Point of View

Misperceptions on electronic health records

October 4, 2013 

I greet a new patient whose spouse hands me papers outlining the medical history, saying, “It’s for you. Keep it.” A blessing. I sit, review the history and take notes on the papers.

This used to happen more often. Before electronic health records, patients and families understood that we providers might miss something important. They watched as we sorted through piles of often-disorganized papers and as clerical staff frustratingly looked for missing charts. It is natural to understand why patients took it upon themselves to gather, organize and summarize their own medical information.

The adoption of EHRs, however, now gives the patient and family the perception that providers know everything. “I assumed you knew about it. It must be in the computer.” If only it were that simple.

EHRs have the potential to improve an individual’s care with better access to information, data-sharing between providers and data integration, among other things. Discrete data elements can be tracked over time to better personalize care. On a population level, the EHR can facilitate monitoring care trends across groups of patients and over time. Variations in treatments can be more readily and accurately associated with variations in outcomes, helping to better define optimal treatments. The possibilities are seemingly endless, and the opportunities for real improvements in the quality and efficiency of care are exciting.

Nevertheless, there are many challenges to realizing these benefits. One I find particularly troubling is trying to understand the context of the information being viewed. While individual portions of the record (clinic notes, test results) can be readily seen, viewing multiple items simultaneously is more challenging. Further, even when viewing multiple items is possible, the user often needs to actively seek the context because the EHR does not necessarily facilitate such contextual review.

As a radiation oncologist, I typically prescribe courses of therapy extending over several weeks. We perform formal evaluations usually weekly and generate a “weekly management note.” During any evaluation, I like to scan the prior notes to remind myself of how the patient has been doing over the last few weeks. This used to be easy with a paper chart (granted, only when we could find the chart); it was almost like reading a short story. The sequential notes tell a story that is most-easily understood if viewed as a package. When generating today’s “new note,” I would concurrently review prior notes to assure that I addressed previously noted problems.

This is not always as easily accomplished in some EHRs. Imagine reading a short story and being allowed to view only one paragraph at a time. Imagine needing to open or close multiple windows to move in between paragraphs or needing to search to determine whether there is a prior paragraph to read.

Patients need to continue to create summaries of health histories. Providers might still benefit from narrative summaries, even in the electronic era. Chronological lists of key events, associated test results and office visits can be very useful. Do not assume that the EHR has made your health care provider omniscient. Having the data in the computer does not necessarily mean that a provider has that data in front of him on the monitor. Indeed, as health care becomes more complex, often involving multiple providers, the patient’s role as an active member of the health care team is critically important. Patient input can help a provider more efficiently sort through an EHR.

Patients often have the best knowledge of the context of all aspects of their health history and sharing that “big picture” with a provider is helpful. The EHR will be a powerful tool to help facilitate continued engagement in care. Patients will certainly have the ability to view most (if not all) of their records, and they will be able to more readily communicate with providers – and do so within the EHR itself.

Messages between patients and their providers may be linked to particular items of concern within the EHR. Patients might be able to make or suggest corrections to the EHR to maintain its accuracy. So whether it is in the paper or electronic world, the active participation of patients in their care is important to both them and their providers.

Lawrence Marks, M.D., is chairman of the Department of Radiation Oncology at UNC Chapel Hill.

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