Art by Kartik A Valluri MD ACP ResidentslashFellow Member
Art by Kartik A. Valluri, MD, ACP Resident/Fellow Member.

Fixing EHRs

Clinicians and tech experts offer solutions.

If you don't feel like your electronic health record (EHR) is as smart and well designed as it could be, you are definitely not alone. “In my record, it takes 32 clicks to order and record a flu shot. I know we can do better than that,” said Christine Sinsky, MD, FACP, a general internist and vice president of professional satisfaction for the American Medical Association.

Dr. Sinsky was speaking at the “The Patient, The Practitioner, and The Computer,” a conference held at Brown University in Providence, R.I., in March. Other attendees, and experts interviewed for this article, added their concerns about EHRs, from how much time physicians spend looking at screens rather than patients to how easy it is to order the wrong medication when presented with an enormous array of options.

“The amount of data that comes into a patient's hospitalization is overwhelming and too much of it is like the terms and conditions when you sign up for a website—nobody reads it, it's not clear why it needs to be there,” said Stephen Martin, MD, associate professor of family medicine and community health at the University of Massachusetts Medical School in Worcester.

Technology experts who work on EHRs acknowledge the many frustrations associated with the digitization of medicine. But they also offer a vision of hope and change, promising dramatically more user-friendly technological advances in the next few years.

Physicians with expertise on the subject also seem convinced that things are going to get better. “We're going through this really painful transition,” said Dr. Sinsky. “At some point, regulation and technology and practice models will converge in a positive way, I believe, so that...we can see data in a way that's so much more clear.”

What doctors want

Many physicians have specific wish lists for these systems of the future, and a common focus is making it easy to see the most relevant patient data at any given time.

“Build into the existing structure tools that allow physicians to better understand a patient's course over time, better understand how multiple clinical conditions or multiple medications are affecting a patient's trajectory over time, or flag patients where things have occurred outside of what you would expect in a patient with these characteristics,” suggested Donna Zulman, MD, an assistant professor at Stanford University in Stanford, Calif.

She was the lead author on a viewpoint, published in the Sept. 6, 2016, JAMA, that offered a number of additional ways that EHRs could evolve to improve care for complex patients, including better triage and fewer workflow interruptions.

One of Dr. Sinsky's specific requests for EHR developers was a reduction in clicks. “I think it is absolutely doable that we hold our vendors to the goal of eliminating a billion clicks per day,” she said.

While physicians are most often asking for less—whether clicks, alerts, or screens—Dr. Zulman highlighted an area where she'd like more. Additional information in the record about social and behavioral factors potentially affecting patients' health would be useful to guide patient care, she said.

In addition to having vendors change the EHR, some physicians want them to change their company operations as well. “I think we should also turn support on its head. You need real-time support. I'm getting stuck one to five times a week. I can't pick up the phone and get help, yet I often need such just-in-time help,” said Gordon Schiff, MD, ACP Member, associate professor of medicine at Harvard Medical School in Boston, speaking at the Brown conference.

The support itself should also be reconfigured, he added. “Don't just show me how to do it. Instead, I want you to watch me show you what I've been doing for the last 20 minutes. I'm not stupid. I tried every button I could find, searched every screen. Watch me, record it, and take it back,” Dr. Schiff said.

EHR developers are, to some extent, following his advice. “If you go really deep into the coder and tech-focused literature, what you'll find is that there is an increasing amount of attempts of coders to try to understand us,” said ACP Member Fuad Bohsali, MD, a hospitalist at Johns Hopkins Hospital in Baltimore, who also spoke at the conference.

Vendors and researchers are “paying people to sit down and watch your click-through pathways and try to understand where is the most time being wasted—how many missed clicks did you have to make in order to get the correct prescription?” said Dr. Bohsali. “The tech really is trying to adapt to what we're doing.”

Such research is slowly changing EHRs, according to Daniel R. Murphy, MD, an assistant professor of medicine at Baylor College of Medicine in Houston who has studied EHRs. “A lot of progress has been made in the last couple of years in terms of understanding workflows, understanding interfaces,” he said.

