Health IT and Diagnostic Safety: Promise and Peril

Making a dinner reservation, depositing a check, or buying a plane ticket online are simple tasks compared with documenting a clinical visit, but most of us give technology our full attention during these mundane transactions. Physicians should give patients their undivided attention, but find that computers are getting in the way (Patel, 2015). Oram (2015) calls this the “big unsolved problem in design for health IT.” It has also created the opportunity for medical scribes, who assist physicians by recording patient data in the EHR, to become a fast-growing segment of the healthcare workforce (Gellert, Ramirez, & Webster, 2015).

Physician, author, and educator Abraham Verghese (2008) thinks that having computers come between patients and physicians is a serious problem, leading potentially to the chart becoming a surrogate for the patient. He writes, “In a digital environment, where residents on inpatient rounds may have a more intimate experience with the record than the patient, there is danger that patients will become ‘iPatients’ and physicians lack the experience, learning and joy that can come only from physically caring for real people at the bedside” (p. 2749). Access to a wealth of digital information may improve diagnostic safety, but if physicians lack hands-on experience, diagnosis may suffer.

Information exchange 

In a digital world, there are good reasons why a patient’s data and information need to be exportable beyond the walls of one institution. People are highly mobile, and their health records should be, too, though this is another area where healthcare’s complexity and business model create problems. Efforts continue in the United States to promote and enable health information exchange (HIE), often through regional, state, or institutional networks (Shapiro et al., 2016), so that physicians can access a patient’s complete medical records from remote sites. Quick access to complete records is especially crucial in emergency medicine, where time is of the essence and patients may arrive without the ability to describe their medical issues and history.

A workgroup of the American College of Emergency Physicians recently studied the role of HIE in emergency medicine and issued recommendations to maximize its effect and value (Shapiro et al., 2016). The advantages of HIE for diagnosis in emergency medicine are similar to other settings—more information is better—with similar challenges: lack of access due to competition between organizations, data quality, workflow, lack of standards, and poorly designed interfaces (Shapiro et al., 2016).

The workgroup also raises a concern related to having more health information about a patient than physicians can review and absorb in the time allowed. Given the volume of data currently generated, demands on a physician’s time and attention, and difficult computer user interfaces, the workgroup questions if physicians should be held responsible for absorbing all of the information supplied by the HIE (Shapiro et al., 2016). Recommending that a standard of care and best practices be established for emergency physicians’ approach to information, they observe, “It is unrealistic that the standard of care require a full review of all records on every patient” (Shapiro et al., 2016, p. 80).

Information overload—especially information that is unmoderated and poorly displayed—is a problem in all settings. Schiff and Bates (2010) observe, “The problem of having too much information is now surpassing that of having too little” (p. 1067).

Innovative solutions 

Getting full benefit from electronic records may require new ways of entering and searching for data to create useful information. In addition to functioning as data interfaces, EHRs are being used increasingly as communication systems—messaging members of the team, ordering tests, tracking results, scheduling follow-ups—and that functionality must be included in newly designed or redesigned systems.

One innovative suggestion comes from John Halamka (2013b), chief information officer of Beth Israel Deaconess Medical Center, chairman of the New England Healthcare Exchange Network, and co-chair of the federal HIT Standards Committee, who imagines how clinical documentation and communication might function in the future. Health information for each patient would include data generated by medical devices and the patient, plus medical records from various providers, in a system that would promote care coordination across the community. Halamka (2013a) also sees “social documentation” becoming the vehicle for clinical notes and communication within a team, including the patient, and using tools such as wikis and social media to create a collaborative, real-time, dynamic electronic record.