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Mike Davis Looks at the Past, the Present, and the Future of EHR Adoption—and Customization

February 11, 2018
by Mark Hagland
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Mike Davis shares his perspectives on the future of the EHR—in the U.S. and abroad

Mike Davis, a well-known healthcare IT leader, is perhaps best known as one of the developers of the HIMSS Analytics EMRAM [electronic medical record adoption model] schematic, which he and other members of the HIMSS Analytics team developed in 2005. HIMSS Analytics is a division of the Chicago-based HIMSS (Healthcare Information & Management Systems Society). The EMRAM, according to the website devoted to the subject, “is an eight stage (0-7) model that measures the adoption and utilization of EMR functions required to achieve a near paperless environment that harnesses technology to support optimized patient care.” Since the development of the original EMRAM, HIMSS Analytics introduced its an Outpatient Electronic Medical Record Adoption Model, or O-EMRAM, in 2010. The EMRAM model has also been modified for use in various regions of the world.

Meanwhile, in June 2017, Davis joined the Orem, Utah-based KLAS Research, as lead analyst. He continues to assess and analyze the state of electronic health record (EHR)/electronic medical record (EMR) development across the inpatient and outpatient healthcare sectors in the U.S., and internationally. The Colorado-based Davis spoke recently with Healthcare Informatics Editor-in-Chief Mark Hagland, regarding the current state of EHR development, and where things are headed. Below are excerpts from that interview.

When you take a 40,000-feet-up view of the past ten years in terms of EHR development, and consider the trajectory for the next few years, what to do you see? Do you think perhaps that we’re at an inflection point in terms of EHR adoption and optimization right now?

I think you’re right that we’re at an inflection point in all this. As always, I think the government is trying to do the right thing, but sometimes, the execution isn’t right. Meaningful use pushed hospitals to implement EHRs as quickly as possible, but it wasn’t always with the engagement of clinicians. So we’ve got the EHRs going now, but a lot of times, the clinicians are up in arms, because some of them see them purely as billing systems. So where we are today is that, now that we’ve got them implemented, and clinicians have to use EHRs, to report on quality measures—how do we go back now and really work with the clinicians to make these EHRs usable? What are the best approaches to actually accomplishing that, so the systems are able to drive quality of care and patient safety? Those are the things you want to look at now.

In essence, given the legislation that created the meaningful use process, EHRs kind of had to be implemented by shotgun, correct? That was one of the key challenges beginning in 2009 [with the passage of the HITECH Act—the Health Information Technology for Electronic and Clinical Health Act, signed into law in Feb. 2009].


Mastering the EHR: How Optimization Services Foster Quality Documentation & Physician Satisfaction

We know the goal of the electronic health record (EHR) is to create an optimal work environment that allows providers to maintain a healthy work/life balance while efficiently capturing critical...

Yes. There were some people who knew what was coming in advance, and that’s what the EMRAM was all about.

Do you feel satisfied that the EMRAM has been used correctly in the industry?

You have to consider the broad history of the efforts to measure EHR adoption both quantitatively and qualitatively. EMRAM was the first objective measure of what was going on with the EMR [in patient care organizations]. Before we introduced EMRAM, there had been efforts, such as the Davies Awards, Most Wired, things like that. But we introduced EMRAM in order to look at the full spectrum of EMR capabilities. And now, at KLAS, we’ve created an initiative called the Arch Collaborative. The icon of KLAS is the Delicate Arch in Canyonlands [Utah—the state where KLAS Research is based]. So they incorporated that symbol. The thing about the organizations that did EMRAM early—the organizations that early on got to Stages 6 and 7—is that those organizations had cultures that were very focused on improving the EMR, and making it something that would be a benefit to their clinicians. And the groups involved in the Arch Collaborative, are comparable groups of people.

The thing is, it’s a bit discouraging every time I hear someone say, “Well, we just bought an EMR from one of the big vendors, and it cost $100 million or $200 million on our EMR, and now, we’re hoping to get something out of it”—that speaks to some of the challenges we still face [in terms of strategically implementing and using EHRs].

Totally agreed. The thing is, the way in which the meaningful use process came about, while it tended to straitjacket EHR implementation processes, without meaningful use under HITECH, we would still have relatively low EHR adoption even now, correct?

