Integrating Technology Into Health Care
Authors: C. Jason Wang, Andrew T. Huang
Journal: JAMA (2012)

TECHNOLOGY IS IN PART RESPONSIBLE FOR INCREASing health care costs; however, new technology platforms, especially those from consumer electronics, have the potential to both decrease costs and increase the efficiency and quality of care. The benefits of electronic health records (EHRs) are well documented, yet their introduction has been greeted with reluctance and sometimes resistance. Indeed, current usage rates are quite low. Similarly, personalized health records (PHRs) for consumers, such as Google Health and Microsoft HealthVault, also have not achieved their predicted uptake. As such, Google shut down Google Health as of January 1, 2012, because “it is not having the broad impact that we hoped it would. . . . We haven’t found a way to translate that limited usage into widespread adoption in the daily health routines of millions of people.” In addition to studying health information technology in its current state, what future conditions will be necessary to promote widespread adoption and use? To fit into the lives of clinicians, technology must optimize the 3 major components of a clinician’s time: time spent with patients, time spent on documentation, and time spent on continuous learning. Similarly, to fit into the lives of patients, technology must help patients do the jobs that they perceive as high priority in their lives. For example, many patients perceive financial health and other concerns as more pressing jobs to be done than physical health. To date, neither EHRs, controlled by clinicians, nor PHRs, controlled by patients, have been designed to integrate satisfactorily into the lives of users. Many existing EHRs have unwieldy designs. Although the user interface has shifted from a 3-dimensional paper chart to a limited 2-dimensional screen, data are still organized by what a clinician would write on a paper chart to capitalize on the user’s experiential knowledge. Most EHRs force clinicians to navigate through a maze before getting to the desired data field. As such, documentation often is more time consuming with EHRs than with paper records, which means that clinicians have less time for patient interaction or for continuous learning. Moreover, existing EHRs offer little innovation in output. Most available output is similar to paper records—a large amount of information in linear text format—and offers little connection, saliency, clinical insight, or prioritization to the user. Few attempts have been made to generate intuitive and useful trending of patient data, such as weight and height. Similarly, laboratory data and tests are populated into EHRs without linkages to the original test order. As such, data in current EHRs are not easily searchable or retrievable at the point of care, or even for qualityrelated data abstraction. Furthermore, the electronic files are logged and filed like paper records. Reviewing a patient’s files can be painstaking, with important clinical information often hidden in the sea of data. For most clinicians, retrieving digestible and up-to-date information about the patient from the EHR is difficult in the time allotted for a clinic visit. Yet, should anything go wrong with the patient, the EHR can be sieved through by others, such as medical informaticians or attorneys. Thus, EHRs have become expensive versions of paper logs, with increased liability for practitioners and health care organizations but without concurrent improvements in the efficiency of care. In this current form, there is little return on investing in EHRs. Costs are passed down to health care organizations in terms of dollars, clinicians in terms of time, and consumers in terms of face-time with clinicians, with few improvements in utility. Large EHR systems resemble mainframe computers, for which the cost of purchasing, implementing, and maintaining a system far exceeds the value it currently provides. It is common for major hospital systems to spend half a billion dollars on EHRs that users still find unhelpful to their day-to-day practices; for smaller organizations, investment in such expensive systems is prohibitive. Similarly, as therapeutic advances reach patients, PHRs are expected to promote shared decision making and patient engagement in the era of consumer technology. Motivating patients to adhere to recommended treatment regimens is the “the last mile” of health care delivery. Volpp and Das have suggested that 40% of premature deaths in the United States are attributable to individual health-