It is hard to get a group of physicians together without discussing electronic medical records. After increased government attention to electronic health records in 2004, an economic stimulus package in 2009 sent large financial incentives to clinics to migrate to electronic records. “Meaningful Use” guidelines were developed by the Centers for Medicare and Medicaid services (CMS). Rather quickly these recommendations transformed into regulations and requirements for all patients and were tied to health insurance reimbursements. Silos of medical data were created from clinic to hospital and hospital system to hospital system because the software systems could not communicate with each other. Physicians had to look up labs and xrays on one system, find procedure notes on another system, and then document the patient encounter on a different system. Software developers improved the products to connect billing information, scheduling, medical records, and reports all into one system. However, these systems were not compatible with other software platforms, and information was difficult to obtain outside the software. Epic, which now is used by over 30% of hospital systems in the country, was developed in a basement outside Madison, Wisconsin in 1979. Now over 300 million patients have an electronic medical record in Epic.
The initial systems were developed to maximize billing, help with exponential changes in coding, and offer some protection in medical liability with legible documentation. With these good intentions came an unexpected shift in the burden of this documentation and became a headache in daily medical practice. The data entry to meet quality metrics causes physicians to now spend over half of their time on the computer, instead of face to face with patients. Not only do physicians use time to talk to the patients to diagnose and treat medical illnesses, but now the physicians are also required to document a wide spectrum of dates of preventative screenings, vaccinations, and social determinants of health. The term “pajama time” for clinicians refers to the time after clinical hours required to complete the chart documentation. Unfortunately, this pajama time usually occurs after 10 pm for the physician and causes frustration and increases reports of burnout. Most importantly, the electronic record does not translate all of the relevant clinical impressions. It does not capture the narrative of the patient encounter that is critical to treat the patient and coordinate care from one physician to the next.
Physicians are trained to lead multidisciplinary hospital rounds with a healthcare team of pharmacists, social workers, and nurses to personalize and coordinate patient care. This physician led team brainstorms the differential diagnoses and shares a variety of perspectives to develop a personalized treatment plan for the patient. Electronic medical records have not met expectations for collaboration and interoperability of medical data. Due to the documentation burdens, in order to save time, medical documentation has moved to smart phrases and templates. Also, patients now have access to the medical documentation prior to completing patient satisfaction surveys. In some hospital systems, patient satisfaction scores are often linked to financial incentives. All these factors contribute to the creation of a bland, vague, and nonspecific medical record.
The COVID pandemic accelerated the collection of data and exposed the gap in interoperability in electronic health systems. Telehealth visits, case reporting, and vaccination information required software products to improve out of necessity. Data scientists moved into the healthcare realm to help compute this ocean of medical data into the visualization of trends and personalized patient treatment plans. Large computational analysis can expedite medical research, but data scientists are not physicians. Now more than ever, physicians are called on to help translate this data into a personalized medical approach. Cancer therapies and treatment have now been transformed and are more personalized under the buzzword of precision medicine.
The future holds the promise of dynamic and integrative treatment options with a personalized approach. The recent advances in healthcare information are promising, but steps need to be taken to reduce the data entry and undue the documentation burden to allow physicians to lead the physician led healthcare team.