EHRs driving a wedge between doctors and patients

There’s a bevy of fears that come along with the notion that technology might someday replace human physicians, but at the heart of many is a loss of patient-doctor relationships and the personalized care that comes with them.

“Patients generally feel more at ease with their situation and [have] more confidence in the diagnosis if they have a personal relationship with the provider,” Cooper said. “If you are on a first-name basis with a provider and they know who you are, then the news they provide is going to be taken so much better as opposed to situations where the provider knows you from a technical perspective — they know your chart, your lab work, but in the five minutes they’re in the room with you they’re mostly looking at those data points and not engaging with you as a person. They may have a ton of information about you in the EHR, but if they don’t stop and pause to get to know you as a person, I think their impact is going to be less. The patient is going to leave that visit with a less positive perspective.”

The issue of EHRs and documentation is not simply an over reliance on cold, hard data. Rather, explained AMA Board of Trustees Chair Dr. Jack Resneck, Jr., it’s often the increased burden these technologies shovel onto clinicians that’s making it harder for doctors to find time

“We’ve now done time-motion studies and we know — not just from people answering surveys, but by following them around — that the average physician, for every one hour they’re spending face-to-face with the patient, they’re spending two additional hours dealing with their EHRs, on the phone with the insurance company, dealing with prior authorization, etc.,” he said at a recent Cleveland Clinic conference. “That’s not OK. This is an example of technology actually getting in the way of empathy and interaction with patients. … We definitely have a potential for the EHR to help connect us to patients, but we fear it’s had the opposite effect.”

A handful of workflow-friendly EHR tools are looking to mitigate this effect as the broader push toward interoperability promises to lift the burden from physicians and other healthcare staff. On the other hand, some experts are looking toward artificial intelligence and automation as a means to both personalize each patient’s care, and allow physicians to focus their time on the patients in their office.

“As you go forward, human intelligence is probably not going to change very much and machines are going to get smarter — we’ve already seen examples of that, very quickly in fact,” Dr. Eric Topol, founder and director of Scripps Research Translational Institute and professor at Scripps Research, said in March. “But we need to get smarter and we need to get better, and that is to be more humane. And in medicine that is what I envision as the extraordinary achievement — the end result of output — the end result [is that we become] activists to stand up for our patients in the years ahead.”

Shortsighted, siloed solutions

Modern healthcare is driven by the concept of specialized care, with many complex conditions and cases requiring referrals to experts or pointed procedures. Unfortunately, many of the tools introduced so far by startups, tech giants and health systems alike have been point solutions addressing specific scenarios or challenges in a patient’s care that do not take all of the patient’s needs into consideration.

“As a theme, I do think that we [in healthcare technology] tend to get myopic about a specific application and assume that that is the one thing to solve for. But in the patient’s experience and the life of a patient, there’s a whole bunch of things that are going on and impact each other,” Manish Shah, CEO and cofounder of PeerWell, told MobiHealthNews. “If they’re going into surgery, for example, physical therapy is going to help them prepare for that upcoming procedure, but it’s also important that they address nutrition because that’s going to have an impact on their outcome in the operating room and afterwards.”

Shortsighted health technology can take many forms, Shah continued. On the one hand, there are cases in which a good functionality is hamstrung by an impractical implementation.

“One thing that I often hear about is the need for two-way messaging between patients and providers. And I agree, having healthy communication and substantive conversation between patients and providers is crucial,” he said. “But to assume that you’re going to have [them] by sheer fact of enabling two-way messaging between those entities I think is an oversimplification of the process. … What ends up happening is they end up messaging their providers at off hours, like on Sundays when they probably have an issue that’s probably pretty normal, but they’re alarmed about it and they reach out to the provider, the provider is not available, and a lot of time goes by. Then a lot of time goes by, and therefore the patient feels unsatisfied with the care they receive even though it’s not an urgent issue.”

The other side is a scenario in which technology is capable of addressing one issue, but completely neglects others that may not be quite as straightforward — for example, the stress and anxiety one may face going into a procedure.

“You have to think of the mental health that they’re going through,” Manish said while describing a hypothetical patient preparing for a medical amputation. “From the patient’s perspective, they’ve been struggling with pain for probably many years, and now they’ve come to the point where the only thing that’s going to help them get rid of this pain is someone cutting open their body and putting something foreign into it. That’s a pretty daunting thing for a person to face, and there’s a lot of anxiety, stress, depression that comes with this major event in a person’s life, and if you’re not doing anything to do that, you’re not addressing the real patient experience. That’s an area that technology tends to neglect because it becomes too myopic.”

This lack of consideration often isn’t limited to the intervention, noted Michael O’Neil, CEO and founder of GetWellNetwork. Often times the biggest slap in the face is when a healthcare organization’s investment in novel technologies trumps simple quality of life considerations.

“What I experienced from a technology standpoint was, I was laying in a hospital bed, hearing and seeing all this amazing technology around me to take care of me,” O’Neil said while recounting his own treatment for Non-Hodgkins lymphoma. “Yet, from a patient experience standpoint, I have this phone that won’t work half the time next to my bed, I’m staring at this 15-year-old TV on the wall that has about eight static-y channels.”

