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Fix the EHR!

After a blizzard of hype surrounding the electronic health record (EHR), health professionals are now in full backlash mode against this complex new tool. They are rightly seen as a major cause of professional burnout among physicians and nurses: Clinicians are spending almost half their professional time typing, clicking, and checking boxes on electronic records. They can and must be made into useful, easy-to-use tools that liberate, rather than oppress, clinicians.

Performing several tasks, badly. The EHR is a lot more than merely an electronic version of the patient’s chart. It has also become the control panel for managing the clinical encounter through clinician order entry. Moreover, through billing and regulatory compliance, it has also become a focal point of quality-improvement efforts. While some of these efforts actually have improved quality and patient safety, many others served merely to “buff up the note” to make the clinician look good on “process” measures, and simply maximize billing.

Mashing up all these functions — charting, clinical ordering, billing/compliance and quality improvement — inside the EHR has been a disaster for the clinical user, in large part because the billing/compliance function has dominated. The pressure from angry physician users has produced a medieval solution: Hospital and clinics have hired tens of thousands of scribes literally to follow clinicians around and record their notes and orders into the EHR. Only in health care, it seems, could we find a way to “automate” that ended up adding staff and costs!

As bad as the regulatory and documentation requirements are, they are not the largest problem. The electronic systems hospitals have adopted at huge expense are fronted by user interfaces out of the mid-1990s: Windows 95-style screens and dropdown menus, data input by typing and navigation by point and click. These antiquated user interfaces are astonishingly difficult to navigate. Clinical information vital for care decisions is sometimes entombed dozens of clicks beneath the user-facing pages of the patient’s chart.

Paint a picture of the patient. For EHRs to become truly useful tools and liberate clinicians from the busywork, a revolution in usability is required. Care of the patient must become the EHR’s central function. At its center should be a portrait of the patient’s medical situation at the moment, including the diagnosis, major clinical risks and trajectory, and the specific problems the clinical team must resolve. This “uber-assessment” should be written in plain English and have a discrete character limit like those imposed by Twitter, forcing clinicians to tighten their assessment.

The patient portrait should be updated frequently, such as at a change in clinical shifts. Decision rules determining precisely who has responsibility for painting this portrait will be essential. In the inpatient setting, the main author may be a hospitalist, primary surgeon, or senior resident. In the outpatient setting, it’s likely to be the primary care physician or non-physician provider. While one individual should take the lead, this assessment should be curated collaboratively, a la Wikipedia.

This clinical portrait must become the rallying point of the team caring for the patient. To accomplish this, the EHR needs to become “groupware” for the clinical team, enabling continuous communication among team members. The patient portrait should function as the “wall” on which team members add their own observations of changes in the patient’s condition, actions they have taken, and questions they are trying to address. This group effort should convey an accurate picture (portrait plus updates) for new clinicians starting their shifts or joining the team as consultants.

The tests, medications or procedures ordered, and test results and monitoring system readings should all be added (automatically) to the patient’s chart. But here, too, major redesign is needed. In reimagining the patient’s chart, we need to modify today’s importing function, which encourages users indiscriminately to overwhelm the clinical narrative with mountains of extraneous data. The minute-by-minute team comments on the wall should erase within a day or two, like images in SnapChat, and not enter and complicate the permanent record.

Typing and point and click must go. Voice and gesture-based interfaces must replace the unsanitary and clunky keyboard and mouse as the method of building and interacting with the record. Both documenting the clinical encounter and ordering should be done by voice command, confirmed by screen touch. Orders should display both the major risks and cost of the tests or procedures ordered before the order can be confirmed. Several companies, including Google and Microsoft, are already piloting “digital” scribes that convert the core conversation between doctor and patient into a digital clinical note.

Moreover, interactive data visualization must replace the time-wasting click storm presently required to unearth patient data. Results of voice searches of the patient’s record should be available for display in the nursing station and the physicians’ ready room. It should also be presentable to patients on interactive white boards in patient rooms. Physicians should be able to say things like: “Show me Jeff’s glucose and creatinine values graphed back to the beginning of this hospital stay” or “Show me all of Bob’s abdominal CT scans performed pre- and postoperatively.” The physician should also be able to prescribe by voice command everything from a new medication to a programmed reminder to be delivered to the patient’s iPhone at regular intervals.

