Digital Health Technologies and Electronic Health Records: Power and Problems
September 6, 2024
by Grete McCoy MPH, RDN, CDCES
Introduction
Digital health technologies (DHTs) and Electronic Health Records (EHRs) have revolutionized today's healthcare. Efforts to develop EHRs began in the 1960s and ’70s, when academic medical centers developed their own systems[1]. The passing of the Health Information Technology for Economic and Clinical Health (HITECH) Act in the US in 2009 spurred rapid adoption of EHRs in the United States with over 80% of hospitals using EHRs in 2015 compared to less than 10% in 2008.[2] EHRs have also evolved rapidly and now streamline scheduling, handle referrals, take care of billing, send prescriptions to pharmacies and order durable medical equipment (DME). They have facilitated increased access to healthcare providers (HCPs), and, with the help of DHTs, provide HCPs access to real-time data for faster response to issues like blood sugar levels and blood pressure. However, EHRs and DHTs are not without challenges. As a registered dietitian treating diabetes since the mid-1990s, I’ve had a front-row seat in seeing how this technology is reshaping healthcare.
Outside the Clinic Walls: Digital Health
Digital health technology can refer to digital technology for a wide spectrum of health-related metrics, but the FDA defines a DHT as a system that uses computing platforms, connectivity, software, and/or sensors, for health care and related uses[1]. DHTs are playing a growing role in health care, more offices are utilizing remote monitoring to stay in touch with patients between visits. Wearable Devices, like continuous glucose monitors, heart monitors, and smartwatches provide real-time data on health metrics such as blood glucose to heart rate to sleep patterns to physical activity. This data helps both patients and HCPs to manage health conditions, medication effectiveness and adherence, and even lifestyle choices. A typical physician visit for someone with diabetes is every three months, and labs to assess treatment are only drawn at those visits. With remote monitoring, an HCP can log in to a designated portal, review their patients’ real-time blood glucose or blood pressure, assess medication and activity levels, and, if needed, make medication adjustments. It can be frustrating for both physician and patient if something has not been working and it is not addressed until the patient’s next scheduled visit, 3 months later. When using a wearable device, the HCP reviewing the data must know their patient and the standards of care for the condition being monitored. In addition, they need to know the device, how it works, and the data it provides. Patients also require training to be able to use the device correctly and link to the HCP system.
Inside the Clinic: Electronic Health Records (EHRs)
Healthcare providers are mixed in their views of EHRs with some disliking the constrained data entry, often requiring the use of drop-down lists, and discouraging (or prohibiting) the use of written notes. However, they also appreciate the ease of access to patient data, including labs and imaging data, from outside the office. EHRs facilitate cutting and pasting and if data has been entered incorrectly it can be carried through to subsequent visits without anyone checking. Once while reviewing working at a pediatric hospital, I noticed the age of the patient was recorded as 48. Going back through the notes from 6 office visits, I eventually found the correct age of 4 years and 8 months. Other drawbacks include power or internet outages and data that was not saved correctly (or at all).
Ideally, EHRs should centralize patient data, making it easily accessible to multiple authorized healthcare providers. Patient medical history, lab results, and treatment plans should be available at the point of care, to improve both efficiency and accuracy. Unfortunately, not all systems are interoperable, and although the newly renamed Assistant Secretary for Technology Policy/Office of the National Coordinator for Health IT (ASTP/ONC) is working to change this, it is often left to the patient to make sure a specialist has all the information needed for a consult. The adaptation of Patient Portals alleviates some of these issues, giving the patient access to their records and the ability to send them to anyone they choose.