“From a technology standpoint for patient experience, it was incredibly frustrating, disheartening experience at a time when I wanted to be in control, informed, entertained, engaged and activated around the most important thing in my life. The technology that was there for me was quite the opposite.”

Far on the other end of the spectrum are instances in which consumers are barraged by countless apps, portals, devices and other tools that are useful in their own right, but overwhelming when employed en masse.

“As much as we want to have an experience where a patient’s health record or their information can follow them from one provider or the next, healthcare is still fairly segmented. Anybody can build a patient portal, so hospitals, urgent cares, provider networks, there is no standardization across that space,” Cooper said. “You may have a family of four or five, but you’ve got six or eight patient portals for your data depending on who you see. I think sometimes the technology is too easily acceptable so everybody gets one.”

Here, both Cooper and O’Neil stressed the need for careful deployments and an ecosystem of connect, complementary services.

“My family has five different patient portals that we’re trying to navigate through to schedule an appointment, see the results of a test, know what to do next. Patients are being caught in the crosshairs of this,” O’Neil said. “What if we were able to create a unified, digital patient family experience that allows you to, from a familiar, personalized standpoint, navigate across your journey. … The core doesn’t have to be rebuilt. It’s just, how do you put a layer above that for the patient’s experience?”

Technology reliance and data security woes

Nearly two decades into the 21st century, much of healthcare’s infrastructure is built on a base of EHRs, complex messaging systems, digital archives and connected hardware. While this gradual shift has come with countless benefits in care, it has also created a system that depends on each of those technologies to perform as expected.

“If you’re entirely reliant on technology to tell you about a patient, [you have problems] when that technology goes away,” Cooper said. “In the healthcare space, the EHR is everything. In a world of redundancy and high availability you can try your best to put those things in place, but too many times we hear about EHR not being available, either through typical technology failures or, worst case, a ransomware attach shutting down a hospital. If the basis of your care and your relationship with the patient is tied up in one system, when that system goes away it can have a real impact.”

For patients, service interruptions due to hospital hacks and system crashes are stressful  patients are stressful at best, and deadly at worst. What’s worse, should any of these incidents result in a data breach, patients are often the ones responsible for securing their private data for the long term.

“You can’t talk about healthcare without talking about data security,” Cooper said. “Your medical records contain some of the most intimate details of a person’s life, and you’re entirely trusting that the technology and security is going to keep that safe. Many people including myself have gotten letters from a healthcare organization saying ‘We think your data might have been compromised. Here’s five steps you should take to ensure your privacy.’ Well, [it’s] your mistake, but now I’m the one who has to fix it. So it adds burden — you’re already dealing with physical challenges and health problems, and now you’re also burdened by having to take care of yourself when your data is compromised.”

Inelegant design and information overload

The fact of the matter is that technology is complicated, and healthcare technology doubly so. As consumerization becomes a growing focus for many in the industry, there’s little shortage of new tools and products being designed for use by patients interested in taking control of their care. But that’s not to say that they are being designed particularly well.

“There’s a lot of technology that is great, but isn’t designed for the most common user in healthcare,” Shah said. “The predominant user in healthcare is actually a senior, somebody in their 60s, 70s and 80s that is receiving lots and lots of care because they have health issues. But a lot of the technology isn’t designed with that person in mind — it has a lot of complications and complexity that I think can, by the nature of it, impede the user’s ability to use that technology to support them through the healthcare they are receiving.”

A big issue is the varying levels of health literacy a single product needs to accommodate. With many users undergoing care ranging from the simple to the complex, a tool that offers information but does not appropriately contextualize it is more likely to confuse the patient than it is to help them.

“The answer for patients is not to flood them with all this non-consumer-facing and non-consumer-relevant information all at one time, and pretend that the fact that I have this information about this clinical care is going to help me navigate my clinical care,” O’Neil said. “Uncurated reams of data and content flowing directly to the patient and families is not helping them navigate, make great decisions, find comfort and be able to do things they need to do. What we really need is for technology to take all of this complex information and to reformat it, framework it, and curate it … so that people can understand it, absorb it and act on it.”

Just as important is the design of the product itself. A bland presentation, unintuitive navigation and excessive negative feedback can all drive users away, explained Greg Raiz, chief innovation officer at customer experience agency Rightpoint. For many digital health design projects — such as his company’s work on the consumer app for Neurometrix’s Quell device — consideration of the target audience’s needs and unique challenges.

“Even within universal design, you can skew the design towards your audience,” he told MobiHealthNews. “When we look at different products we try to think what’s the demographic — are you older, younger — are there different impairments that the particular audience may or may not have? We’ve actually designed a number of applications for folks who are blind or visually impaired, so that’s a lot more emphasis on things like accessibility, design, typography, visual contrast and things of that nature.”

“For us,” Shad said, “we spent quite a number of years with seniors to learn the ways in which they would prefer to use that technology. It actually boils down to some very obvious things: reading level, tap targets within a user experience, guiding the patient through a user experience. Things like that actually help a lot [in] getting people over that technology barrier and making it a part of their healthcare experience.”