In this case, a number of potential pitfalls are worth exploring. The most obvious is privacy – will EHR lead to an erosion of centuries-old protections of doctor-patient confidentiality? The answer appears to be that safeguards are currently in place, but none are fully tamper-proof. Even if we judge that the current political climate in the United States supports an adequate degree of confidentiality, who can say with assurance that creation of permanent electronic health records will not open the door to future abuses in an era less tolerant of individual liberty?

But there is an even more significant and pressing question about going nationwide with EHR. Are these highly touted systems as functional as their proponents claim, particularly proponents who have a financial or career-building stake in closing the biggest sale of their lives? In the rush toward across-the-board EHR, the voices in favor are currently drowning out those expressing serious doubts. One has to dig deep to find out why anyone would oppose these massive changes.

Rather than attempt to cover the full range of questions raised by those skeptical of the EHR juggernaut, I want to suggest as a starting point two sources to examine and consider. These were recommended to me by Marc Micozzi, MD, PhD, a member of our Health Insights Today editorial board. The first is an article by Koppel and Kreda¹ published in the Journal of the American Medical Association in March 2009, which notes that “health care information technology (HIT) vendors enjoy a contractual and legal structure that renders them virtually liability free—“hold harmless” is the term of art—even when their proprietary products may be implicated in adverse events involving patients. This contractual and legal device shifts liability and remedial burdens to physicians, nurses, hospitals, and clinics, even when these HIT users are strictly following vendor instructions.” This is reminiscent of the legal immunity granted to manufacturers of vaccines and nuclear power plants. Why are EHR software companies being granted similar protections? I’m not certain, but the question clearly needs to be asked. And answered.

The second source I recommend for clues as to how things can go wrong is a chilling and intentionally provocative 8-part blog post by Scot Silverstein, MD, a medical informatics specialist at the College of Information Science and Technology at Drexel University in Philadelphia. Dr. Silverstein is alarmed by EHR program dysfunctions he has witnessed in hospitals, some of which involved life-threatening risks. He asserts that these dysfunctions are the rule, not the exception, and provides specific examples to buttress his case. He sees current moves to take EHR system-wide as constituting “an outrageous cross-occupational piracy with doctors’ time, professions, and ability to deliver care held hostage … It is unbelievable to me that a system like this could be put into production in a hospital. Simply unfathomable … These ‘user experiences from hell’ are causing clinician cognitive overload, distracting and tiring them, and due to violations of fundamental good practices in information display, actually promoting error [emphasis in original].” Read Silverstein’s full commentary, click on his links, and then ask yourself how it all squares with government and vendor descriptions of EHR functionality.

Good policy results from thoroughly examining all sides of an issue. Despite the “freight train barreling down the track” nature of the current push for system-wide implementation of EHR, I remain hopeful that current problems can be corrected. What concerns me most is that we may not know the full ramifications of the shift until it is too late to make a smooth course correction.

Daniel Redwood, DC, Editor-in-Chief
editor@healthinsightstoday.com

REFERENCE

1. Koppel R, Kreda D. Health care information technology vendors’ “hold harmless” clause: implications for patients and clinicians. JAMA. Mar 25 2009;301(12):1276-1278.