We’re living in an automated world. When it comes to women’s health, it’s worth taking a close look about the role of electronic health records because these systems dominate patient-doctor communications.
Electronic health records are a huge business. The market is expected to generate $28.6 billion in 2024 and $30.1 billion in 2025.[1] The U.S. government has invested in these systems, as have private medical providers because of the efficiencies they can create: data integration, error reduction, continuity of care and information sharing among specialists. The initial push behind implementing these systems was the hope that electronic health records would save time and money for patients, doctors and our healthcare system. But like all aspects of the medical industrial complex, it’s not that simple and baked-in biases are perpetuated when it comes to women’s health journeys.
Patients and Doctors Have Concerns
Not all doctors and patients feel well-served by these technological advances. So many women I have worked with have expressed that they feel cut off, treated like numbers, confused by what they read or by the complexity of their health portals altogether. They already sense that their concerns are dismissed by the system in many situations and circumstances and these systems make them feel locked out of quality communication at times when they need and deserve it. Many women I work with agonize over messages they write in their portals, only for answers to be too little too late. But they feel they have no choice because they cannot get their overscheduled doctors on the phone. One woman I have supported mentioned to me that her electronic health record portal makes her feel anxious in the same way that checking her child’s grades on the school system does: there are numbers and grades, but no information to help understand the bigger picture. I can see the parallel. You log on nervous and are either further worried or somewhat elated by what you read. Or you’re confused! She has a point.
Many doctors find these systems troublesome too. They report that all the screentime and automation cuts into their already heavily monitored moments with patients. Doctors tell me that they do not always feel at liberty to write freely about their observations, sometimes censoring themselves to avoid negativity, blowback or unnecessary patient confusion. They explain that patients aren’t trained to read the shorthand or the medical jargon, so if a doctor says, for example, that a patient is a “spotty historian” that’s for the benefit of colleagues trying to get the facts. But when a patient reads that, she might find it offensive. The same goes for words like “unremarkable” or “lesion,” the first of which just means normal but and the second of which is not an automatic problem but reads like one to a layperson. Sometimes what they write is keyed to medical coding so that treatments are covered by insurance, but it can alarm patients without context. All of this can be exacerbated by the feedback loop. Because medical systems are competing for patients, they want and ask for ratings after appointments. You might call it “the YELP effect,” or as one doctor expressed to me, it is “as though your experience with a doctor is akin to a hotel stay.” A thing to be rated on a scale.
Medical Storytelling is Stymied
For most doctors and patients, the story of the health journey matters. Doctors look for clues for diagnoses and treatment and patients want to be heard. Most women I work with want to share their lives and talk about their stressors as they take on illness. Women are often culture keepers and storytellers, and electronic health records often distort and abridge stories. Reducing doctors to data generators asking canned questions during a limited time frame where they are mostly looking at a screen doesn’t help doctors and patients as much as the people selling the electronic health records application and the administrators counting the dollars. Numbers, lab tests and check listed answers do not frame out a story. In the end, electronic health records may lead to inefficiency because they can cause frustration, repeat appointments, messaging and calls. Or worse, to women giving up and getting sicker.
In assisting many women as they interpret their electronic health records in this brave new world, I’ve noticed something: to save time, medical history and information often be cut and pasted every time there is a new appointment. If, for example, fifteen years ago a woman was treated for anxiety her records could lead with “a 58-year-old woman with a history of anxiety” and this will be repeated in doctor’s notes. Sometimes this can affect the tenor of the appointment, particularly if it is for a wholly different medical reason. It’s well-documented that women’s pain gets minimized, that women have historically been treated as “hysterical” and that often their descriptions of symptoms get dismissed or unheard. When the top-line identifier in the record is about a past mental health situation it can exacerbate these patterns. One hilarious and smart patient I’ve supported has joked that we could write “MyChart: The Musical” and it would be full of thrills and chills, laughter and tears. Imagine the Act One finale!
Vulnerable Women Are Disadvantaged
Physician burnout is real. As it is, processing claims for Medicaid and Medicare plans take extra administrative time and effort and yield low reimbursements for doctors. Electronic health records are an added burden, a straw that can break the camel’s back, driving doctors away from accepting these plans. This disproportionally hurts women, who are more likely than men to be economically challenged and therefore Medicaid eligible. One Medicaid patient I have worked with has had a string of specialists drop her plan mid-treatment and this happens often. Since women live longer than men, they also make up a larger percentage of Medicare participants, so when those plans get dropped, there is similar fallout.
What’s the Fix?
The horse is out of the barn when it comes to electronic health records. But there are some promising developments on the horizon that may alleviate some of the identified challenges. One is that speech recognition can be used to turn the “check box” information collection into more organic storytelling. Another is that the applications will become cheaper over time and most major hospital systems are well past the implementation phase, which was both expensive and janky. Probably the most encouraging thing of all is that more doctors and patients are giving input and feedback into the design of the technology. Given that they are the two groups who use it most, this only makes sense. When it comes to women patients, let’s hope their specific concerns will be considered and addressed. We’ve seen what happens when women are left out of the research! We can’t go back to that.
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