Yes, I absolutely agree; had the government not pushed this, we would have made very little progress. The challenge is that the academic people want outcomes data, without understanding the impact on clinician workflow; and the vendors want to quickly modify systems to get payments. And meaningful use has slowed down, and we’ll see if Stage 3 even gets implemented. But I think everyone understands that the data being collected is valuable; and that we’ll be able to get better insights into best practices, and how they’re impacting outcomes, and making sure we reward quality as we pay people; those are pretty important concepts.

When I was in Spain last autumn, meeting with healthcare IT leaders in hospitals and health systems there, they noted that the Stage 7 requirement that hospitals establish single-dose-based medication administration, has been an obstacle to achieving Stage 7 there; they simply don’t administer meds in that format. And they’ve been hoping that HIMSS will make certain customizations to allow more international hospitals to achieve Stage 7 EMRAM. Do you have any thoughts on that?

I can’t really comment on that. Before I left HIMSS Analytics—and we were working with Denmark at that time—and I said, look, Stage 5 is closed-loop meds administration, and so many things get implemented through that. And when I go to a hospital, I’d like to see the five rights of meds administration followed; that’s a patient safety issue.

But you can see where HIMSS International might consider modifying that requirement around single-dose?

Sure. And I thought they’d already made the modification myself, but yes, I think there’s a very good chance they might be making that change. And we’re surveying organizations in the UK and Australia, and we look at how they’re implementing the electronic patient record, or EPR, as they call it. And what we’re finding is that the issues that everyone is having, across all countries, are pretty much the same. We’re talking with other countries about participating in the collaborative. And when you work internationally, you have to be pretty sensitive to how other countries work, and we are.

What are your aspirations for the new Arch Collaborative?

We’d like to continue to take this and blow this out. We want to figure out the best practices for education, for personalizing EMRs, and for EMR governance.

What is the scope of the collaborative, or what will it be? Do you see entire countries joining and participating?

That’s the hope, with the UK; we’re working with one of the leading NHS [National Health System] hospitals over there, so yes, that’s the hope. In the US, the process is that we have a standard survey that we distribute; it involves 25 questions. We do allow some modification of that, including for demographics: for example, some versions of the survey include nurses, some don’t; some include specialists, some don’t. And maybe they use different EMRs for inpatient and outpatient. So we make modifications. Once we establish a complete survey for an organization, we help them work with their clinicians. We leave that open for 30-45 days. And we get about 20-percent participation, and somewhere between 85 and 90 percent complete the survey.

What have the results been so far?

We’re just doing this on Survey Monkey right now. We may look at using a standard tool that KLAS uses. The key thing is to keep this simple. When you look at the type of data that we get out of those 25 questions, it will blow you away. That generates about 125 PowerPoints. We create a net EMR experience score. There’s a total score for the entire organization; we can care inpatient and outpatient scores. So we can look at inpatient satisfaction, or ambulatory satisfaction, or any point.

You mentioned just now that physicians and nurses are involved?

It’s much bigger than that: it encompasses physicians, residents, fellows, advanced practice providers (PAs and nurse practitioners), and nurses.

When did this process begin?

They got their first survey done in the first quarter of 2017. We’ve been modifying it. Not only do they get the raw data and PowerPoints, but we get a formal report. We’ve done about 30 final reports. In process, another 40-plus organizations are at some point in process. If they signed up to say yes, we want to be a collaborative member, we take them through the process. And if an organization just wants to do the survey, we do that with them. So, here’s a question for you: when you buy a smartphone, how much time do you spend personalizing it?

Not much…!

So you would be one of those “bad” physicians! I just bought one recently, and spent about two hours personalizing it. My point is that, when it comes to EMRs, you want physicians to personalize their EMR, to meet their individual needs. Some organizations have limited that, saying, geez, if I give them that capability, it will be a nightmare to support. Other organizations will customize by specialty; and a third group says, we’ll let them do whatever they want to.

Is there a best approach, in that context?

There has to be some allowance for personalization. It depends on their EMR governance and education. With good education, they don’t have much trouble supporting a lot of customization.

Will customization will lead to greater usability and success?

Governance and culture go together, and are key. If organizations are really behind this and want to make it work, that’s number one. Number two is that the second-biggest impact is initial education or training. When you do the initial training—when you go in and work with a cardiologist, and help them set up their workflow, they find they’ve learned the EMR well enough to be successful. And the third thing is the personalization; the more they personalize that EMR and the more personalized, they more successful they’ll be.

What about data collection?

