Electronic health record (EHR) systems came under fire when Texas Health Presbyterian Hospital stated that a "glitch" may have contributed to Ebola patient Thomas Duncan's discharge from its emergency department. Though the hospital has since retracted its statement that the EHR was to blame, questions linger about how electronic records can be better integrated into clinical care.
We reached out to physicians by email to ask:
If you could change one thing about your EHR system, what would it be?
The participants this week:
, past Chairman of Emergency Medicine and Chief Medical Informatics Officer at Maimonides Medical Center in Brooklyn, NY, and founder of
, internist and Chief Information Architect at Beth Israel Deaconess Medical Center, Boston
, pediatric radiologist, Emory University School of Medicine, Atlanta
, pediatrician and Assistant Medical Director for Informatics, University of California, San Francisco
, radiologist, NewYork-Presbyterian/Weill Cornell, New York City
, internist at Florida International University in Miami, Fla., and past Chief Medical Information Officer for AT&T
, family medicine hospitalist and Executive Director of Medical Informatics, Tallahassee Memorial HealthCare, Tallahassee, Fla.
, pulmonary, critical care, and sleep medicine specialist, Grand Blanc, Mich.
, Chair of Radiology, Medical College of Georgia, Augusta, Ga.
, Director of Cardiac Electrophysiology, The Christ Hospital, Cincinnati, Ohio.
, internist, Beth Israel Deaconess Medical Center, Boston, Mass.
, brain injury rehabilitation specialist at Shepherd Center in Atlanta, Ga. and contributing writer for Bloomberg View
, emergency physician at Kaiser Permanente San Francisco and developer of and
, President of EHR Workflow in Washington D.C., and past Chief Medical Informatics Officer at EncounterPRO Healthcare Resources
Lay Off the EHR
Henry Feldman, MD: "Let me start with the basic premise: the EMR was in no way at fault for the Ebola discharge. That was a basic human failure to communicate a critical situation.
Let's make it slightly more extreme (but more routine): The patient was in cardiac arrest/Code Blue in the waiting room. Would a triage nurse just simply put that in the triage nurse EHR note and put the patient at the front of the line for ED admission? Of course not ... Ebola is on that scale of medical diagnosis."
Deep Ramachandran, MD: "What's the biggest problem with EHRs? Sorry to say this, buddy, but it's you. Yes, EHRs are a mess. Yes, they create a hodgepodge of barely comprehensible gobbledlygook. Yes they make your job harder ... But they are here to stay. So the biggest thing you need to change about your EHR is you.
Specifically, your perception that your EHR is going to adapt to you.
It's not. The first thing you need to do with any EHR in order to unlock its potential ... is to realize that you need to adapt your way of doing things to this new piece of technology."
The User is King
Graham Walker, MD: "Usability, user interface, and user experience. EMRs are sadly designed with little emphasis on safety, provider workflow, and information priority. Some screens show the most recent lab results on the right, others default to the left. Some at the top, others at the bottom. Clinically insignificant alerts and hard-stops create 'alert fatigue,' and tabs upon tabs of screens and sub-screens make finding relevant, important information overly challenging.
EMRs should provide intelligent assistance with medical care and should alleviate mental burdens and solve care problems, not create them."
Randa Perkins, MD: "I wish it had been designed by the clinicians and patients in the trenches, starting with their needs and goals. Informaticists work daily at bending hard-coded EMRs to the will of the clinicians using them. Imagine if we'd started the initial code with what the providers needed, instead of drastically shifting their workflows?"
Aaron Stupple, MD: "Signal versus noise: I'd boost the signal in favor of the noise. The signal is relevant, useful, important information for medical decision making that impacts patient health. Noise is everything else.
Unfortunately, the distinction between signal and noise, what matters and what is merely clutter, is ultimately a clinical question best answered by a clinician.
Therefore, in order for the signal to be readily available, an EMR must be designed by clinicians who know what is important. It can't primarily be a means to bill, to document, or to feel modern and slick."
Open Source
Carolyn Bradner Jasik, MD: "The one thing I would change about my EHR (which happens to be the same one as Texas Health Resources) is that it would have a more open platform so that more decision support tools could be developed on top of its great foundation.
Without an open source approach, or at least open application programming interfaces, we don't have a fighting chance to innovate in digital health to make decision support tools that would have caught this issue.
The vendors will talk about their integration approaches, but they are cumbersome and expensive. We can do better. We need to do better."
Get Clinicians Talking to Each Other
Matt Hawkins, MD: "EMR systems should promote increased interconnectivity between clinicians and teams. Currently, each team functions within a silo, whether composing notes, searching for data, or developing a care plan for patients. If EMRs would allow for physicians to interact with one another remotely -- either in live time, or asynchronously -- it would be one small step towards truly cultivating a multidisciplinary approach to patient care."
Steven J. Davidson, MD, MBA: "I'd ask EHR vendors to ease the challenge of integrating EHR content into telecommunication devices and software. Effectively, EHRs vendors now tout the use of their EHR database as a substitute for communication, coordination, and workflow technologies -- driving clinicians to a hunting and gathering expedition and leading to the sort of occurrence where a patient with recent travel and symptoms of Ebola was apparently discharged from a hospital emergency department.
EHRs forestall the implementation of contextual communication among clinicians. Instead, they impose this additional cognitive workload manifested as searching and recomposing of patient context that adds to the burden on clinicians seeking to respond to a patient's need and burdening systems of care.
The flexible, mobile communication, coordination and workflow tools that support contextual communication are out there, but aren't being implemented because of EHR vendor obfuscation.
