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Director's Letter

In the November 12 edition of The New Yorker, Atul Gawande writes insightfully about the conficting effects of the electronic health record (EHR) on doctors and medical care. Clinicians are increasingly frustrated with their electronic records, which have inundated them with reminders, lab alerts, notes from colleagues, and queries from patients, to the point that they are taking hours of computer work home with them each night. An increasing share of each offce visit is spent typing into the computer rather than building real relationships with their patients. Not coincidentally, burnout rates among physicians are at worrisome levels. Yet at the same time, it is only through the EHR's ability to capture standardized data that health systems have been able to track performance across all their clinicians and patients, and drive out unnecessary variation. Gawande quotes Gregg Meyer, CMO of Partners Health System in Boston, who observes that EHRs are for patients not clinicians. Patients are the benefciaries of this improved quality, and they are now the most numerous among users of EHRs, whether to ask questions of their healthcare team, renew medications, or check test results. Even as everyone complains about the current state of EHRs, no one actually envisions going back to paper records.

Gawande cites experts who have documented the inevitable progression of computer systems: they often begin as small, homegrown tools built to solve very specifc tasks effciently, but as they succeed they grow to serve larger audiences with more diverse needs. This growth brings with it a need to control the level of variation across the system, bringing bureaucratic change control processes that squelch the innovation and confict that played out in the evolution of VA's Computerized Patient Record System (CPRS). It began as a locally grown program designed by computer-savvy clinicians to make their job easier, but it gradually grew into a national medical record system responsible for coordinating a much larger set of tasks across multiple different data systems. As CPRS spread to over 160 medical centers, it developed many local variations and customizations which made it impossible for VA to easily deploy useful new tools and advances across a national system. This failure to modernize, as much as the need to share records with DoD, made moving the VA to a new EHR system necessary.

Gawande poses two possible paths forward, one bleak and the other hopeful. In one, the record continues to evolve to make care safer and more effcient, while making the daily lives of clinicians and staff more depersonalized and miserable. The more hopeful vision is one enabled by open application programming interfaces (APIs) that retains a consistent, standardized core of the EHR but allows for innovators to create (and clinicians to choose) customized apps that present data in a way that better suits specifc clinical needs. Initially resisted by large vendors as a threat to their revenue, open API is slowly being adopted. One could dream of a future where Cerner and VA cooperate to allow bright VA clinicians to innovate on the Cerner core, producing advances that make clinicians' lives better while building value for the Cerner platform.

David Atkins, MD, MPH, Director, HSR&D

Gawande A. "The Upgrade: Why Doctors Hate their Computers," The New Yorker, November 12, 2018, p. 62-73.