Experts discuss why electronic health records must be redesigned

Troy Parks
Staff Writer
AMA Wire
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A focus on the design and end-user experience of electronic health records (EHR) is key to improving the practice of medicine for both physicians and their patients. Find out what five experts had to say about why improving EHRs must be a top priority.

What’s the problem with EHRs?

With the Medicare Merit-Based Incentive Payment System (MIPS) on the horizon, EHRs must be designed to work more effectively so the new system does not repeat the issues of the past.

“Constraints are interfering with the evolution of the technology,” said AMA President Steven J. Stack, MD. “The vendors have designed products to satisfy the government and its certification program but … do not fulfill the needs of the clinicians.”

“We have to help the technology blend into the background as a supporting role,” Dr. Stack said. “One of its central failures right now is that EHRs are the central actor in a play of people, and we need to get the people—the patients, the physicians and the other caregivers—back in the center of this performance.”

“Physicians spend too much time away from their patients and also continuing their work at home,” said Christine Sinsky, MD, AMA vice president of professional satisfaction. A study at the University of Wisconsin found that doctors spend 38 hours a month of their own personal time on documentation, with a peak on Saturday nights, Dr. Sinsky said. “I don’t know if that’s good for patients …. I want my doctor to love her job.”

Physicians often feel that their jobs have transformed from doctor to typist, Dr. Sinsky said. “In a courtroom, we don’t expect the judge or the attorneys to do their professional work … and [simultaneously] create the legal record of the proceedings, but we have asked that of our physicians. [In addition], we’re asking for a near verbal recounting of every detail that happened—and that’s not humanly possible.”

What does the future of EHRs look like?

Designing the future first requires a dream, which then becomes a reality through hard work and diligence.

“My dream for the EHR is to be able to provide the infrastructure, the technology to make it really, really easy for physicians to get back to the art of caring for the patient,” said Nancy Gagliano, MD, chief medical officer of CVS Minute Clinic. “Put in the pieces that let the system do the system kind of work, and let the physician be the doctor.”

Population health also has been an important part of the conversation about the future state of EHRs. Michael Wasser, CEO of BloomAPI, spoke of promise in this realm. “We’re going to see populations of people getting healthier en masse [and] living longer, more healthy lives,” Wasser said.

When reading current EHRs, “it’s almost like you have a scroll, and you have to read through the whole scroll to see what’s actually happened to this individual,” Wasser said. “There’s no index; you can’t look the thing up.” The ability to see this kind of information broken down into usable data for improved health outcomes will make a difference in the future, he said.

