• Dreaming the (Im)Possible Dream: EHR?S Future

    Author: Deborah L. Benzil

    What do Google, Apple, Nike, and Polar (along with hundreds of tech and gadget start-ups) have in common? All of these astute companies have recognized the potential in “digital medicine” and are looking to create a system or a niche product (think Fitbit) that has or may significantly impact the health of Americans. Despite this rash of forward-thinking companies, the Electronic Medical Record (EMR, also known as EHR—Electronic Health Record) that serves our current health care system is a mess and only getting worse. Therefore, trying to envision how the EMR/EHR of 2065 will look and function for both physicians and patients is quite challenging. Will this electronic system become the creative foundation for innovation, efficiency, improved population health, true outcomes, and value analysis? Or will it continue to be mired in an ever-tighter vortex of regulation and inanity? Let us examine both of these possibilities based on a little history, the current health care policy, and dreaming the (im) possible dream.

    Current EHR systems function as they do for several reasons:

    1. The software was developed primarily for the business and finance of health care, and as such, less attention was given to physician-friendly applications.
    2. When software companies started developing EHR systems, there were no standards or universal foundations precluding common language and interoperability.
    3. Software development has been driven exclusively by open-market competition without regard to quality control.
    4. The Accountable Care Act has led to a barrage of regulations such as PQRS and Meaningful Use, which has further impacted EHR software and physician use of EHR systems.

    EHR technology development and usability has too often excluded physician input. As a result, the adaptation of these business systems for clinical care has resulted in suboptimal systems with severe limitations. These same issues apply equally to the Centers for Medicare and Medicaid Services programs (established with enticing incentives and converting ultimately to punitive penalties).

    As outlined in the 2013 summer issue of the CNS Congress Quarterly magazine,1 the most basic wish list for contemporary EHR would include:

    1. Privacy: Going beyond confidentiality (HIPAA), data is made available to relevant parties but is protected from abuse by insurers, employers, and others.
    2. Universal interoperability: Labs, reports, and imaging are fully interchangeable across locations, practices, and settings.
    3. Portability: System is accessible across computer platforms and devices.
    4. Queriability: Data can be utilized to support approved clinical research projects.
    5. Speed: System can be accessed quickly, easily, and securely.
    6. Flexibility: Many agents can contribute different but predictable pieces to a rich, multidimensional canvas.
    7. Decision/Management Support: System is embedded with logic and educational materials.
    8. Universal Final Chart: System provides safe and comprehensive transmission of information.

    Add to this now outdated list the facile incorporation of individual health devices into a patient’s EHR system. In Silicon Valley and beyond, people are imagining the ability for individuals to have a fully portable and comprehensive EHR that they can make available to all practitioners involved in their care. There are also visions of incorporating fitness and diet data into the healthy living components of health care delivery, as well as a simple means of transmitting health moments such as glucose and BP testing, EKGs, and more.

    All of these ideas in some way emphasize a few basic concepts. First, they assume a critical need to bring all health care data, whether subjective, objective, physician driven, or patient engendered, under a single umbrella (accepting the information is likely to come from a variety of sources).

    This brings us back to 2065 and the EHR. There are two scenarios that seem equally possible.

    IMPOSSIBLE: The physician sits forever in front of the computer, trying to manage the enormous volume of data for each patient and the endless government, institutional, and practice-related mandates, still using “fly by the seat of the pants” decision making while the patient feels increasingly disconnected from their physicians, health care, and ultimately their own health.

    POSSIBLE: The patient has a fully integrated, absolutely portable, instantly accessible health log that is compatible with all systems used by any of their healthcare providers and institutions. This health record is automatically updated with every pharmacy change, every physician encounter, and every hospitalization. This remarkable record eliminates all mistakes in knowing current medications, family history, etc. The system is seamless and includes HEALTH information (diet, exercise, habits) fully wired with NUDGES (you haven’t done any back exercises in five days, you need to see the ophthalmologist in follow up, etc.) with readily accessible health education materials. The system also serves as a powerful research tool for physicians to better understand true value, quality, and outcomes.

    I know which system I am hoping for when I reach the age of 105!



    1. Benzil D, Prasad S. Electronic health record (EHR): neurosurgeons define meaningful  use. Congress Quarterly. 2013;14(3):23

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