Creative Minds: Building a Better Electronic Health Record

Is 5 too few and 40 too many? That’s one of many questions that researcher David Chan is asking about the clinical reminders embedded into those electronic health record (EHR) systems increasingly used at your doctor’s office or local hospital. Electronic reminders, which are similar to the popups that appear when installing software on your computer, flag items for healthcare professionals to consider when they are seeing patients. Depending on the type of reminder used in the EHR—and there are many types—these timely messages may range from a simple prompt to write a prescription to complex recommendations for follow-up testing and specialist referrals.

Chan became interested in this topic when he was a resident at Brigham and Women’s Hospital in Boston, where he experienced the challenges of seeing many patients and keeping up with a deluge of health information in a primary-care setting. He had to write prescriptions, schedule lab tests, manage chronic conditions, and follow up on suggested lifestyle changes, such as weight loss and smoking cessation. In many instances, he says electronic reminders eased his burden and facilitated his efforts to provide high quality care to patients.

Still, Chan was troubled by the lack of quantitative evidence

that electronic reminders actually enable healthcare providers to provide better patient care, as well as by anecdotal evidence that too many electronic reminders may actually have a detrimental effect on care. Indeed, getting a better handle on the efficacy of electronic reminders is crucial as the US healthcare system continues its transition from paper to electronic health records. It’s been estimated that eight in 10 office-based physicians and six in 10 hospitals now use some type of EHR system, and that number continues to grow [1].

Now an assistant professor at Stanford School of Medicine, Palo Alto, CA and a physician-scientist with Veterans Affairs (VA) Palo Alto Health Care, Chan recently received an NIH Early Independence Award to explore the impact of EHR electronic reminders on the quality of primary care. His research will focus on the Veterans Health Administration (VHA), the country’s largest healthcare delivery system serving about 9 million enrollees at 150 hospitals and 819 community-based outpatient clinics. Because the VHA was among the first healthcare systems to adopt EHRs, it will provide Chan with an excellent window into the real-world experiences of doctors, nurses, and other healthcare professionals accustomed to working with electronic reminders.

Preliminary research by Chan shows that, depending upon the VHA facility, the same type of healthcare provider caring for the same type of patient may have to process as few as 5 or as many as 40 electronic reminders relating to preventive care and disease management. Building upon this work, Chan will study in greater detail how electronic reminders vary not only in number, but in topic breadth, complexity, and comprehensibility. Most importantly, he will analyze the impact of all of these factors upon the productivity and efficiency of healthcare professionals and the quality of care received by patients.

Such work is part of a much larger, ongoing NIH effort to generate the evidence base needed to guide the design, use, and evaluation of an ever-expanding array of health information technologies. For example, the recently announced Precision Medicine Initiative will enable volunteer participants to partner with researchers to develop creative new approaches for the gathering, use, and sharing of genomic, health, and lifestyle information via EHRs, mobile health devices, social media, and other electronic information platforms.


[1] Despite substantial progress in EHR adoption, health information exchange and patient engagement remain low in office settings. Furukawa MF, King J, Patel V, Hsiao CJ, Adler-Milstein J, Jha AK. Health Aff. 2014 Sep;33(9):1672-1679.


David Chan (Stanford School of Medicine, Palo Alto, CA)
NIH Director’s Early Independence Award Program
VA Palo Alto Health Care System
Precision Medicine Initiative (NIH)
HealthIT.gov (US Department of Health and Human Services)

Francis S. Collins, M.D., Ph.D., was officially sworn in on Monday, August 17, 2009 as the 16th director of the National Institutes of Health (NIH). Dr. Collins was nominated by President Barack Obama on July 8, and was unanimously confirmed by the U.S. Senate on August 7.

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4 replies »

  1. If an airline pilot was spending excessive time looking at his cockpit instruments and not enough looking out his window, and this was becoming hazardous, management and its engineers would correct this. This is what is happening to us with the EHR experiment. It is not our job to fix it. Handle it.

  2. It’s great to see NIH funding EHR development, and long overdue.

    Clinical medicine has no secret ingredients and the current trend to make clinical software secret harkens back to “Snake Oil” cures a century ago.

    Decision support, summarization, sensor fusion, alerts and alarms, coding, and quality measures are all essential clinical software ingredients and need to be accessible for peer review and local improvement the way the rest of medicine is.

    It would be good to see NIH adopt a reference implementation policy for all clinical software. That would also make the interoperability problem much easier to solve.

  3. Jerome Carter, MD is doing great work on Health IT over at his site EHR Science. http://www.EHRscience.com

    “the recently announced Precision Medicine Initiative will enable volunteer participants to partner with researchers to develop creative new approaches for the gathering, use, and sharing of genomic, health, and lifestyle information via EHRs, mobile health devices, social media, and other electronic information platforms.”

    I am reading the new book “Biocode: the new age of genomics” at the moment, and will be citing it on my blog in detail. As I’ve initially cited:

    “I have a couple of concerns. Docs often don’t have enough time TODAY to get through an electronic SOAP note effectively, given workflow constraints. Adding in torrents of “omics” data may be problematic, both in terms of the sheer number of additional potential dx/tx variables to be considered in a short amount of time, and questions of “omics” analytic competency. To that latter point, what will even constitute dx “competency” in the individual patient dx context, given the relative infancy of the research domain? (Not to mention issues of genomic lab QC/QA — a particular focus that I will have, in light of my 80’s lab QC background).

    President Obama’s current infatuation with “Precision Medicine” notwithstanding, just dumping bunch of “omics” data into EHRs (insufficiently vetted for accuracy and utility, and inadequately understood by the diagnosing clinician) is likely to set us up for our latest HIT disappointment — and perhaps injure patients in the process.”