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The people interviewed for this story about shortcomings of the EHR really hit the nail on the head in their article posted Feb 10 . <br/> <br/> Our Emergency Medicine group implemented Epic without a discernible loss of productivity compared to before when we used T-System paper version, (Productivity = Patients per hr or RVU per hr). That is uncommon, if not unique. Nonetheless, the designers of these electronic health record systems and the executives who lead them need to receive the following messages, to my view, because the products fall way short of anything that the Federal government meant to incentivize with their meaningful use statutes, that have prompted health care systems and doctors to have to purchase before they were really ready to be marketed:<br/> 1) WORST PROBLEM: EHR notes are ungainly, they don't proceed in a logical fashion<br/> EHRs do not enable communication between health care professionals in the manner evolved over time by doctors and nurses for efficient communication about our patients. Doctors generally start their communication with patient name and chief complaint, not stupid useless data like mode of arrival. Chief complaint is buried too deep in the record of our Epic system. This is one of numerous examples.<br/> 2) A CLOSE SECOND: I'M A DOCTOR, NOT A DATA ENTRY CLERK. <br/> As Dr Sinsky noted in the story, above, doctors and nurses spend too much time at a keyboard. It would help decrease the end-effects of our nation's physician shortage if doctors' efficiency could actually be maximized by an EHR. As it is, I can choose to add overhead of hiring a scribe to free myself from the keyboard, but since I am responsible for the document, scribes are a far from perfect answer. Given that NIH funding has become more scarce and there is growing faith being placed in "Big data", it feels like doctors are being expected to populate fields of data for researchers to query, and the expense is being borne on doctors' backs….even for hospital-based doctors who did not purchase an EHR, because decreased productivity hurts our incomes. In other words, the productivity drag inherent in the EHR makes the opportunity cost to doctors, who have to spend time hurting their efficiency by entering data, into a form of a hidden tax. <br/> <br/> 2a) One more thing: How short-sighted is it that as a society, rather than holding EHR vendors' "feet to the fire" to design and produce a product that helps our efficiency, our "work-around" is to increase medical school class sizes, to meet future physician shortages?<br/> If physicians could see 4 patients per hour rather than 3, and accomplish the same good care, we'd all win, right? Well, current EHR systems generally slow the doctor down. Doctors who see less patients per day are doctors with whom it takes longer than necessary to obtain an appointment. At the end of the day, it is clear to see that EHRs contribute meaningfully to the delays most patients must endure between requesting an appointment and obtaining one. EHRs exacerbate America's doctor shortage, because EHRs decrease efficiency, they don't increase it. <br/> 3) When will the designers of EHRs learn that THE PRESENCE OF MORE DATA DOES NOT AT ALL IMPLY THE PRESENCE OF MORE USEFUL, EASILY ACCESSED ACTIONABLE INTELLIGENCE? We need EHR systems that let us, as doctors, function as executives (who obtain information and make decisions...that is what an executive does, after all) and NOT as data entry clerks.<br/> <br/> Continued in next posted reply…..
4) INACCURACIES THAT NO ONE SEEMS TO RECOGNIZE: <br/> The current EHR has so many time stamps that it looks more like a document of whom to blame rather than being a useful record of patient care. Never mind the fact that many of the time stamps are inaccurate. For instance, I may go to the bedside of a critically ill ambulance-arrived patient on their arrival and then "sign up" for them 15-30 min later. The EHR would lead one to believe that the patient sat for 30 min waiting for my care. So much for the accuracy of the EHR!!! (And so much for the accuracy of many studies that use "big data" to draw conclusions that are not valid because no one questions the accuracy of the data used to draw those conclusions.) In short, the idea that the EHR is highly accurate is, at the end of the day , A BIG FAT LIE. That said, I am not a Luddite, I don't want to go back to paper charts. In fairness, for instance, obtaining info about prior patient visits and my writing of prescriptions is faster, more legible and more accurate with our EHR. <br/> 4a. But while I'm at it, if I specify when writing a prescription that the med is to be taken BID for 10 days, then could someone please explain how the number of pills to be dispensed is not automatically filled in as "20"? I have one med that is to be used TID prn for one week and when I do the prescription the default number to be dispensed is always 120. Doesn't anyone ever "proofread" these products before they are sold?<br/> 5) FAILURE TO ACHIEVE INTER-OPERABILITY:<br/> Finally, if I can use my Apple Mac or my PC to look at a web site, then could someone please explain to me why it is not possible to seamlessly view a Cerner record while logged into an Epic system, or vice versa? We need someone to do the equivalent of designing a "C3PO" (The protocol droid from Star Wars who speaks all languages) for translation. And here is the central question. Since inter-operability of systems has clearly been envisioned by advocates of the EHR from the start, and since EHR vendors have not yet achieved interoperability on their own, despite having plenty of time to do so, and since inefficiencies caused by lack of EHR inter-operability cost $$ including $$ paid by the Federal government for care, then who wants to join me in finding a law firm to file a civil suit under the Federal False Claims act to recover $$ from the companies that have designed and sold EHR systems that are not interoperable? If we want to REALLY get their attention about the need to improve their product, let's hold the threat of a False Claims suit over every EHR vendor, and desist only if they develop true interoperability at some date-certain in the very near term such as next 12 months? <br/> <br/> If you would like to join a search for a law firm to initiate such a False Claims action, email me at [email protected] <br/> If a "False Claims" lawsuit were to succeed, the triple damages awards that result when it is found that a false claim has occurred could go a long way toward funding a comfortable retirement!<br/> <br/> The Feds have a hand in the inefficiencies of the EHR, too, via CMS rules regarding documentation required for various levels of service. They could change the rules to quit requiring useless Family and Social histories and 10 point reviews of systems that add regulatory burden without improving patient care. It is obvious that CMS leaders understandably want some sort of "itemized receipt" upon which payment can be based, but the only sensible coding requirements that exist are those for critical care.<br/> <br/> In summary, if a truly efficient EHR were designed to complement meaningful and useful changes in the rules inherent to achieving the ability to code for the level of service actually provided, our current doctor supply could see more patients per hour, and access of the people to timely medical care would be enhanced. And that's what we all want, right?
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