Unintended Consequences of Nationwide Electronic Health Record Adoption: Challenges and Opportunities in the Post-Meaningful Use Era

The Path Forward

Some proposed solutions to highlighting relevant data include tailoring physicians' use of EHRs to document what they are thinking about the patient's situation, transferring some data entry to patients, or new policies to facilitate health information exchange (HIE). Such proposals are unlikely to succeed in isolation as they require clinicians to enter or import even more information into already bloated records. In addition, the effectiveness of HIE seems to be understudied; although some studies report HIE-associated improvements, others report the opposite.

Concise documentation that highlights relevant data will come from smarter EHRs that actively participate in patient care; however, to be smarter, EHRs must be able to capture and process more information about the patient's context and clinicians' reasoning. Previous studies suggest that clinicians seem to always know something that is only partially represented in or is missing entirely from the EHR. For example, EHRs are incapable of understanding why clinicians order what they order, or how current symptoms are related to previous problems. Although most EHRs allow medical records to be structured on a problem-oriented basis, such structure does not capture the reasoning behind the relationship between problems and other clinical concepts. For example, a medication can be linked to a problem, indicating that it was ordered to treat a particular problem, but the reasoning (why) behind the choice for this particular medication is not captured by the EHR. If such data were captured, several opportunities for informatics research would emerge to apply (and improve) computational methods (eg, machine learning, natural language processing, and text generation methods) to empower the EHR to use patient's care context data. Context-rich data could be used to facilitate note creation, to create automatic notes ready for review, and to increase the accuracy of CDS, potentially mitigating the already infamous alert fatigue. However, 2 major challenges remain: (1) A formal representation of the semantic relationships between clinical concepts (eg, symptoms, findings, problems, diagnoses, and treatments) does not exist and (2) Effective methods for capturing and representing clinicians' reasoning need to be developed. EHR vendors have avoided this path to avert coliability for medical errors when eventual system failures lead to misleading recommendations. What vendors have avoided translates into several opportunities for informatics researchers. The development of a formal representation of clinicians reasoning seems to be a promising alternative to empower EHRs to represent patients' situation. However, the application of such a representation into actual patient data will demand new, more effective data-entry approaches, improvements to data visualization, and computational methods.

On balance, despite the unexpected effects and challenges of nationwide EHR adoption, several opportunities for developing more effective EHRs and evaluation methods are likely to emerge from the forces promoting progress. The UCs here discussed do not intend to be exhaustive; other consequences may be revealed as new, more robust HIT evaluations are reported. We hypothesize that overcoming these UCs will likely require a path reverse to the one that produced them. By creating smarter clinical information systems with more intuitive navigation and data entry functionality, clinicians could save time searching, synthesizing, and documenting data in the EHR, which would contribute to alleviate data obfuscation and mitigate burnout. Such systems will likely come from external applications developed through cutting-edge research conducted in academic medical centers that tend to be a natural replacement for earlier informatics innovators. These applications, if successfully implemented and evaluated, may back providers up on their demands to have most large EHR vendors opening their platforms, which would facilitate the development of new business models and decrease market oligopoly. Finally, by accumulating evidence of the effectiveness of these applications, in isolation and in conjunction with commercial EHRs, a better understanding of the true positive effects of HIT can be obtained by future systematic reviews and meta-analyses.

The multiple efforts proposed here will demand collaboration between diverse players such as health care providers, administrators, HIT vendors, policy makers, informatics researchers, funding agencies, and outside developers toward a single goal: to realize the full potential of a digitized health system.