The tech perspective

EHR vendors are increasingly hiring physicians, human factors researchers, and interaction designers to try to improve these issues, according to company representatives.

“Everything I complained about, I am now helping them fix,” said J.D. Tyler, MD, a physician executive with EHR vendor Cerner Corporation, based in North Kansas City, Mo., who spoke at the Brown conference. “I think the biggest mistake that was made was that when we decided to digitize the paper medical record, we just digitized it....It didn't address how we think, how we work as physicians, how we interact.”

Lessons learned from watching physicians interact with EHRs included that copy and paste should be discouraged and that rigid templates and check boxes may need to be replaced with free-text fields, he and other tech experts said.

“When things become electronic, you do become tempted to capture more information because it's right there, and you think, ‘Oh, we can capture this, so let's go ahead and do that.’ One of the things we've realized is just because you can does not mean you should,” Josh Holzbauer, an executive R&D liaison for EHR vendor Epic in Madison, Wisc., said at the conference.

Photo by Thinkstock
Photo by Thinkstock.

On the other hand, tech experts are excited about computers' potential to capture even more information without much effort on physicians' part. Dr. Tyler described the potential to use a smartphone to document a patient's history of present illness (HPI) with no typing at all.

First, the physician would ask the patient to tell his or her story and then say, “I'm going to repeat exactly what you just said and kind of paraphrase it into a little story. Let me know if that's correct,” Dr. Tyler said. The physician's phone would then record what he or she said and turn it into the HPI.

This scenario relies on a number of recent developments in computer science, which may eventually allow even more hands-off approaches. “Advances in voice recognition and natural language processing, and even storage, have gotten so much where you could theoretically video every office visit and use that as an audit trail if you were ever audited about how much time you spent with the patient and what you talked about,” said Sam Butler, MD, a physician in the clinical informatics division at Epic.

Less is more

The trick will be for these systems to gather all this information but only show physicians what they want to see. “When we look at a screen, we want [what's shown] to be relevant to the physician and their specialty, but also to the patient's condition...It doesn't make a lot of sense to say, ‘This patient hasn't recorded their allergies' when they have no blood pressure, for example,” said Dr. Butler.

The efforts to observe how physicians use EHRs are part of the work toward this goal, too. “It seems simple that if I walk into an ICU patient's room and they're septic, then the first thing I want to see is blood pressure,” said Dr. Butler. “If we look at the history, and we said, ‘Whenever a doctor walks into the room with a patient who turns out to have been septic, what they always look at first are the vital signs,’ we can learn that behavior and suggest, ‘Here are the things you looked at last time on a very similar patient.’”

Such advances are still at least a few years away, he cautioned, but work is underway on them. Even short of this in-depth understanding of physician needs, a medical record that learns from how it's used should be able to make itself easier to navigate. For example, “If there is activity you just don't use, you've only touched once in six months, that should automatically hide in a menu somewhere,” said Mr. Holzbauer.

EHRs are also expected to learn more about prescribing. Whether they're programmed in or picked up by the computers observing practice, links between medications and diagnoses will become a common feature, experts predicted.

Dr. Schiff demonstrated how currently, when you type “penicill” into prescribing software, you get far too many drug options, some of them dramatically inappropriate for most cases, such as penicillamine. “Instead of putting in the drug, you should be able to start with the indication,” he proposed. “Put ‘strep’ in, and it will narrow the choices to the more appropriate drugs to order.”

Computers advising physicians on what to order, known as clinical decision support, is also likely to become more common. “When I'm evaluating a patient with a collection of symptoms or signs, I'll be guided a lot more by our collective past experience as to what is the best, most accurate diagnosis,” said Dr. Butler.

Such interventions are in the very near future, he said, citing the in-the-works Medicare requirement that physicians consult appropriate use criteria before they order an advanced imaging procedure.

“Now we can do that electronically and that scoring can also make suggestions and say, ‘That's not the best imaging study. Here's one with less radiation, more accurate, and perhaps cost is even better.’ That's the beginning of a world where you'll be guided a lot more to what test will give the most predictive value,” said Dr. Butler.

