The Future of EHRs: Back to Basics?

If I had a dime for every time I heard someone in the medical field complain about tedious data entry in their EHR, let’s just say I would have a lot of dimes. This complaint isn’t new, in fact over the last 5 years it seems to have gotten louder and more widespread with the introduction of the HITECH act. Even though the HITECH act was intended to spread adoption of EHRs for long-term quality, safety, and interoperability, the immediate frustration has been the additional “click” burden on clinicians.

I’ve heard Dr. Terry Ketchersid say, “Today the doctor serves the technology, yet the goal is for the technology to serve the doctor (and ultimately the patient).” The question is, how do we get there?

Last Friday, the Journal of American Medical Informatics Association (JAMIA) released a “Report of the AMIA EHR 2020 Task Force on the Status and Future Direction of EHRs”. This report is the result of a 15-member taskforce made up of diverse members in the Health IT community. Their assignment was to recommend practical solutions on how to improve the use of EHRs over the next five years.

The taskforce broke down their study into five different areas:

1. Simplify and speed documentation
2. Refocus regulations
3. Increase transparency and streamline certification
4. Foster innovation
5. Support person-centered care delivery

Simplify and speed documentation

• Decrease data entry required by the physician. This is pretty much self-explanatory. The interpretation of CMS final rules seems to put the heavy data-entry lift on the provider (the most expensive member of the team). The taskforce’s recommendation is to spread out the data entry to other care-team members in addition to the provider—including the patient.
• Separate data entry from data reporting. This recommendation suggests removing a templated progress note and allowing providers to continue the narrative, free-text notes of the past. Instead of a codified template, the taskforce proposes allowing patients and other care-team members to enter discrete data (as stated in the above recommendation) along with pushing policy makers to require other IT systems (such as lab, radiology, electrocardiography, and immunization systems) to send structured clinical data into the EHR to prevent manual, duplicative entry.
• EHRs should enable systematic learning and research at the point of care during routine practice. This one comes down to a simple cost-benefit analysis. The taskforce advocates that more research should be done to recognize the cost to enter in data (in time) and the benefit that data provides (to care delivery, research, and billing). For example, what benefit does typing in a patient’s history bring versus doing a quicker sound recording?

Refocus regulations

The past few months have been filled with proposed rulings from CMS and ONC that require both providers and EHR vendors to jump through additional and, perhaps, unnecessary hoops. This section of the taskforce report was longer than any other.

• Clarifying and simplifying certification and MU regulations. Simply put, instead of adding more requirements, the taskforce recommends refining the requirements already in place (specifically surrounding safety, security, quality measures, and interoperability). This will allow EHR users and vendors alike the time to stabilize their products and focus on enhancing workflows and innovation.
• Improving data exchange and interoperability. This one builds on the recommendation above. By focusing the EHR certifications on interoperability—and requiring other systems (such as data registries) to comply with EHR code sets and standards—can reduce time and costs to exchange information. In addition, the taskforce suggests that reducing costs of interfaces may lead to “new business models funded through business interests or public good.”
• Reduce data entry and focus on patient outcomes. Reducing data entry seems to be the theme of this report with a strong stance that data entered should only relate to the information needed to treat the patient and should be directly related to the clinician’s specialty. As stated in the report, “EHR users should not have to implement functionalities or document findings where the main benefits do not accrue to the patient or practice but rather to others such as payers or other secondary data users.”

Increase transparency and streamline certification

Along the lines of regulation, the taskforce recommends that ONC be more flexible in terms of how to pass a specific requirement/objective. Currently, ONC provides prescriptive instructions on how to meet each objective required for certification. The unintended consequence is that EHR companies design new functionality exactly as specified by ONC instead of focusing on the user experience and workflow for that particular function. Instead of the prescriptive instructions, they suggest ONC work with vendors, informatics professionals, and the industry to develop “clear, flexible, and transparent methods for testing whether the product meets the MU functional objective.”

In addition, the taskforce believes that the EHR certification process should be more visible to the public so consumers understand how each EHR works and passes the test.

Foster innovation

This section focused on moving EHR vendors into using public standards-based application programming interfaces (APIs) and data standards. The taskforce believes moving to APIs and data standards will enable EHRs to become more open to innovators, researchers, and patients.

Support person-centered care delivery

Last, but not least, they hope that in the near future the EHR will be a shared record between the patient, the care provider teams, and the institutions that pay for and provide care.

• Promote the integration of EHRs into the full social context of care. Incorporating data from different sources into an EHR (such as patient-generated, laboratory, pharmacy, home health, specialist care, behavioral, and physical therapies to name a few), can “spur development of new care delivery models, improve population health, aid in the development of precision medicine and support other healthcare transformations.”
• Improve the designs of interfaces so that they support and build upon how people think. The last recommendation of the report is arguably one of the most impactful. Design systems to be usable. Justify design around empirical findings from areas like human-factors engineering. Get away from displaying information with tacked-on alerts and screen nags (that probably stemmed from MU) and focus on a design with minimal cognitive effort that supports our pattern-matching abilities.

These recommendations cannot be acted upon without the support of national policy and more lenient regulatory requirements, but we’d like to know what you think. Do you believe instating the recommendations of the AHIMA taskforce will bring us to a place where EHRs serve the doctors and ultimately the patient? What areas do you agree or disagree with? We would like to hear your comments below!

Diana Strubler, Senior Product Analyst, Health IT Standards, joined Acumen in 2010 as an EHR trainer then quickly moved into the role of certification and health IT standards subject matter expert. She has successfully led Acumen through three certifications while also guiding our company and customers through the world of Meaningful Use, ICD-10 and PQRS.