The Computerization of Medicine: What Direction Will It Take?

by Richard Morganstern, MD

Despite heroic and expensive efforts on the part of the federal government, only 50% of physicians are using EHR systems. (http://www.hhs.gov/news/press/2013pres/05/20130522a.html)

80% of hospitals have demonstrated some sort of meaningful use but it is estimated that only 1.5% of hospitals have an EHR system that reaches into all major clinical areas.(http://www.medsphere.com/commercial/openvista-mental-health)  Since psychiatric hospitals are to date exempt from financial incentives to computerize their medical records, we can assume their numbers are even lower. 

So, one direction is for increased penetration of this technology into actual clinical practice. There is ample room.

There will be a tipping point when the penetration will quickly move toward 100%. There are a number of reasons for this.

For one, as with any new technology, it takes a while for productivity gains to appear at the worker's (clinician's) level. There is a learning curve. Also, there is a selection process going on, as software programs compete in the marketplace, and in so doing improve. As they improve and as productivity gains become obvious, clinicians will demand the adoption of technology that makes their work easier and faster. Administrators and other decision makers will happily comply. When this happy synergy occurs, increased use of computerization will rapidly occur. 

Also, as alluded to above, computerization will reach into every important clinical area to the point where it is impossible to communicate correctly and safely except through a computerized system. When this occurs, the use of computerization will be demanded by all interested parties.

For example, when the prescribing clinician in a hospital practice writes a clinical note and indicates that a new medication has been prescribed and orders that medication from the note (CPOE), what can happen in a well functioning EHR that communicates with all clinical areas? 

The order is automatically and instantly transmitted to the nursing Medication Administration Record and to the software in the pharmacy. The MAR becomes a real-time document.

The pharmacist is alerted that a medication order has been written and makes a determination about the safety and appropriateness of the order. If approved, the pharmacist sends a message to the Nurses' MAR that the medication is approved for administration. That order in the MAR is "unlocked." The nurse is automatically alerted that new orders have been written.

The new medication order is logged chronologically for future reference. It is featured on a list on the front of the chart. The medication is checked against the patient´s history of allergies and adverse drug reactions. The medication is checked for negative interactions with other medications prescribed for the patient. If a problem is detected, the clinician is automatically alerted. 

Similar interactions between the clinical record and the laboratory, the imaging facility, the local pharmacy, the dietitian, consultants, other clinicians, and other such entities will occur. Orders will be automatically sent and results automatically received into the medical record, where they are presented for consideration by the clinician and then entered into the clinical record and into chronological logs. 

The improvement in communication and the accessibility of medical information and the automation of safety features are all compelling, if not yet entirely in place. When they are in place, they will be impossible to not be part of.

Furthermore, it seems clear that we are working toward one medical record per patient, no matter how many clinicians are treating the patient, regardless of what kind of treatment facility is involved.  The advantages of this are so overwhelming that its inevitability seems evident.  

One record into which each clinician writes notes and orders. All the medications the patient takes are in one place, available to all with the privileges to see them. All the laboratory and imaging results are in one place, and accessible to all, no matter who ordered them. One medical record that follows the patient from outpatient treatment to inpatient treatment, to a rehab facility or other setting. One treatment plan, with each treating clinician establishing goals and markers of treatment progress and completion. Each treating entity sees what other caregivers are doing and what their goals for the patient are. And of course, there is one comprehensive record available in case of emergency.

Here too, the improvement in communication and the improvement in continuity of care and the avoidance of dangerous and expensive duplication of testing makes the adoption, eventually, of a single record compelling.  When there is a single record then all care providers will, obviously, need access to it through an EHR system.

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