While many of the other innovations match closely with what physicians are already requesting, clinical decision support may eventually raise some hackles. Dr. Schiff described the conflicted perspective of some physicians. “On one hand, you don't want Big Brother to tell you what to do. On the other hand, clinicians are increasingly feeling the frustrations of drug restrictions, insurance prior authorizations, and denials, and want the computer to just tell me what to do, and help me do it,” he said.

At some point, physicians will have to acknowledge that computers excel in some areas and clinicians in others, according to Dr. Butler. “Our value is to be human and get the patients to tell us what's wrong and explain things to them and to help them get better, but to be able to remember 100 differential diagnoses and which test is the best test, that's something that our minds are not the best at,” he said.

Tech experts also hope that future EHRs will make diagnostic and treatment advances beyond what human researchers have been able to do so far. “New advancements in the practice of medicine will be more and more from big data. The traditional approach to new breakthroughs in medicine is slow, by today's standards, and getting the new best practice to providers is just as slow,” said Jigar Patel, MD, a vice president and chief medical officer for physician alignment at Cerner.

The idea is that EHRs will gather and crunch information about patients' genetics, treatments, and outcomes to make new discoveries. The computers will also then help to apply those findings to individual patients, based on their characteristics, Dr. Patel predicted. “As a pathologist, I am very excited by the prospect of the EHR enabling precision medicine,” he said.

Of course, to have access to such big data, EHRs will have to communicate with each other, an aspect of health care digitization which has moved very slowly. But the experts say that substantial progress has finally been made on that front. “I think we are getting to the inflection point for interoperability,” said Dr. Patel, noting that major groups of EHR vendors have agreed to work together to allow easy exchange of information.

Like physicians, the big EHR companies may have to adjust to new roles in the near future, predicted Robert M. Wachter, MD, FACP, author of a book called “The Digital Doctor” and chair of the department of medicine at the University of California, San Francisco, who spoke on the topic at Internal Medicine Meeting 2017 in San Diego in March.

“It's unlikely that Epic or Cerner or those companies will be good enough at this new set of functions [to] use data in effective ways,” he said. “You're seeing Apple, Google, Microsoft—all these companies and startups—come into the field with the premise that in the future it will no longer be all that hard to get your data out of your EHR, do magic with it, and give it back to you.”

Barriers to perfection

So why are current EHRs so commonly frustrating instead of providing all these fantastic capabilities? Obviously, some of the more elaborate potential features are waiting on advances in software development, but experts blame a number of other factors for the shortcomings of current systems.

One problem is the lack of physician involvement in initial EHR development and implementation. “Up to this point, I feel like physicians haven't had as big a say as they could,” said Dr. Murphy. “EHRs were kind of thrust on physicians due to the financial benefits, and I think we just haven't had the time to iron out all the kinks.”

Even when physicians are consulted in development, they will want different things from their EHRs, which poses a challenge to optimization efforts, for example, when a vendor is deciding which alerts to remove to reduce unnecessary interruption and alert fatigue. “There are a few types of messages that nobody across the board wants. After you take those out, there's going to be a lot of variability in terms of what physicians want to receive,” Dr. Butler said.

There's an even bigger gap between what physicians want and what regulators and payers want, an issue that many experts believe underlies many physician complaints about EHRs. Speakers at the conference from countries with less complicated payment and measurement systems reported much greater satisfaction with their EHRs.

“One of my goals is to get some of the EHR vendors who are international and do a comparative study,” said Dr. Sinsky. “We can start see how much of our pain is related to local regulations and how much is related to our EHR vendor.”

Current problems may also have been the necessary discomforts of a dramatic transformation, according to Dr. Wachter. “I am not sure we could have done this much better than we did,” he said. “In the old days when I'd order a chart and the chart would show up a foot thick or it would never show up, and, if it did, I'd have to flip through to find stuff....The old days sucked. You can easily forget that.”

Hospitalists have reason to hope that someday the hassles of today's EHRs will be equally difficult to recall, according to the experts. “It's going to get better,” promised Dr. Wachter.