If you personalize workflow, that should make it much easier to collect and report on data. Now, we train the physicians on how to put data into those systems. Most people don’t do a great job of that. Our big example is customized report views. There are certain types of information as a cardiologist that I want to be able to get easily, and I don’t want to have to go to a lot of places. If they can go in very quickly, they can get it. That’s the stuff we don’t do a really good job right now on setting up for the clinicians, or even on training them to do it. We understand that you have to put the data in, to get paid. But getting the data out, is really important!

Will we get to a point where physicians will be in a better place with this? One of the complexities in all of this now has to do with physicians feeling overwhelmed, and turning to scribes. But the use of scribes itself introduces additional complexities.

It’s interesting that you brought up scribes. We’ve found that most people aren’t satisfied with their scribe services, or people entering their orders for them. So that has to be looked at. And what about voice recognition? What we’re finding is that a lot of people aren’t getting the expected benefits out of voice recognition. I think that they’re not doing the appropriate integration into the EMR. I think we will see it—I think at some point in time, the voice recognition will start to provide us with an approach that works. The other element is the templates and order sets—if those are done correctly, they should be able to very quickly document what they need to document, and as a byproduct of that, the ICD-9 and CPT-4 codes, should be encoded, to drive data collection. So I think you’ll see better designs of workflows that will codify information, and then you’ll see improvements in how that information is captured, and that will be a byproduct.

I think that’s what physicians are looking for. They’re complaining now about the number of clicks it takes them to get through an order set. And I don’t blame the vendors; they’re trying to stay afloat, and have been putting everything into R&D so that people could get paid. I think the vendors will do a much better job of making the EMRs more intuitive, and that will drive efficiency. I think that’s where I think this will go.

Do you think we’ll get to a point where EHRs will be user-friendly, physicians will no longer be deeply dissatisfied, and the workflow and data flow will easily facilitate the data collection and measurement we need in order to support population health management and value-based healthcare? How optimistic or pessimistic are you on all that, overall?

I am more optimistic now than I’ve ever been, actually. I think we’re getting closer to that reality. I think the clinicians recognize that the practice of medicine is changing, and EMRs are a part of that. So they’re getting engaged. So I think we’re getting there. And we’ll be successful.

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How BI Tools Are Helping Jefferson Health Battle the Opioid Crisis

September 21, 2018
by David Raths, Contributing Editor
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Helping clinical leaders identify prescribing patterns across the health system

Making health system changes to address the opioid crisis is challenging if you don’t have actionable data about prescribing patterns. With guidance from their chief medical officer, the business intelligence team at Jefferson Health in Philadelphia took advantage of the recent enterprise EHR implementation to create dashboards highlighting potential prescribing issues. Internal EHR development teams have already made changes to address the issues they found.

In a recent interview, Cara Martino, enterprise business intelligence manager at 14-hospital Jefferson Health, said that Jefferson was one of the first health systems to implement its Epic EHR and Qlik Sense at the same time. Many organizations that go live on Epic use Crystal Reporting, she said. “It was the combination of the two that allowed us to do this project,” she added. Before going live on Epic and using this new BI tool, Jefferson clinicians used a bunch of disparate systems for ambulatory, inpatient and emergency department physicians. “We weren’t able to aggregate the data,” she recalled.

Jefferson departments had tried to look at opioid prescribing previously, but “they were trying to manually abstract opioid data from the system, compile it in Excel, and try to see trending across the continuum of care, but they really weren’t able to do that very well,” Martino said. “Once we went live with Epic, we were able to standardize the work flow of entering the opioid order and prescription, and Qlik Sense allowed us to look at it from that enterprise view and to slice and dice the data a bunch of different ways.”

In response to the opioid epidemic in the Philadelphia area, Jefferson has created an opioid task force. In January 2018, Edmund Pribitkin, M.D., Jefferson’s chief medical officer, came to the BI team because he saw they didn’t really have good data to share. “We were bringing physicians and pharmacists together in a room to think through what we can change to address the opioid crisis,” Martino said, “but they didn't’ have baseline data to understand where we are going wrong.”

Pribitkin asked the BI team to develop a high-level dashboard with five key metrics to share at the clinical chair department level: 


Mastering the EHR: How Optimization Services Foster Quality Documentation & Physician Satisfaction

We know the goal of the electronic health record (EHR) is to create an optimal work environment that allows providers to maintain a healthy work/life balance while efficiently capturing critical...