As a consequence, clinicians are challenged making timely decisions and instituting effective actions (medical orders) by unsustainable cognitive workloads and anxiety required by hunting and gathering through the EHR database."
Get Patients Talking Too
Stupple: "Runner up: I wish patients could see it."
More Signal, Less Noise
Edward J. Schloss, MD: "Data formatting and organization is a big problem with current EHR systems. The 'good stuff' is mixed in with line after line of junk. Finding nuggets of truth is challenging and time consuming.
Inaccurate input by ill-informed clinicians is perpetuated from note to note, and displayed with the same degree of weight as the detailed reporting of the most compulsive caregiver. Regulatory mandated documentation creates bloat that intrudes on the mission of caregiving.
In the paper chart days, sometimes the best notes were the shortest. The short, meaningful notes may still exist, but they reside as needles hidden inside the swollen EHR haystack."
Perkins: "Usability, but we are improving it daily. Usability isn't a 'nice to have;' it's a critical safety feature. Any system not designed by the users will inherently fail to initially meet those users' needs, such as recording relevant data buried in the irrelevant/arbitrary and outside of practical workflows."
Feldman: "Currently our EHR is more slanted towards ambulatory care, and in fact the majority of our care is ambulatory. When documenting inpatient stays, either your notes -- comprising a tiny portion of a patient's medical 'life' -- add noise to the outpatient record or are put way on the side so as to be basically invisible to the providers.
We need some mechanism for efficiently filtering notes automatically such that important concepts of inpatient stays (not just the 12-page discharge summary) are brought forward, but the minutia of daily care in the hospital are filtered out to improve the signal-to-noise ratio.
The reverse must also be true, in that you often see situations where the patient has a major device or prior surgery for many years, which since 'everybody knows' about it in the outpatient setting, is no longer mentioned, and can cause medical errors when admitted."
Search Function
James Rawson, MD: "I need the EHR to provide me relevant information on the patient whose images I am viewing at that moment. Often the hierarchy or structure of the EHR does not lend itself to quickly finding a discrete piece of information -- whether it be a document such as a procedure note or the result of a test.
The feature I would like to add to our EHR is a search engine. If we could quickly search a patient's entire EHR, we would more rapidly find information that would be helpful. Since we can get search engines on our phones, it seems reasonable to expect search engine functionality in our EHR.
Of course the effectiveness of the EHR search engine will be limited by the number of documents that are scanned in and not searchable."
Automate
Chuck Webster, MD: "If I could change one thing about EHRs in general, it would be for them to be implemented on true workflow platforms, instead of the currently used structured document platforms. True EHR workflow systems have a workflow engine that does things for users automatically, saving them time and effort.
Further, and possibly relevant to the Ebola vs. EHR case in Dallas, workflows can be created and customized by physicians, who know their workflows best. For example, a workflow definition could have been created that would have been triggered when the nurse entered the information the patient had traveled from Liberia.
This work item could have been posted to a generally visible status board, so all the members of the staff could know it was there. Patient data and task visibility is a big problem in many current EHRs, and workflow technology has a solution to this invisibility.
Looking ahead, if we can model and execute clinical workflows, then we can transmit and monitor them as well. Eventually, public health entities will transmit candidate workflows to EHRs, to have useful effects at the point of care, but without the workflow disruption physicians find so troublesome."
Don't Assume Automation
Geeta Nayyar, MD, MBA: "EMRs cannot aim to and are not meant to 'automate' everything in the practice of medicine. Clinical judgment and final decision making still belongs with the physician and care team.
EMRs are not meant to find and identify an outlier case such as a potential Ebola outbreak. The question we should ask is what could we have automated via the EMR so the physician would have had more time with Mr. Duncan to illicit his travel history during his initial history taking.
Surely the doctor doesn't need the EMR to tell him he was in Liberia with a fever but perhaps 5 more minutes with the patient would have itself been enough to get this relevant history with his symptoms."
But It's Not All Bad News
Geraldine McGinty, MD, MBA: "I really like my EHR (we use Epic) but if I could change one thing it would be that I would like never to have to type in a login and password again!
In my fantasy world I would use a fingerprint or retina scan, every system I use would open, and I could close them all again just as easily. I'd love it if the user interface were more beautiful because I think that would allow me to focus on the information more effectively. I really like the Mana Health user interface, for example.
Overall though, as a radiologist, I find that the information I glean from the EHR improves the relevance of my reporting immensely. I think having a picture of the patient is really important especially since I may be reading their images remotely. It helps me feel connected to my patients."
Ford Vox, MD: "I've often talked about the fact that I started out with physician order entry as a medical student and enjoyed real-time labs and radiology on a PDA as an intern, and it's only gone downhill from there. My life as an attending seemed to become progressively more paper-based.
Here at Shepherd Center we recently bit the bullet and have converted from a half-EMR and half-paper system to full-out EMR. I must say that for my purposes so far I'm finding far more that I appreciate and even enjoy about this EMR system, Soarian, than any other I used in my years of training. Soarian was designed for general acute hospitals but through yeoman's work the company and many key members of our staff have made the necessary modifications for our purposes.
What's the one thing I'd change? Cerner, the EMR behemoth, recently announced its purchasing the Siemens division that produces Soarian. Mergers and acquisitions in the EMR world do put me on guard about the future evolution and support for a product with which I'm so far impressed."
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Friday Feedback is a feature that presents a sampling of opinions solicited by ľֱ in response to a healthcare issue, clinical controversy, or new finding reported that week. We always welcome new, thoughtful voices. If you'd like to participate in a Friday Feedback, or suggest a topic, drop us a line or two.
Disclosures
The author disclosed no relevant relationships with industry.