In spite of the profound functionality of these complex computerised programmes, both the ability of the vendors to create and of the providers to describe a system that achieves the creation of a truly complete product has not been realised. The current problems are multifactorial. Workflows are shifted from supporting personnel to providers, so that promised increases of free time are gobbled up by the added burdens of widened responsibilities, such as more complex documentation. Or, attempts at expedience set in, with shortcuts taken, so that the provider can move on to the next chore, such as the unrestrained use of “copy forward” to fill the clinical notes with outdated, voluminous, and unnecessary information.

In order to solve these problems and create a functional electronic health record, vendors must ensure that their products conform to the needs of those actually using them. Groups such as the “Health Information Technology Standards Panel” and the “Certifying Commission for Health Information Technology” will set and continually elevate the expectations and specifications for the electronic health record. Vendors and users will need to collaborate to realise the blend of functionality and usability lacking in the tools available today.

Stop me if you have heard this one before. A baby walks into a cardiology clinic … in the arms of his parent. He has the diagnosis of tetralogy of Fallot and has recently undergone surgery to repair his defect. He also has a microdeletion at the locus on chromosome 22q11, which is already documented in the electronic health record, or EHR. This microdeletion means that he also happens to have clefting of his palate, and he may have an immunodeficiency. His cardiologist looks at the record of the patient record in the computer. She knows that his surgery was not only successful, but also was performed with preservation of the pulmonary valve. Thus, the lack of a murmur of pulmonary regurgitation is not surprising to her. After reading the note from the cardiologist, the otolaryngologist, whose appointment occurs directly after the cardiac follow-up, is aware that this child will require prophylaxis for endocarditis in the ensuing 6 months after cardiac repair. For this infant, the surgery to repair his palate falls into this window of time. The immunologist, who will be evaluating this child for the putative immunodeficiency, reviews the electronic chart and understands that he has to wait longer to obtain blood for the necessary studies, due to the recent cardiopulmonary bypass and various associated transfusions. As a result, the desired studies are entered into the computer as requests for a future date.

Thus, the promise of the electronic health record is to provide multiple functions, including:

• • the ability to easily share information among providers,

• • the ability to order studies,

• • the ability to review the results of studies,

• • the ability to improve the safety of patients,

• • the ability to coordinate plans of care,

• • the ability to enrich the making of clinical decisions,

• • the ability to schedule patient encounters,

• • the ability to track patient encounters,

• • the ability to utilise anonymous data about patients for both improvement of internal measures of quality and for research,

• • the ability to utilise anonymous data about patients for aggregation with data from other institutions for improvement of quality and research, and so on.

What is the reality? The head of the list of challenges and problems includes:

• • large expenditures of money,

• • large expenditures of time and effort, and

• • a persistent communication gap between the designers and the users of these electronic medical records.

Numerous versions of electronic health records exist that can perform segments of the tasks that are needed, However, despite the profound functionality of these complex computerised programmes, both the ability of the vendors to create and of the providers to describe a system that achieves the creation of a truly complete product has not been realised. Current problems are multifactorial:

• • Workflows are shifted from supporting personnel to providers, so that promised increases of free time are gobbled up by the added burdens of widened responsibilities, such as more complex documentation.

• • Or, an attempts at expedience set in, with shortcuts taken, so that the provider can move on to the next chore, such as the unrestrained use of “copy forward” to fill the clinical notes with outdated, voluminous, and unnecessary information.

Even with slowly expanding standards for the acquisition and storage of data, the ability to save and, subsequently, to use the information about the patient as a meaningful tool to improve processes is hampered by a lack of understanding of true governance of data by most vendors and most providers. The electronic health record could facilitate use of the data to improve processes such as improvement of quality, processes of making decisions, workflow, and even capture of charges for billing. Although the ability to create clinical documentation is typically seen as useful and important, the value and methods of turning information into discrete data are not always obvious. And, in the end, physicians are a difficult, conservative, independent-minded group in which to affect change; conveying the message that they are doing something wrong, or that there needs to be improvement, or that there needs to be alteration of prior habits is frequently met with complaints, stonewalling, passive-aggressive behaviour, delaying tactics, and the like.