Population health data and research findings should also be available by voice command. For example, a doctor should be able to say: “Show me all the published data on the side-effect risks associated with use of pembrolizumab in lung cancer patients, ranked from highest to lowest,” or “Show me the prevalence of postoperative complications by type of complication in the past thousand patients who have had knee replacements in our health system, stratified by patient age.”

AI must make the clinical system smarter. EHRs already have rudimentary artificial intelligence (AI) systems to help with billing, coding, and regulatory compliance. But the primitive state of AI in EHRs is a major barrier to efficient care. Clinical record systems must become a lot smarter if clinical care is to predominate, in particular by reducing needless and duplicative documentation requirements. Revisiting Medicare payment policy, beginning with the absurdly detailed data requirements for Evaluation and Management visits (E&M), would be a great place to start.

The patient’s role should also be enhanced by the EHR and associated tools. Patients should be able to enter their history, medications, and family history remotely, reducing demands on the care team and its supporting cast. Patient data should also flow automatically from clinical laboratories, as well as data from instrumentation attached to the patient, directly to the record, without the need for human data entry.

Of course, a new clinical workflow will be needed to curate all of this patient-generated data and respond accordingly. It cannot be permitted to clutter the wall or be “mainlined” to the primary clinical team; rather, it must be prioritized according to patient risk/benefit and delivered via a workflow designed expressly for this purpose. AI algorithms must also be used to scrape from the EHR the information needed to assign acuity scores and suggest diagnoses that accurately reflect the patient’s current state.

Given how today’s clinical alert systems inundate frontline caregivers, it is unsurprising that most alerts are ignored. It is crucial that the EHR be able to prioritize alerts that address only immediate threats to the patient’s health in real time. Health care can learn a lot from the sensible rigor and discipline of the alert process in the airline cockpit. Clinical alerts should be presented in an easy-to-read, hard-to-ignore color-coded format. Similarly, hard stops — system-driven halts in medication or other therapies — must be intelligent; that is, they must be related to the present reality of the patient’s condition and limited to clinical actions that truly threaten the health or life of the patient.

From prisoners to advocates. The failure of EHRs thus far to achieve the goals of improving health care productivity, outcomes, and clinician satisfaction is the result both of immature technology and the failure of their architects to fully respect the complexity of converting the massive health care system from one way of doing work to another. Today, one can see a path to turning the EHR into a well-designed and useful partner to clinicians and patients in the care process. To do this, we must use AI, vastly improved data visualization, and modern interface design to improve usability. When this has been accomplished, we believe that clinicians will be converted from surly prisoners of poorly realized technology to advocates of the systems themselves and enthusiastic leaders of efforts to further improve them.

Robert Wachter, MD is chair of the Department of Medicine at the University of California, San Francisco.

Jeff Goldsmith is national adviser to Navigant Consulting and an associate professor of public health sciences at the University of Virginia.

This post first appeared in Harvard Business Review.

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KattyHoffmanCrescereMed IncHealthViewXPesto Saucemeltoots Recent comment authors
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KattyHoffman
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KattyHoffman

After a blizzard of hype surrounding the electronic health record (EHR), health professionals are now in full backlash mode against this complex new tool. As we think about improving electronic health records, we need to broaden the discussion of EHRs and their role.

Thanks for sharing the great info and I am looking forward to your next post

CrescereMed Inc
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CrescereMed Inc

Good ideas. Let’s see how far the improvement goes in the EMR.

HealthViewX
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HealthViewX

Today healthcare is totally shifting from fee-based to value-based care. The journey towards smart health will help solve major challenges. Digitization in healthcare is growing exponentially and HIPAA compliant solutions like patient referral management, chronic care management, and care management will help solve many challenges. These solutions can easily integrate with the providers current EMR/EHR and seamlessly help share patient information. Help providers give better care to their patients and see better patient outcomes. Learn more about HealthViewX solution.
To know more please check http://www.healthviewx.com

