The Swiss Army Knife

Are the best tools Swiss army knife-like – flexible, adaptable, multifunctional, and easy to use? Or is a knife-like tool – optimally sharpened, single-purposed for cutting – ideal? When framed as a simplistic dichotomy, it is obvious that tools do not have a universal or intrinsic “bestness,” but are context dependent and best viewed instrumentally – with purposes, goals, and outcomes in mind. In applying the lens of instrumentality to the Electronic Health Record (EHR), its purpose and contexts of use more clearly come into focus. Initially designed as a practice management tool, it has been shoehorned and exapted into the services of patient care. However, despite fifteen years of iteration since the HITECH Act it remains a tool that is neither fit-for-purpose of patient care, nor fit-for-the-mind of the physician providing that care under the constraints and pressures of the contemporary healthcare system. 

This mismatch is even more glaring for the unique cognitive requirements of the emergency physician operating in the regime of the tragedy of the commons, often at the edge of thrashing, under the marked constraints of bounded rationality, and with the imposing mandate to navigate the spectre of uncertainty and identify often surreptitious risk. Although the EHR cannot obviously bridge many of these gaps, an ideally configured EHR can serve as a cognitive scaffold for emergency physicians. At the very least, it should decrease the information retrieval and documentation burdens on emergency physicians, allowing them to develop and hone the all important emergency physician skill of mindreading. More ambitiously, it would ease the inference burden by identifying outliers and augmenting the capacity of physician metacognition. 

However, despite the fifteen year project of EHR optimization for patient care and decision support, EHRs as currently configured continue to be mostly a passive database requiring physician time to read and write into. Information retrieval continues to be an active search process that serves as a time-sink. At best, the drive to efficiency and standardization with the development of one-click order-sets, copy and paste techniques, and templated documentation saves time, but mostly serves to facilitate an illusion of fluency. This in turn amplifies and ramifies perceptual biases, leading to the insidious effects of false positives and the more immediate consequences of false negatives. Additionally, templated and copy and paste documentation has rendered large parts of the physician note valueless for patient care and secondary use (upcoming essay). It would not be an overstatement to claim that most physician documentation serves the financial, legal, and administrative functions of coding, billing, risk-minimization, and metric satisfaction. Physician documentation has transitioned from a thick description designed for clinical care and physician education to a thin one that primarily serves legal, economic, and bureaucratic purposes (next essay).  

In retrospect, it is not surprising that EHRs are mismatched for the purpose of patient care and medical decision-making. Much of the mismatch occurs from the fact that EHRs were essentially practice management tools designed primarily to facilitate administrative and financial tasks such as scheduling appointments, billing, and patient check-in, rather than to serve the information and inferential demands on physicians working in modern-day industrialized healthcare systems. Despite the years of iteration around the margins to transform the EHR into a Swiss Army Knife – flexible, configurable, and multifunctional – it remains knife-like – a tool fit for the single purpose of meeting administrative, financial, and legal objectives. Maybe what is required is neither a knife or a Swiss Army Knife but a scalpel – a tool specifically designed to fit for the purposes of medical decision making in the modern healthcare landscape.