The Crisis of Fragmented Electronic Health Records
The State of EHRs
The rapidly growing digital world is teeming with healthcare information. Digital health data, specifically Electronic Health Records (EHR), has become instrumental in its ability to provide a seamless healthcare experience. However, the current state of EHR systems worldwide reveals a crisis of fragmentation that requires urgent attention.
A brief historical recall will remind us of the Health Information Technology for Economic and Clinical Health (HITECH) Act, part of the American Recovery and Reinvestment Act of 2009. Similar, but unlike GDPR in Europe, the HITECH Act forced all healthcare providers to adopt EHR. The objectives were in part: 1) to accelerate the adoption and promote the “meaningful use” – the utilization of EHR systems in a way that improves quality, safety, efficiency, and patient engagement in healthcare delivery- and 2) to modernize the healthcare industry’s use of technology to improve the exchange of health information. The HITECH Act also imposed a deadline of January 1, 2014, on medical providers to demonstrate meaningful use or incur a hefty federal penalty. In contrast, the HITECH Act provided financial incentives for adopting and utilizing certified EHR technology in a meaningful way .
From my own personal experience, I recall the transition from the “doctored chicken scratch” patient notes that could barely be deciphered by myself and my colleagues in residency to typing and clicking away Subjective-Objective- Assessment-Plan (SOAP) notes as a resident. After graduating as a young physician with a technical background in computer science, I volunteered to lead the transition and customization of the EHR for my surgical department. In the initial stages, the EHR was simply a well-organized and searchable digital repository. It allowed clinicians to easily retrieve patient notes and test reports, saving valuable time from combing through several manilla folders retrieved from the records room in the back office.
An often overlooked consequence of the HITECH Act is the heavy proliferation of different EHR systems on the pretext that no one EHR was suitable for every medical practice, facility, or specialty. Along with the multiplicity of EHR systems came commercialization and proprietary software that often lacked interoperability and hence the rise of fragmentation in EHR.
Another consequence of the deadline imposed by the HITECH Act was the haste in which EHR systems were brought to the market, inevitably fostering their clinical limitations. These limitations include 1) user Interface complexity, 2) burdensome manual data entry and extensive documentation requirements, 3) poor integration with patient engagement tools, and 4) limited effective communication and interaction between healthcare providers and patients.
Fragmented EHRs: Impact on Healthcare Delivery
Just like the 18th Amendment (Prohibition), the HITECH Act worsened the very problem (interoperability) it sought to address. Interoperability remains a significant challenge in EHR systems. Different EHR systems often use different data standards, formats, and protocols, making it difficult to exchange data seamlessly between systems. Although there have been several initiatives to promote the interoperability of EHRs both at the federal and state level, including the enactment of the 21st Century Cures Act (Cures Act) of 2016, the Trusted Exchange Framework Common Agreement (TEFCA)** is far from making interoperability a reality.
User interface complexity, exacerbated by a multiplicity of screens or distant data locations and complex navigation systems in EHR systems, contributes to what experts call “Display Fragmentation” . The complex user interfaces can be challenging to navigate, leading to workflow inefficiencies and potential errors. Doctors and allied health personnel spend excessive time searching for information or entering data, which can impact productivity and patient care. This can be time-consuming and burdensome for healthcare providers, contributing to physician burnout.
The Impact of Fragmented EHRs on Patient Care
The ramifications of EHR fragmentation extend beyond healthcare providers and directly influence patient care quality. Unstructured and inadequately linked data may lead to errors, misinterpretations, and potentially life-threatening patient safety issues. Further, many EHR systems often do not provide seamless integration with patient engagement tools, limiting effective communication and interaction between healthcare providers and patients. This can impede patient education, remote monitoring, and shared decision-making.
Toward a Unified EHR Future: Potential Solutions
Enhancing the EHR systems’ usability and efficiency should be a critical goal in this era of digital health transformation. There is a need to reduce cognitive workload and prioritize physician-patient engagement. EHR designs must be optimized to fit seamlessly into healthcare workflows and cater to individual work patterns depending on size, specialty, and setting.
An effective solution could involve making EHRs more modular and configurable, allowing physicians to customize their health IT environment, and improving both workflow and patient care. Additionally, encouraging team-based care by enabling task delegation would not only boost productivity but also promote a cooperative care atmosphere. Moreover, visualization techniques and microanalytic methods could be utilized to reduce fragmentation and streamline navigation structures.
Harnessing digital technologies may offer significant advantages in resolving the fragmentation crisis. During the COVID-19 pandemic, the importance of real-time data tracking and analysis was underscored. Such technologies, if integrated effectively with EHR systems, could potentially provide timely insights, and enable effective crisis management.
Digital technologies have also demonstrated promise in enhancing disease surveillance, improving communication, and bolstering patient engagement. Incorporating these capabilities within EHRs can lead to more comprehensive and coordinated care delivery, addressing the current fragmentation problem.
The Role of Artificial Intelligence in Mitigating the Impact of Fragmentation
Artificial intelligence (AI) in healthcare can be promising in data extraction and analysis and in the integration of fragmented EHRs.
AI can process large datasets within EHRs, identifying and extracting relevant patient information, regardless of whether it is structured or unstructured. This automation can help to increase efficiency and save time for clinicians.
Similarly, AI can integrate fragmented data, providing a comprehensive view of a patient’s health history and assisting clinicians in making informed decisions.
However, challenges such as algorithmic accuracy, data privacy, regulatory considerations, and the potential for unintended negative consequences of AI on health outcomes need to be addressed. Continued collaboration between AI developers, clinicians, and other stakeholders is key to addressing these challenges and maximizing the benefits of AI in patient care.
The crisis of fragmented EHRs, while complex and multifaceted, presents opportunities for healthcare innovation. Solutions to this crisis, including improved EHR design, integration of digital technologies, and the application of AI, have the potential to enhance the quality of patient care, improve the healthcare experience, and foster a more efficient and effective healthcare system. However, implementing these solutions will require a concerted effort from all stakeholders in the healthcare ecosystem, including healthcare providers, EHR developers, and policymakers.