Pesto Sauce
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Pesto Sauce

There goes Dr. Wachter, flip flopping in the direction the wind blows. He’s a wily McNugget who just 3 months ago in the UCSF magazine wrote glowingly about EHR’s single handedly curing disease, bringing clinicians together and successfully ridding the world of ISIS and responsible for world peace. https://www.ucsf.edu/news/2018/01/409541/doctors-providing-smarter-care-electronic-health-records There is nothing Dr Wachter writes that I would approach in a serious manner. Let’s see the COI report. How about Epic, how much did you get from assisting the Epic roll out at UCSF? https://www.beckershospitalreview.com/healthcare-information-technology/digital-doctor-author-dr-robert-wachter-defends-epic-s-business-model-product.html From 70 clients in 2000 to 315 in 2015. Epic is used at most academic… Read more »

pjnelson
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pjnelson

HEALTH may be defined as a person’s daily expression of life-long, stable survival that is ….ENDOWED BY maternal gestation before birth with a set of individually unique “Clusters of Human Capabilities”, innate temperament and its baseline homeostasis to become a dependent person after birth; ….NURTURED BY the person’s Caring Relationships originating – ..from within the person’s Family before birth to fulfill the person’s cognition “Cluster of Human Capabilities” to become an independent person And ..from within the person’s Extended Family and neighborhood network of the person’s Family who offer support to the person’s Family for the Person to acquire a… Read more »

Niran Al-Agba
Member

“Clinicians are spending almost half their professional time typing, clicking, and checking boxes on electronic records.” That is the only sentence the health policy people should read. Of course “automating” ended up adding staff and costs! Duh. As a solo doc, I could not afford an EHR in the first place. I am so glad I have not bought in to all this hype. Dictating using a microcassette recorder takes 1 minute per patient encounter. My transcriber has been working for the office for 47 years. Why should a physician be forced to change to a clunky system that is… Read more »

Paul @ Pivot ConsultingLLC
Member

Wasn’t the Hi-tech taxpayer payment $40,000 per doctor to subsidize ehr adoption? Were independent doctors ineligible, or were you just astute and didn’t take it?

meltoots
Member
meltoots

I can’t tell if this was a joke or a real question…40000 is over 5 years and you had to jump thru 1 billion nebulous hoops to get reimbursed all the while risking audits and a clawback. PLUS the hardware software support ongoing costs updates for EVERY EHR is WAY more than 40K. Plus you get the added bonus of huge losses in efficiency, burdensome reporting, burnout, failed interfaces, etc. So again, you were kidding asking this right?

Paul @ Pivot ConsultingLLC
Member

Meltoots, thanks for the information….that is what I was looking for as i had little idea how the subsidy effected small or individual practices….not sure what was humorous about the query except for my lack of knowledge….but I suspect i have some good company. For the record, I always thought a subsidy for immature technology would be a disaster…sorry to say I was right.

William Palmer MD
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William Palmer MD

George Polya, who was a mathematician at Stanford for many years, wrote a famous book “How to Solve It” in 1945 which remains a classic tool for approaching difficult problems. You will see–at a glance–that his ideas might have use in figuring out what to do with the EHR. This really is a difficult problem and we should be patient with ourselves. He has four rules and a very wise comment. First, you have to understand the problem. [What precisely are we trying to do with the EHR? Maybe we are trying to please too many stakeholders? What is the… Read more »

Res Morgan M.D.
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Res Morgan M.D.

“What precisely are we trying to do with the EHR?”

Thank you, thank you, thank you.

So far, EHRs have been just a pretty lousy solution in search of a problem to solve.

Our failure to answer this most basic question is the cause of most of the misery we’re experiencing. As long as we continue not to answer it, we’re doomed to repeat past and current failures.

Jeff Goldsmith
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Jeff Goldsmith

Our answer was: help the clinical team, which includes the patient and family, make better decisions in managing the patient’s problem. Dr Palmer is precisely correct:
the EHR has too many “stakeholders” and has mashed up too many functions to do any of them well. We need to pick ONE and make it central.

Res Morgan M.D.
Member
Res Morgan M.D.

That’s a laudable aim and one that is actually possible.

But it would mean completely dumping all current HIT and telling a lot of very powerful people to get lost.

How do we accomplish that?

Jeff Goldsmith
Member
Jeff Goldsmith

The powerful firms that control this tool need to re-invest some of the many hundreds of millions of dollars they have made from selling EHRs into the user interface. Their engineering dollars have gone into features and functions, and patching up rocky installations, not improving the user experience.

