EHR as the Sun

The HITECH Act was passed in 2009 to promote and expand the adoption of health information technology with the objective to improve care processes, the quality of care, and overall health system productivity. Although the push to digitize medical records has mostly been accomplished, as Electronic Health Records (EHRs) have become ubiquitous in healthcare, the policy has yet to realize its aims of improved quality and productivity. Healthcare expenditures continue to increase. Broad measures of system quality as measured by population-level outcomes have remained stagnant at best over the past fifteen years and have lagged comparable health systems. Public sentiment of the healthcare system hovers near dissatisfaction but often skews towards anger and resentment. Burnout amongst physicians and nurses is rampant and routinely described as an epidemic. Despite the lack of progress on many of its intended objectives, the HITECH Act  has profoundly transformed the practice of medicine and the delivery of healthcare.  

In following the larger societal trend of reification and deification of “information,” medicine and healthcare is  transitioning into an information science (future essay). Information is the grist for the mills of evidence generation, which in turn are used to ground all decisions. It naturally follows that the EHR, as the primary repository of healthcare information, has ascended in importance for all stakeholders, at every level of the healthcare ecosystem. Similar to other top-down imposed and large-scale technological transitions, the legacy of EHR can be found in the unforeseen and unintended consequences. In the adaptation and co-evolution of its stakeholders (upcoming essay). As EHRs have become ascendant, there has been a complementary proliferation of tools and methods to service, support, manage, optimize, and extract value from them. Workflows and workarounds have proliferated, a medical specialty has matured, business models developed, and technologies implemented with the EHR and its users foremost in mind (upcoming essay).

Administrators measure clicks and survey documentation, coders and billers optimize diagnostic and procedural codes. Insurers cross-check these codes with physician documentation to ensure coherence. These cross-checks form the basis of the cat-and-mouse game of coding, billing, and reimbursement (upcoming essay). De-identified aggregations of physician generated patient representations are the “data-gold” that technologists, entrepreneurs, and researchers clamor to access and mine (upcoming essay). For physicians, the patient as represented in the EHR has surpassed the patient at the bedside as the object of attention (upcoming essay). The ascendancy of the EHR  with its standardized, transportable, and interchangeable documentation has allowed health systems to become “physician-agnostic.” Physicians are now largely relegated to the role of shift-workers on the assembly line of healthcare delivery (upcoming essay).  

Over the past fifteen years, there has been a profound change in practice of medicine and the delivery of healthcare. Large-scale EHR implementation has been a driver of this transition. Following the north star of “information-driven” decision making, healthcare data, and its primary repository, the EHR,  has become dominant in the healthcare ecosystem. The EHR is the locus of activity, the object of optimization, and the subject of much discourse in medicine and healthcare.  It is the “sun” around which all healthcare processes revolve. In the next few essays, I would like to explore the trade-offs, opportunity costs, implications, the by-products, and the winners and losers of this transition for patients and physicians.