EP446: Hey, Let’s Not Talk About EHRs, With Spencer Dorn, MD, MPH, MHA

This show is about getting or not getting patient outcomes and getting them in an efficient or not efficient way that is in alignment or not in alignment with the values of clinicians trying to care for their patients in the best way that they can. And I’m beginning this conversation with this preface, lest anyone lose track of the ends which we seek, which are Quadruple Aim–type goals.

For a full transcript of this episode, click here.

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I’m starting here so that we don’t get confused between what is a goal and what is a means to achieve a goal because today we’re sort of gonna talk about technology, but we’re really not gonna talk about technology. And if we’re not gonna talk about technology, then, of course—because go big or go home on this show—we’re not gonna talk about the mother of all healthcare technology: EHR systems (electronic health records). Ah, so cryptic, but let’s proceed.

I want to dig in here because this is really important, actually, to everybody, including (and especially) anyone buying healthcare services such as employers. It’s also a level set for anyone involved in or about the purveyance of said healthcare services.

Here’s my first point. Conversations about technology may be unduly focused on technology, and this includes EHRs. I saw a Tweet recently by Joshua Liu that struck me because it really mirrors my own experience working with clinical teams.

Joshua wrote, “Let me show you … why studies evaluating the same tech can have very different outcomes. Why the very same tech implemented with different workflows and people can lead to wildly different results.” See the great (and pretty funny, actually) visual that Joshua Liu made about this, but the point is this: Technology is not a thing unto itself. It is not a magic pill like those gelatin caps that you can buy at toy stores and when you toss them in the bathtub, they expand into surprisingly large foam dinosaurs. I mean, you can buy any given healthcare, digital technology, anything … and what doesn’t pop out of the box along with purchase are any sort of “why” for an end user to actually use the thing, or implementation plans, processes, change management, empowered people who are bought in, adequate training, adequate staffing levels, and ongoing communication.

So, look … here’s the point. Unlike the bass, it’s not all about the tech. There are people; there are processes. I say all this to say, it’s weird to me; and Spencer Dorn, MD, MPH, MHA, my guest today, said pretty much the same thing. It’s weird to me how we evaluate technology, and this includes EHRs and patient portals, which we talk about today, and even AI, which we will talk about in a shorter episode that will air in September. But it is so very, very common to talk about tech like it exists in a vacuum and is an end unto itself.

For example, you hear often enough people talking about optimizing the EHR. Maybe instead, the title of the conversation should be “Optimizing the Patient-Doctor Encounter” or “Optimizing Patient Health” or “Optimizing the Ability of Clinicians to Work Together as a Team.” Tech is certainly a vehicle to achieve these goals.

But whether said tech is a force of good or bad or something in the middle, or succeeds or fails, isn’t inherent in the tech itself. As Dr. Dorn says, there is no intrinsic property of the technology that determines the outcome. It’s how we use it, how we implement it, how we put it into daily practice, is really, ultimately, the arbiter of what happens and how it impacts lives.

I’d also add, just to be a bull in the china shop, even if the tech itself has some glitches, someone decided to make everyone use it in its current form. So … yeah. Therefore, first takeaway from this show is going to be don’t ascribe any given technology a label of good or bad or even neutral. This, by the way, is Kranzberg’s First Law of Technology, which, of course, comes up because you know me … I cannot miss any opportunity to nerd out over something like Kranzberg’s First Law of Technology. And that wraps up takeaway one: Technology by itself is not good or bad or even neutral. Reference Kranzberg’s First Law of Technology. Thank you, Melvin Kranzberg.

Second major takeaway is that if you’re thinking about the ultimate impact of people and processes that have some technology in their midst, technology such as an EHR system, the ultimate impact will not be a black or white binary. Let’s just acknowledge that we as humans love binaries, especially polarized binaries, because it’s very tidy. Putting things in clear boxes removes ambiguousness that our lizard brains just do not like.

But I’m keeping in mind what Tom X. Lee, MD, said on episode 445 last week. Most things in life, IRL, are somewhere in the gray murky middle. And if we understand that, we can make that middle space productive. Dr. Lee called it the productive middle. Here’s how I’d put it: Don’t be an edgelord. It’s generally not a fact-based place to be, but also, it’s not productive. Dr. Spencer Dorn and I discuss all of the above, and he makes some great points and he’s very articulate.

Here’s the three dimensions (lots of nuances). Listen to the show for a ton of nuances, but just top-line:

1. EHR-embedded operations have the capacity to empower clinicians with information and/or overwhelm clinicians with information. Most likely what’s going on will be somewhere in the middle of these two poles.

2. Impact, which is so often stated as a binary that is actually not a binary but, again, a continuum. An EHR deployment may extend or diminish human connections between docs and patients and between clinicians working together.

3. Not a binary but a continuum is whether operations with EHRs (or any tech really) make clinicians more effective and efficient or less effective and efficient from a clinician standpoint.

Dr. Spencer Dorn, my guest today, is a gastroenterologist practicing in North Carolina. He spends his time doing a few different things. That includes taking care of patients. He also helps lead a large academic practice. And lastly, Dr. Dorn works in healthcare IT and clinical informatics. So, therefore, the perfect guest to talk about this whole topic with today.

This is a really interesting conversation, so I hope you listen to it.

Also mentioned in this episode are UNC Department of Medicine; Joshua Liu, MD; Tom X. Lee, MD; Robert Wachter, MD; and Shawn Gremminger.

You can learn more at the UNC Department of Medicine Web site and by following Dr. Dorn on LinkedIn.

Spencer Dorn, MD, MPH, MHA, is vice chair and professor of medicine at the University of North Carolina (UNC), where he works to develop care models that best support clinicians and meet patients’ needs, serves as a UNC lead informatics physician, conducts clinical trials, and examines the broad forces shaping healthcare. Clinically, he works with adults experiencing disorders of gut-brain interaction and GI motility.

06:15 Breaking down Kranzberg’s Laws of Technology.

08:16 How do EHRs go right?

12:49 “EHRs empower us with information, yet they also overwhelm us with information.”

16:00 How do EHRs bring healthcare workers closer together?

19:35 The Digital Doctor by Robert Wachter.

21:33 “The whole point of healthcare is to help people live healthier, happier lives.”

22:41 How the same EHR deployed in different places can be more or less efficient.

25:51 Why the problem is not necessarily the EHR but actually operational.

28:51 How technology has also changed our expectations on timing and value. 

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