Over the past few weeks, I’ve been recovering from a shoulder fracture. (For the record, I wasn’t injured engaging in some cool athletic activity like climbing a mountain; I simply lost my footing on the tile floor of a beauty salon and frightened a gaggle of hair stylists. At least I got a free haircut!)
During the course of my treatment for the injury, I’ve had a chance to sample both the strengths and weaknesses of coordinated treatment based around a single EMR. And unfortunately, the weaknesses have shown up more often than the strengths.
What I’ve learned, first hand, is that templates and shared information may streamline treatment, but also pose a risk of creating a “groupthink” environment that inhibits a doctor’s ability to make independent decisions about patient care.
At the same time, I’ve concluded that centralizing treatment across a single EMR may provide too little context to help providers frame care issues appropriately. My sense is that my treatment team had enough information to be confident they were doing the right thing, but not enough to really understand my issues.
My insurance carrier is Kaiser Permanente, which both provides insurance and delivers all of my care. Kaiser, which reportedly spent $4 billion on the effort, rolled out Epic roughly a decade ago, and has made it the backbone of its clinical operations. As you can imagine, every clinician who touches a Kaiser patient has access to that patient’s full treatment history with Kaiser providers.
During the first few weeks with Kaiser, I found that physicians there made good use of the patient information they were accumulating, and used it to handle routine matters quite effectively. For example, my primary care physician had no difficulty getting an opinion on a questionable blood test from a hematologist colleague, probably because the hematologist had access not only to the test result but also my medical history.
However, the system didn’t serve me so well when I was being treated for the fracture, an injury which, given my other issues, may have responded better to a less standardized approach. In this case, I believe that the industrial-style process of care facilitated by the EMR worked to my disadvantage.
Too much information, yet not enough
After the fracture, as I worked my way through my recovery process, I began to see that the EMR-based process used to make Kaiser efficient may have discouraged providers from inquiring more deeply into my particulalr circumstances.
And yes, this could have happened in a paper world, but I believe the EMR intensified the tendency to treat as “the fracture in room eight” rather than an individual with unique needs.
For example, at each step of the way I informed physicians that the sling they had provided was painful to use, and that I needed some alternative form of arm support. As far as I can tell, each physician who saw me looked at other providers’ notes, assumed that the predecessor had a good reason for insisting on the sling, and simply followed suit. Worse, none seemed to hear me when I insisted that it would not work.
While this may sound like a trivial concern, the lack of a sling alternative seemed to raise my level of pain significantly. (And let me tell you, a shoulder fracture is a very painful event already.)
At the same time, otherwise very competent physicians seemed to assume that I’d gotten information that I hadn’t, particularly education on my prognosis. At each stage, I asked questions about the process of recovery, and for whatever reason didn’t get the information I needed. Unfortunately, in my pain-addled state I didn’t have the fortitude to insist they tell me more.
My sense is that my care would’ve benefited from both a more flexible process and more information on my general situation, including the fact that I was missing work and really needed reassurance that I would get better soon. Instead, it was care by data point.
Dealing with exceptions
All that being said, I know that the EMR alone isn’t itself to blame for the problems I encountered. Kaiser physicians are no doubt constrained by treatment protocols which exist whether or not they’re relying on EMR-based information.
I also know that there are good reasons that organizations like Kaiser standardize care, such as improving outcomes and reducing care costs. And on the whole, my guess is that these protocols probably do improve outcomes in many cases.
But in situations like mine, I believe they fall short. If nothing else, Kaiser perhaps should have a protocol for dealing with exceptions to the protocols. I’m not talking about informal, seat-of-the-pants judgment call, but an actual process for dealing with exceptions to the usual care flow.
Three weeks into healing, my shoulder is doing much better, thank you very much. But though I can’t prove it, I strongly suspect that I might have hurt less if physicians were allowed to make exceptions and address my emerging needs. And while I can’t blame the EMR for this experience entirely, I believe it played a critical role in consolidating opinion and effectively limiting my options.
While I have as much optimism about the role of EMRs as anyone, I hope they don’t serve as a tool to stifle dissension and oversimplify care in the future. I, for one, don’t want to suffer because someone feels compelled to color inside of the lines.