"Standardizing interoperability means not only the idea of sharing data between system A and system B, but also the idea that the clinician who's rounding at the hospital in the morning, seeing patients all day in [the] clinic, and rounding at a different hospital in the afternoon, can have a calming sort of user experience, if you will," Middleton says.
At the same time, he adds, "We're moving well away from kind of the doctor-on-a-pedestal or omniscient, all-knowing clinician, to someone who, ideally, is collaborating with a patient, designing care goals together, and helping the patient toward those goals in a very effective manner."
Middleton arrived at Vanderbilt in February 2013, having previously been at Boston-based Partners HealthCare and Harvard Medical School. Vanderbilt uses a homegrown EHR, and over time the medical center is showing more of this EHR to patients. "There are reports from operating rooms and procedures and whatnot, but we don't show the full notes yet," he says.
"With docs and nurses and even patients now documenting into electronic tools, what's the quality of the information as documented? For the legal record to evolve to be inclusive of the electronic record and its core components, we have to have the same kind of amending or addending process that is the rule, or the standard of practice, for the paper-based record," Middleton says.
In 2012, Middleton coauthored a paper for the American Medical Informatics Association, Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA. The paper recommends that providers give systematic feedback to EHR vendors to improve EHR usability and safety.
Meanwhile, patients are more and more able to suggest annotations for the clinician's record. The Open Notes movement—which began as a Robert Wood Johnson Foundation study at Geisinger Health System and research done at Beth Israel Deaconess Medical Center and Harborview Medical Center—has spread to the Cleveland Clinic. All told, including patients of the Veterans Administration, 1.8 million patients nationwide are able to access their medical records.
In the event of patient feedback, "it's up to the clinician to write something useful in the record to take note of the patient's input," Middleton says. "There has to be an auditable trail of all such changes to the record, as the record becomes increasingly an important point of collaboration and communication between doctor and patient, and nothing should ever be deleted. It may be suppressed and invisible, but one needs to be able to review that through an audit kind of report."