Sizing Up EHRs: What Are We Getting Right – and Wrong?

Recently I was asked by a colleague how I would I size up current EHRs: what are the major wins and what needs improvement? In about an hour, and off the top of my head, I wrote this list. It is neither comprehensive nor deeply reasoned. However, it is a compilation of frustrations and grateful moments that come from having help design, implement, and use an EHR over the past 2 decades.

Check out this video from CRICO, a Boston EHR interest group. It’s quite provocative. I don’t agree with all of it, but it provokes a lot of discussion.

Let’s start with the major wins we’ve seen with EHRs:

• Engaging the patient using the portal. online communication, access to records, Open Notes, Open Results, are just the beginning of a needed improvement in information transparency. Anything that eliminates the telephone tag circus is good.
• Having the chart accessible anywhere, anytime avoids missing data (medical errors from handoffs of care), paper filing, and paper shuffling costs. As one colleague wrote: Paper Kills. In the 1990’s, between one third and two thirds of patient appointments did not have the relevant paper chart pulled in time for me to see the patient. How embarrassing. This no longer happens. Also, our paper filing, despite a team of 50 in medical records, was always 2-3 weeks behind. Even if you did receive the paper chart, there was a good chance you didn’t see the recent report you needed.
• Improvements in legibility (sometimes at the cost of unreadability due to note bloat). How many times per day did used to I take a paper chart to a colleague or nurse and ask, “What you think this says?”
• Easy narrative documentation using Speech Recognition, and increasingly, Natural Language Processing (detecting codified concepts using machine learning). We’re only just starting to see the fruits of these technologies. A typical physician’s cost for human transcription, per year is about $15,000. And the turnaround time can be days, resulting in missing data during that time. Speech recognition is instant, and NLP has the potential to create instant alerting and reminders.
• Reminders and alerts improve the frequency of doing the right thing at the right time more often (when well-designed). This is the flip side of Alert Fatigue (see below). I love when my system reminds me to vaccinate, or screen for colon cancer, or screen for depression, particularly when I catch and prevent an illness that I would otherwise have missed.

That being said, here are the areas in which major improvements are needed:

• Alert fatigue: poorly designed, terrible signal-to-noise ratio of alerts. Enough has been written about this. Our Physician Informatics Group constantly struggles to improve the signal-to-noise ratio of these alerts, and to reduce alerting. I consider it a personal failure if we implement a best practice alert that stops a doctor’s work, instead of designing a smarter EHR that guides and nudges a doctor’s behavior, so that we make the right thing easy.
• Better ways of capturing physician-patient interaction (see #1). Maybe a full video recording instead of typing out a history, and having the machine collate into a timeline, concise narrative.
• User interface design (see #1). Why can’t the electronics disappear into the wall until they are needed, and then pop in with reminders and context-sensitive help just-in-time?
• Eliminating communication barriers and snafu’s based on nurse-physician-patient ping-pong messages.
• An appreciation from clinical leaders that an EHR is NOT the solution. Instead, we need to focus on a clinical re-invention that uses an EHR as tool to create better teamwork and communication. How to get that across? Our biggest successes come from clinics that realize this one fact (see my previous posts – EHR Sprint and Transformation).

What’s missing from this list? What do you take issue with? Let’s craft a message to our EHR vendors and demand something better. I’m convinced we’re in version 20 of something that will need 50 versions to get right.

This piece was originally published on The Undiscovered Country, a blog written by CT Lin, MD, CMIO at University of Colorado Health and professor at University of Colorado School of Medicine. To follow him on Twitter, click here.