Res Morgan M.D.
Member
Res Morgan M.D.

“The powerful firms that control this tool need to . . . ”

But will they?

Pesto Sauce
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Pesto Sauce

Good luck with that. The money’s in Cayman.

BobbyGvegas
Member

I feel like I’m stuck in “Groundhog Day.”

pjnelson
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pjnelson

Me, too.

Jeff Goldsmith
Member
Jeff Goldsmith

It’s a 20 year old technology that basically hasn’t evolved very much. Sort of like the
Nokia flip phone. As John Kennedy would say, “We can do bettah . . . !”

BobbyGvegas
Member

Duly noted now at my http://KHIT.org. Just getting started.

davidkibbe
Member
davidkibbe

All: As someone who coined the term “clinical groupware” and suggested it replace the current EHR paradigms (see my guest editorial in Healthcare IT News from 2009 http://www.healthcareitnews.com/blog/why-clinical-groupware-may-be-next-big-thing-health-it ), I wholeheartedly agree with the basic premises of “Fix the EHR!” from Robert Wachter and Jeff Goldsmith. Brian Klepper and I wrote extensively on this idea from 2009 through 2011, at which point the Meaningful Use EHR bonus programs came along, giving the incumbent EHR companies and their technologies a huge boost: $34 billion dollars was spent between then and now by taxpayers to instantiate the adoption of status quo EMRs… Read more »

Barry Carol
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Barry Carol

How do you define both value and quality in healthcare? It’s not that simple. For example, suppose one drug is slightly better than another at thinning the blood to reduce the risk of a second heart attack but it costs 25 times more than the other. This is the case for Brilanta vs., generic Plavix. Which one should doctors prescribe and which one should patients demand especially if he has already met his deductible? Maybe we should find better ways to identify the most cost-effective good quality providers and direct more of our business to them. If an ambulatory surgical… Read more »

Jeff Goldsmith
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Jeff Goldsmith

It is the “check the box” fever masquerading as “value based” payment that has overwhelmed caregivers. The cure is, in fact, worse than the disease. We aren’t going to see fee-for-service disappear any time soon. What we need to do is apply evidence based principles to the landslide of “core measures” inundating practicing physicians and nurses, and pare back what we ask them to document to measures that matter to patient risk and outcomes. We can start with the E+M coding fetish imposed by Medicare, move on to shrinking back ICD-10, and making ICD-12 about coding for patient risks, rather… Read more »

Res Morgan M.D.
Member
Res Morgan M.D.

Interesting comment.

Could you define precisely what you mean by “team based care” and how it’s different from what is now available.

Thanks.

Jeff Goldsmith
Member
Jeff Goldsmith

Most complex care-most surgery, cancer care, etc.- is provided by clinical teams, not individual doctors. Those teams need to be knit together by clinical protocols and easy access to shared information- e.g. the record we propose. A lot of this care used to be hospital based, but is increasingly migrating out of the hospital where team members are physically separated (eg. surgery, rehabilitation, home care, etc.). So multi-site, multi specialty, lots of supporting cast members).

Pesto Sauce
Member
Pesto Sauce

This is true for academia. It doesn’t work that way in flyover land. It’s still care that is problem and task oriented. Got a hernia? We shall fix it. And then we all leave each other alone. Seriously where is this great team that sits around the campfire and succeeds? I’ so tired of the glib words.

pjnelson
Member
pjnelson

The EMR for each Physician ultimately is a financial system tied to an accounts receivable, line-item on under the Assets section of their Balance Sheet. I would wager that there is probably only a very few, ? < 3%, of physicians who could tell you what their own "receivable days" represents each month. Similarly, it is unlikely than any one physician or standard sized group of physicians could have any impact on the entry process of the EMR that they use. The likelihood of physician-directed, meaningful impact on EMR design principles represents a modern day iteration of "the Emperor's New… Read more »

Steve2
Member
Steve2

Just some minor corrections. As reported, it is not clear that this is adding costs. The cost of the scribe in the story was taken out of the doc’s salary. I think that we have 2 or 3 scribes in our system and that is what we did. Tens of thousands? The total number of scribes in the US went from 7,000 to 17,000. Drop the plural. Then this. “The patient portrait should be updated frequently, such as at a change in clinical shifts.” Did you do this when you had paper? I really doubt it. That said, I agree… Read more »

Pesto Sauce
Member
Pesto Sauce

Doctors aren’t equipped to do a thing about it. They aren’t coders, they’re doctors. They were given this handbag to hold. I’m glad beyond belief I’m still using paper, and my trusted local colleagues are doing the same. Increasingly patients are demanding that WE NOT USE EHRs because they believe the info is eminently hackable. They’re right.

