The Promise and Peril of EMRs

Electronic medical records (EMRs) are evolving rapidly and in the U.S. the federal stimulus is incentivizing their adoption in both behavioral and physical health settings. Years ago EMRs were mainly efficient revenue capturing and documentation tools with features such as e-scheduling and cross checks between service units billed and progress notes entered.

But now EMRs are evolving to support practitioners in the clinical workflow. These systems can detect prescribing errors, provide decision support, and prompt clinicians to ask specific questions and complete specific text fields before moving on to the next task. In other words, EMRs are becoming part of the workflow and have the power to prompt and shape the behavior of clinicians in their daily work. And this, in my opinion, is both the promise and the peril of EMRs.

The peril of EMRs is that they are simply hardcoding bad clinical practice. Bad practice is paternalistic, deficit-based and focused on symptom reduction, not recovery. Examples of hardcoding bad practice in an EMR include features such as:

1. Decision support tools that are uni-directional (for clinicians only)
2. Lack of holistic/complimentary evidence-based information in decision support tools
3. Lack of transparency of information
4. Permissions for only clinical staff to annotate the medical record
5. Data mining privileges for clinicians only
6. Unilateral decision making instead of shared decision making
7. Emphasis on symptom reduction instead of functional recovery goals
8. Emphasis on documenting problems rather than strengths

The promise of EMRs is that they could prompt and reinforce recovery-based, person-centered, strengths-based, collaborative practice within the daily workflow.

Imagine an EMR that prompted clinicians to ask people about their strengths and functional recovery goals. Imagine an EMR that provided traditional, holistic and complimentary decision support information to clinicians and to people/patients. Imagine an EMR that had the voice of people/patients at the center of the care team and that supported shared decision making and the development of shared care plans. Imagine being able to annotate our medical record so that our perspective and opinion were included. Imagine being able to explore our progress through personal data mining and being able to discover, for instance, that our depression co-varied with our sleep patterns or that our racing thoughts co-varied with our use of alcohol.

Now is the time when more sophisticated EMRs are being built and decisions are being made about hardcoding deficit-based practices or recovery based practices into these systems. Those of us who are consumer-survivors must get involved in EMR development while this window of opportunity is open. Prior to investing in an EMR, mental health organizations should confirm that people with diagnoses had a voice in the development of the EMR. They must demand the EMR vendor include strengths-based prompts, bi-directional decision support and shared care plans.

CommonGround represents my contribution to this window of opportunity. CommonGround hardcodes strengths-based, recovery-oriented practice. I think it embodies many recovery-based principles that should be at the heart of all EMRs.