EHRs and the continuum of care, Part 2: the problem with paper-oriented EHRs.

One of the main problems with paper exams is that they are structured around an exam-specific episode of care. A new form is used for each encounter. Connecting the knowledge contained in these separate exams is through a written problem list, and sometimes other lists such as a medication and allergy list. A sequence of events, a change over time or a variation in clinical flow can only be seen by human eyes observing the flow of data from episode to episode.

In EHRs, we see some ability to tie consecutive episodes of care together and reduce end-user need to enter repetitive data and join the dots, so to speak. We see features like Carry Forward and Populate Normal being incorporated. This helps in some measure but also has some pitfalls. It is still a system in which significant clinical findings are separated into episodes of care rather than being presented in ways that show trends and make the continuum of care intuitively obvious. 

If we have a patient developing a traditional cataract, the caregiver must know how quickly the cataract is progressing. The key clinical indicators are type, severity, change in refractive status, change in visual acuity, and other causal factors. In order to make appropriate clinical decisions for this patient, we need information from a sequence of exams. In a paper chart, the provider would flip through the various exam forms. In almost all electronic health records, the user still must “flip” through previous exams to get this information, even though the data is electronic. The problem is that electronic “flipping” tends to be much slower than it was to flip pages in a paper chart. Complaints that EHRs are slow come largely from this separation of related data and the increased time it takes to re-assemble and re-assess.

Maintaining an episode-of-care concept in the design of EHRs has proven to be a fundamental flaw and a major inhibitor to their adoption. A key tenet of health care reform is to challenge episodal care. Reform is recognizing that each episode of care actually has little value in the continuum of care. Health care reform is designed to change the focus from the patient seen on a particular day with numerous tests, to an emphasis on long-term outcomes and how effectively a team of providers can get the best patient outcomes. 

Health care reform is changing reimbursement from paying primarily for episodes of care to paying for long-term outcomes, also known as pay-for-performance. A system based on episodal care does not create the most efficient and effective health care. It creates an expensive, fragmented health care system shown consistently not to deliver the best quality of care. EHRs that win the day will be those that help us easily see the most important value in the data: the trends.

Jim Grue, O.D.