Data
EHRs collect a vast amount of data that can be analyzed to identify trends, improve treatment protocols, and enhance patient outcomes. Data analysis helps in identifying at-risk populations, incidence of chronic conditions, or tracking the effectiveness of new treatments.[2] They can also be used to track the performance or level of care a physician provides, however, caution should be used as information can be entered and/or interpreted incorrectly. The extreme detail in the ICD10 coding can lead to confusion over the best coding choice to enter and there can be a discrepancy between the true diagnosis and the code entered. For example, a new patient who did not bring past lab work might be misdiagnosed as having acute renal failure when they have CKD (chronic kidney disease). A diabetes patient seen via a telemedicine visit might tell a primary care provider (PCP) their A1c has been good, and they have no additional problems leading to a code for “type 2 diabetes without complications” when a physical exam would have shown poor pedal pulses and a random blood sugar might be elevated indicating the correct diagnosis is “type 2 diabetes with peripheral circulatory complications uncontrolled”. Confounding that problem, a skilled biller/coder knows that some codes will not be reimbursed or are reimbursed at a lower level than others, and codes that provide reimbursement may be used preferentially. For example, CKD is reimbursed where Kidney Disease Stage 3 is not, and the HCP may choose to code CKD and note the stage in the narrative. This can cause problems or at least extra work for studies that are seeking to use a stage or the disease as inclusion or exclusion criteria for an RWD clinical trial. These differences in coding and subsequent reimbursement can be a large factor between a thriving small practice and having to shut down.
Medication switching trends may also be misinterpreted due to a PCP having to change medications to those that will be covered by a patient's health plan, not because the initial medication was ineffective. When this happens, the reason for the switch is rarely documented in the EHR. Users of EHR data for secondary purposes, such as supporting safety or efficacy for a placebo arm of a new drug or biologic, need to be aware of potential errors in EHRs as well as regional practices in coding and standard of care which could bias results especially when pooling data from patients in different areas and with diverse demographic profiles.
Patient Engagement
Many EHR systems include patient portals to allow individuals to access their health information, schedule appointments, and communicate with their healthcare providers. This increased transparency and access will ideally lead to increased patient engagement and that should lead to better health outcomes and patient satisfaction. However, HCPs and allied health practitioners may decide to not document critical information such as patient comprehension, adherence to treatment, and other issues in the EHR if it could upset a patient. This is especially a concern for pediatric or geriatric practices where parent or caretaker behavior and attitudes can impact treatment. An office doesn’t want to risk a caregiver not bringing the child or patient in for care. Technology can be used to address this but would need to comply with rules addressing patient data access.
Moving Forward
Digital health technologies and electronic health records are revolutionizing the healthcare sector and the future of healthcare is undeniably digital. Challenges still exist, but work is being done to solve them. As technology continues to evolve and improve, we can expect even greater advancements in digital health tools, EHRs, and the use and analysis of the data collected from both technologies. Healthcare providers and patients must work together to ensure that accurate data is being collected and used in ways that facilitate its use in identifying optimal healthcare, both for the patient and for the wider US population. Innovations for secure data sharing, increased usage of linked and wearable technology, and more sophisticated algorithms for data checking as well as for analysis and diagnosis offer multiple opportunities for increasing healthcare access, improving healthcare delivery, empowering patients to participate in their care with the potential to contribute to improved patient outcomes and a healthier population.
[1] Digital Health Technologies for Remote Data Acquisition in Clinical Investigations Guidance for Industry, Investigators, and Other Stakeholders, December 2023.
[2] Ryan, D.H., Lingvay, I., Deanfield, J. et al. Long-term weight loss effects of semaglutide in obesity without diabetes in the SELECT trial. Nat Med 30, 2049–2057 (2024). https://doi.org/10.1038/s41591-024-02996-7
[1] Atherton, Jim. Development of the Electronic Health Record, https://journalofethics.ama-assn.org/article/development-electronic-health-record/2011-03
[2] Ratwani R. Electronic Health Records and Improved Patient Care: Opportunities for Applied Psychology. Curr Dir Psychol Sci. 2017 Aug;26(4):359-365. doi: 10.1177/0963721417700691. PMID: 28808359; PMCID: PMC5553914.