LeoHolmMD
Member
LeoHolmMD

Unfortunately, DrMorgan is correct. We will not be rid of these bungled legacy systems now that they are entrenched. God forbid patients become the data owners, CMS, insurers,and other corrupt organizations will have no part of that. Facebook is the future they hope for. Oops, sorry that happened to your data. Oh, was that us that committed the largest HIPPA violation of all time? We are so sorry. We had no idea who we were selling your data to. So you can dream about your Star Trek AI enhanced touchscreen all day long. Who is going to fund it? Taxpayers… Read more »

meltoots
Member
meltoots

I completely agree with this comment. The hobbyist MD leaders of the past in CMS ONC etc. had literally no idea what they were doing with even the most basic understandings of how clinical practice works. They threw down a 1 size fits none artificial market and ram rodded it down our throats all the while telling us that the slaughterhouse is a pleasant experience. They had ZERO ability to look ahead and see how this would play out. Every single one of them should be vilified and looked down upon for their complete destruction of the practice of medicine… Read more »

Jeff Goldsmith
Member
Jeff Goldsmith

I don’t think a single soul in the lay world has any idea how much anger there is in the practicing physician community about this “tool”. The vendors seem oblivious. My physician told me on my last visit that it took him an HOUR on the phone with his staff and the help desk to figure out change the diagnosis (!!) in his request for an imaging exam thru Epic. An hour. . Tens of millions of physician and nursing hours are being consumed by this stuff.

Res Morgan M.D.
Member
Res Morgan M.D.

Very true.

And no one is more oblivious that the leadership of the medical societies.

Those who were charged with representing the interests of physicians and their patients, who should have been saying “Slow down, let’s get this right or we’ll have a huge mess on our hands” – instead, they chose to act as the uncritical, unpaid sales reps for Epic and Cerner.

They were wrong over and over and over, and should never be listened to again.

Pesto Sauce
Member
Pesto Sauce

#TRUTH. We didn’t orchestrate EHR and we didn’t want them. I didn’t buy one, the “reward” being a pittance in comparison to the licensing fees, implementation fees, subscription fees, etc. Didn’t take a PhD in economics to see that I would go bankrupt if I purchased this for my practice. The EHR is a great fraud that was perpetrated on American healthcare abetted and aided by the government at the time–Obama (yes the Voldemort that shall not be named) and his sycophants were giddy about the utopia that was coming…well they’re all gone now and personal accountability has long been… Read more »

agropper@gmail.com
Member

I’m a huge fan of Wachter’s work on transparency and much else but I this post misses by a mile. EHRs are an essential mediator between clinicians and patients and will be even more so as tech and AI become more powerful. But the physicians don’t make the rules and neither do the patients. We’re where we are because our profession has ceded control of an essential tool. We are allowing ourselves to turn into highly trained technicians like plumbers and airline pilots. Clinical chemists made this transition as a result of technology many years ago. It’s easier when you… Read more »

Res Morgan M.D.
Member
Res Morgan M.D.

EMRs about collecting and selling data.

Patients provide the data, physicians enter it into the system.

End of discussion.

pjnelson
Member
pjnelson

Putting aside the urban inner-city definition of “to light a candle,” I can only say that the post follows the more traditional imperative that “It is better to light a candle than to curse the darkness!” Unlike EHR issues, the future of managing uncertainty regarding the alternate strategies underlying healthcare will likely depend on a more precise definition of HEALTH and the ‘Dysruptive Processes’ that underlie its expression during a person’s life-time. One observation might suggest a new understanding of auto-immune disorders. Doesn’t the underlying process really reflect a disturbance of immune tolerance? . Using the World Health Organization definition,… Read more »