Time To Build EHRs That Address Human Complexity

As things stand in our world, caring for patients generally falls into two broad categories: treating the body and its innumerable mysteries, and caring for practicalities of the patient’s mental and social health. The two are interrelated, of course, but often they’re treated independently, as if each existed in a separate world.

But we know that this is a false dichotomy. People don’t go from being patients at one point and human beings later, and treating them that way can fail or even cause them harm. At every point, they’re people living in a complex world which may overwhelm their capacity for getting good healthcare. Their values, social networks, resources (or lack thereof), education and mental health status are just a few of the many dimensions that influence a patient’s overall functioning in the world.

This isn’t a new idea. As Frances Peabody noted in a 1927 lecture to Harvard Medical School students, “the secret of the care of the patient is in caring for the patient,” by understanding how a patient’s personal and emotional circumstances influence their health status. It’s a concept that needs revisiting, particularly given that the automation of care seems likely to further alienate doctors from patients.

Given how seldom physicians have a chance to address patients’ life circumstances, and how important it is that medicine returns to this approach, it was good to see the The Journal of the American Medical Association weigh in on the issue.

In the Viewpoint piece, entitled “Evolutionary Pressures on the Electronic Health Record: Caring for Complexity,” the authors contend that next-generation EHRs will need to do much more to help physicians address an increasingly complex patient mix.  They suggest that rising patient complexity – due to issues such as co-occurring chronic and rare diseases, organ transplantation and artificial devices – are changing the practice of medicine. Meanwhile, they point out, patients’ personal experience of illness and the social context in which they live are still important considerations.

But EHRs aren’t developing the capacity to meet these needs, they note:

The evolution of EHRs has not kept pace with technology widely used to track, synthesize, and visualize information in many other domains of modern life. While clinicians can calculate a patient’s likelihood of future myocardial infarction, risk of osteoporotic fracture, and odds of developing certain cancers, most systems do not integrate these tools in a way that supports tailored treatment decisions based on an individual’s unique characteristics.

Existing EHRs aren’t designed to help physicians use predictive analytics to deliver preventative care or services to targeted individuals either, they note. Nor are they helping clinicians to learn from past cases in a systematic manner, the piece says:

When a 55-year-old woman of Asian heritage presents to her physician with asthma and new-onset moderate hypertension, it would be helpful for an EHR system to find a personalized cohort of patients (based on key similarities or by using population data weighted by specific patient characteristics) to suggest a course of action based on how those patients responded to certain antihypertensive medication classes, thus providing practice-based evidence when randomized trial evidence is lacking.

The JAMA authors also take EHR vendors to task for doing nothing to capture social and behavioral data (otherwise known as “social determinants of health”)  which could have a big impact on health outcomes and treatment responses:

In this world of patient portals and electronic tablets, it should be possible to collect from individuals key information about their environment and unique stressors – at home or in the workplace – in the medical record. What is the story of the individual?  The most sophisticated computerized algorithms, if limited to medical data, may underestimate a patient’s risk (eg, through ignorance about neighborhood dangers contributing to sedentary behavior and poor nutrition) or recommend suboptimal treatment (eg, escalating asthma medications for symptoms triggered by second-hand smoke).

If EHRs evolve successfully to embrace such factors – and move away from their origins in billing support – physicians may spend much less time with them in the future. In fact, the authors speak lovingly of a future in which “deimplementing the EHR” becomes a trend, and care no longer revolves around a computer. This may not happen anytime soon.

Still, perhaps we can speak of “rehumanizing the EHR” with information that address the whole, complex person. A rehumanized EHR that Francis Perkins would use, were he alive today, is something physicians should demand.