April 3, 2018

Access, electronic health records, and the ecology of care


Improving long-standing problems of access in the digital age requires a critical look at today’s electronic health record, writes Dr. Eric B. Larson.

by Eric B. Larson, MD, MPH, Kaiser Permanente Washington Health Research Institute (KPWHRI) executive director, and Kaiser Foundation Health Plan of Washington vice president for research and health care innovation

Digital technology provides increasingly more ways for patients to connect with their providers. And many primary care physicians appreciate the convenience patients now have via systems like web-based portals and secure messaging. At the same time, many physicians feel challenged to manage a new, 24-hour cycle of incoming requests for information and advice.

Discussing this with colleagues recently, I mused that access has been a challenging issue for decades — at least as far back as 1962. That’s when Kerr L. White, MD, published a paper in the New England Journal of Medicine (NEJM) describing “the ecology of medical care,” quantifying rates at which adults typically seek medical help. He found that during a typical month, about 68 percent had symptoms of illness or injury, and 23 percent consulted a physician.

Fast forward to 2001 when Larry A. Green, MD, published a similar study in NEJM that showed little had changed. Each month, 80 percent of people had symptoms, and about 22 percent visited a physician.

So despite how communication technologies evolved between 1962 and 2001, our care-seeking behavior remained much the same. Most people felt bad fairly frequently and many sought care. (Interestingly though, the majority didn’t contact their providers when this happened. As Green explained, about 33 percent thought about seeking care, but only 22 percent actually had an office visit. What happened to the one-third who considered a doctor visit but then didn’t go? His study didn’t say, but we know from decades of primary care research that most probably got better on their own.)

Think of all that’s possible

Should we be surprised that care-seeking behavior changed so little over four decades? Maybe not. While society changed dramatically in the intervening years, most people still experienced their sense of well-being as people always have; they had physical complaints and illnesses; they looked to doctors and nurses for comfort and relief.

And what about today? I’m not aware of recent studies updating the work of White or Green. But I do know that 17 years later, digital technology has continued to evolve — creating more challenges for primary care providers who aim to keep pace with patients’ expectations for convenient access. Think of all that’s now possible with smartphones, text messaging, interactive video, personal health monitoring devices, social networking sites, and more. In an editorial accompanying the Green piece, Thomas H. Lee, MD, wrote, “Patients today are increasingly unwilling to live with the perception that their needs are going unmet.”

Faced with such pressures, how will dedicated primary care providers achieve high standards in meeting patient demands? As a researcher practicing internal medicine for the past 40+ years, I don’t pretend to have the answers. But it helps to take the long view: The “access problem” is not new; what’s new are digitally based channels of access, as well as technologies that could be better designed to more efficiently and effectively meet patients’ needs.

Take, for example, the tools we’re now using for collecting, storing, sharing, and analyzing information about patient-provider encounters. It’s no secret that many physicians are quite dissatisfied with the current state of the electronic health record (EHR). Heralded more than 15 years ago as a way to provide reliable patient data at the point of care, the EHR has dramatically changed how providers work, taking time and attention away from valuable patient-provider interactions. In a 2016 study by Christine Sinsky, MD, in the Annals of Internal Medicine, observers documented that for every hour of direct clinical time with patients, physicians spent 2 additional hours on EHR and deskwork. EHRs have been linked to higher physician burnout and safety concerns. A 2017 patient safety review published in the Agency for Healthcare Research and Quality’s Patient Safety Network reported that adoption of the EHR may lead to decreases in medication errors and improved guideline adherence, but usability issues are also contributing to medical errors.

It doesn’t have to be this way

I don’t raise these concerns out of nostalgia for the “good old days” of paper records. Rather, I’m calling for a better future when health information technology can be as efficient and customer-centered as we see in other industries. Think banking, retail, aviation — and all the efficient tools workers have to predict and meet customer demand. To match these realms, however, we must be committed to designing the EHR as a tool to serve high-quality patient care and create efficiencies for providers, not extra work. Unfortunately, today’s EHR systems are designed for other purposes, primarily to improve billing and regulatory compliance.

It doesn’t have to be this way. Given all the skills and knowledge that today’s computer scientists are amassing in fields of predictive analytics and user-centered design, we should be able to develop something better for our patients. Providers should have an EHR that serves health care’s entire quadruple aim: improving the experience of care, improving the health of populations, reducing per capita costs, and improving provider experience. (Note that improving revenue generation in a fee-for-service system is not on this list.)

Designing a better EHR will require a very different focus, one that centers on our mission to provide high-quality, affordable care to improve the health of our members and the communities we serve. This mission is the reason most of the Kaiser Permanente physicians I know came to medicine. As highly skilled professionals, we have a calling and a belief in our work and our model of care. None of us want to experience burnout — and especially not from using tools that require excessive bean-counting and tracking irrelevant metrics. There is an alternative and that is to create a tool that better serves our patients and our mission.

Learn more about Kaiser Permanente Washington Health Research Institute. Sign up for our free monthly newsletter.