This opinion piece was written by Jennifer D. Miglus, NNLM/NER Health IT Community of Interest leader for 2014-2015. Information about this COI can be found here: http://nnlm.gov/ner/communitiesofinterest/healthit.html
In the spring of 2014, NNLM/NER hosted two webinars on librarians and ways they might be involved with their institutions’ Electronic Health Records (EHRs). Suggestions ranged from embedding a search request form in a homegrown system (Vanderbilt) to piloting ways to link out to basic patient education and point of care resources (St. Louis Children’s). The Biomedical Informatics department at the University of Utah, School of Medicine is exploring ways to streamline requests for answers to complex questions, and John Halamka of Harvard, which also uses its own in-house system, would look to librarians for patient education information resources, metadata indexing of data uploaded to EHRs, and possibly the curation of decision support rules.
For many librarians, even getting a seat at the table for IT discussions of EHR functionality is a challenge. Institutions are racing to comply with Meaningful Use stage II requirements and an ‘out of the box’ version of an EHR appears to be the only way forward. Institutions with the will and the resources to develop their own EHR in-house are few and far between.
Searching for other avenues for librarians in this area, I came across a report  of a keynote speech for the Association of Academic Health Sciences Libraries (AAHSL) Symposium in 2009 given by Dr. Kenneth D. Mandl. Dr. Mandl has strong credentials. He is associate professor at Harvard Medical School and director of the Intelligent Health Laboratory at the Children’s Hospital Informatics Program, Harvard University-Massachusetts Institute of Technology Division of Health Science Technology. Dr. Mandl believes that “the very nature of EHR systems is deeply flawed.”  His 2012 piece for the New England Journal of Medicine is titled: Escaping the EHR Trap – The Future of Health IT .
Here is a brief synopsis of Dr. Mandl’s NEJM article:
Vendors of EHRs would have you believe that they, and only they, are capable of managing health information in a safe and effective way. This is not the case. There is no reason why healthcare providers should hand over control of their data to these vendors. Furthermore, these systems are hugely expensive and do not talk well with other systems. Often, even the parts of a single system do not work well together.
Dr. Mandl would like to move beyond EHRs and he describes alternative Health IT efforts as “disruptive innovations”. If you’re interested, Jill Lepore has written a thoughtful, well-researched piece in The New Yorker , effectively de-bunking this trendy theory as a way to transform systems. However, this in no way detracts from his argument, and Mandl goes on to give four components of Health IT that could be well served by existing generic technologies.
The first component is secure private storage. Many people will cite privacy concerns and HIPAA when talking about health data management. To those who cleave to EHRs to protect patient privacy, he counters: “Many industries depend as much as health care does on the security and confidentiality of their data.” Banking comes to mind. Are we any less concerned with the safety and security of our financial information than we are of our health data? Last year, influential members of the Health IT community published an article in JAMA promoting “Health Record Banks” . In Health Record Banks, the patient controls his or her patient data which is deposited from all the patient’s providers into a local Record Bank. This is not a fringe idea.
The second component is secure communication. Certainly there are existing protocols that would fulfill this basic need for health information exchange. The Office of the National Coordinator for Health Information Technology (ONC) itself is promoting “a secure communications system for health care based on SMTP (Simple Mail Transfer Protocol)” through its Direct Project.
Documentation tools are the third component of Health IT that could be served by generic technologies. Mandl cites other industries’ project management software. I grant you that these, like EHRs, are also often expensive and proprietary, but Mandl gives Teambox, Basecamp and Huddle as examples of software that could serve.
The fourth component is tools to aid in the analysis of health data. Software applications to facilitate data loading, graphing, mapping and analysis are used practically everywhere. Why should health data require special ones? In sum, while Mandl acknowledges that Health IT has unique requirements, he believes that the tools to accomplish these tasks can be found in “flexible and generic toolkits”.
How can librarians serve institutions grappling with this fractious and complex topic? By doing what they do best; providing information and education. Learn as much as you can about your current institution’s use of EHRs: What system are they using? Can you attend a training session? What problems have they encountered? Then help them find solutions. You might find the opportunity to tell people about the concept of Health Record Banks and point them to the website: http://www.healthbanking.org/. You can point stakeholders to the published literature on alternatives to vendors peddling stand-alone EHRs.
I know that Meaningful Use is marching onward and that institutions are under pressure to be compliant now, with little time to explore other options. I know that there is still huge opposition to information sharing between institutions. I know that politics is not necessarily driven by evidence. However, I believe we can be included in discussions around Health IT at our institutions. We just need to be informed, and we need speak up.
- Curtis, J.A., Electronic health records, platforms, libraries, and evidence: report on the Association of Academic Health Sciences Libraries symposium’s keynote presentation by Kenneth Mandl. Journal of the Medical Library Association: JMLA, 2010. 98(3): p. 206.
- Mandl, K.D. and I.S. Kohane, Escaping the EHR trap—the future of health IT. New England Journal of Medicine, 2012. 366(24): p. 2240-2242.
- Lepore, J., The Disruption Machine: What the gospel of innovation gets wrong. The New Yorker, 2014.
- Yasnoff, W.A., L. Sweeney, and E.H. Shortliffe, Putting health IT on the path to success. JAMA, 2013. 309(10): p. 989-990.