should be on this list? What features of electronic health systems would really make a difference in the lives of older adults?
Please comment or just email and let us know.