Thus, approaching the acquisition and integration of a new electronic health record into a medical practice, whether big or small, also requires the users to enter the proposition with their “eyes wide open”. It means leadership – being able to get out in front of an organisation with a vision and a plan to get there as well as the means to encourage, to enthuse, to empower, and to energise those following to work alongside. It means learning – learning about the true capabilities and limitations of these systems, about their own expectations, about the needs of the practice, about the state of the art and science of these systems, about management of change, about management of data, and about how to “algorithmicise” workflows. Just as every home with a computer in it requires at least one person to be the “security officer of information technology” and erstwhile “help desk”, medical practices need to be able to devote resources to empowering select physicians as champions who can bridge the multiple gaps that exist:

• • between vendor and provider,

• • between those savvy about information technology and those ignorant about information technology,

• • between administration and those seeing patients, and

• • between the highest and lowest of station within the enterprise.

And, it means change, something very difficult to achieve in organisations, especially those full of the aforementioned independent-minded, conservative physicians.

Of course, it is also important to decide how the electronic health record will actually be used, be it for documenting visits, billing, and scheduling patients, or for improving processes, assessing quality, and acquiring data. Moreover, the ability to understand multiple concepts and processes starts out as foreign to institutions that may have never had formal policies in place nor personnel to parse them:

• • the governance of data,

• • security of data,

• • choices about hardware,

• • impacts on work and workflows,

• • planning for disaster and recovery,

• • dedicating personnel as champions for change,

• • dealing with transition from paper to electronic charts, and

• • other complex decision-making.

These quickly overwhelm the unprepared cadre of wanderers in the wilderness. Interestingly, the same dilemmas, decisions, concerns, and pitfalls occur in institutions across the country, yet few take advantage of the experiences of others and continually reinvent their own wheels of implementation of the electronic health record within their silos. As medical facilities, from clinics to intricate medical systems, adopt the electronic health record in fits and starts and find their own individual ways, it will become increasingly important for several central processes to mature:

• • standards of nomenclature,

• • standards related to governance of data,

• • standards of adoption of the electronic health record, and

• • standards of communication.

As in the platonic view of perfection, achievement of the ideal electronic health record will be iterative. Although we are “not there yet”, the foundational changes are being made. Standards of acquisition of data for various disciplines are increasing. Groups such as the “Health Information Technology Standards Panel” and the “Certifying Commission for Health Information Technology” set and continually elevate the expectations and specifications for these systems.

In the final analysis, therefore, in order to achieve continued certification at ever-increasing levels, vendors must ensure that their products conform to the needs of those actually using them. However, placing full responsibility for the attainment of the “nirvana” of the electronic health record on these various agencies will result in a slow, arduous process that can lay the foundation for these systems, but never create the actual device. Coordination of standards of data among medical specialties will need to be accomplished, either on a national or international basis. Furthermore, hospitals need a better understanding of the management of change within and among institutions, as well as the management of projects. In addition, behaviours need to truly be changed and not just worked around. Vendors need to realise that the practice of medicine is not just another process of manufacturing: designing and building an electronic health record from the viewpoint of the clinician and the method of the provision of care is as important as the workflow. Yet, hospitals and institutions need to also open their eyes to not “reinvent the wheel”, using processes and technologies that have already been successfully applied both in medicine and in other non-medical domains. The utopian goal will be achieved under a combination of these regulatory agencies and commissions, such as the “Health Information Technology Standards Panel” and the “Certifying Commission for Health Information Technology”, in collaboration with the vendors, and the users who push them to realise the blend of functionality and usability lacking in the tools available today. Thus, when the infant with tetralogy of Fallot is older, and is able to actually walk into the clinic, the infrastructure will be in place to record his data, to share it with other providers, to save time for the providers, and to limit redundant activities, and the vision will become a reality.