• Prescriptions by provider and service;

• Number of orders with over 100 pills;

• Prescriptions written for more than 7 days, 5 days and 3 days;

• Patients with two or more opioid prescriptions within 30 days; and

• Morphine-equivalent daily doses over 50.

The metric around patients with two or more prescriptions within 30 days had been difficult to see when data was being entered in a lot of different ordering systems, but is much easier now because everyone is ordering through Epic.

Within a month, the BI team had a prototype created. In the dashboard, you can pick a patient with the most scripts, and below it populates the different providers who are prescribing for them. “Sometimes you pick someone on the higher end and only one person is prescribing to them. Usually it is a chronic pain clinician, and it is probably appropriate,” Martino said. “But then you pick someone who has six different providers providing them opiates. They may have no idea about each other. Now we get to have that conversation about what we can do in the EHR to notify them at the time of ordering that the patient already has something prescribed. Also, our quality department can notify these six providers via e-mail. They might ask whether we should refer this patient to a chronic pain physician. If they really need this much pain medication, are we treating them the right way?”

Showing clinical leaders a trending graph such as prescription orders of 7 days or more can have an impact on ordering trends and EHR recommendations. Martino, who is a nurse herself, described an example of how her team worked with clinician informaticists who build EHR workflow tools to make some key changes.

They saw in the data that there were examples of doctors were prescribing six opioids to the same patient within two minutes. On further examination, they found that clinicians were entering orders incorrectly and quickly canceling them. But the e-prescription interface with the pharmacy system wasn’t necessarily canceling the incorrect orders, and the patients could have six prescriptions waiting for them at the pharmacy.

“Our first step was to get a message out to providers to let them know if you are prescribing and sending to an outside pharmacy, you need to pick up the phone and talk to the pharmacy about a change in an order and make sure they know which is the correct one,” Martino said. They also worked on the pharmacy interface to generate those canceled order messages, so that if something is ordered and then canceled within 30 seconds, it alerts the pharmacy not to prepare it.

The BI team saw another EHR change that they thought might make a big difference in prescribing patterns. In the EHR quick buttons, duration of the prescription defaulted to 10 days. The quick button on order days had choices of 7, 10, 15 or 30. “We knew those were too high,” she said. “We wanted 3, 5 or 7.”

They worked with an emergency department doctor who was also an informaticist to pilot that change in the ED. “In the first month, we saw a drop from 32 scripts over 7 days to just two,” Martino said. The following month they saw a reduction of more than 65 percent in prescriptions of more than 7 days. “The best part is no one complained or said they were looking for the 10 button and it wasn’t there,” she added. Now that change is being rolled out enterprise-wide.

Although there are some other requests from clinicians for data about opioid prescribing, Martino said the BI team’s current goal is to help more clinicians gain insights into the data that already exists. “It is really hard to go from an institution that was not data-rich and had disparate systems and manually collected data to one that has one EHR and a robust BI tool that allows us to slice data in a million different ways,” Martino said. “We are trying to get the clinicians comfortable with the tools. There is so much we can do, but we have to get the data to the right people and educate them about how we are pulling it out of the EHR. It is easy for this not be a priority for clinicians because they are so invested in taking care of their patients. It is our job as informaticists to go to their meetings and talk about changes we can make. It is also important for us to have clinicians on our team and to be able to offer that informaticist viewpoint.”



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Survey: Physicians Sour on Value-Based Care Metrics, EHRs

September 19, 2018
by Rajiv Leventhal, Managing Editor
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They new research has several key findings related to value-based care, health IT and burnout

More than 50 percent of U.S. physicians who receive value-based care compensation said they do not believe that the metrics the reimbursement is tied to improve the quality of care or reduce costs, according to a new survey.

The research comes from The Physicians Foundation, an organization seeking to advance the work of practicing physicians and helps them facilitate the delivery of healthcare to patients. The Foundation’s 2018 survey of U.S. physicians, administered by Merritt Hawkins and inclusive of responses from almost 9,000 physicians across the country, reveals the impact of several factors driving physicians to reassess their careers.

Specifically, the new survey underscores the overall impact of excessive regulatory/insurer requirements, loss of clinical autonomy and challenges with electronic health record (EHR) design/interoperability on physician attitudes toward their medical practice environment and overall dissatisfaction—all of which have led to professional burnout.

The research revealed several key findings, including that value-based compensation is directly connected to the overall dissatisfaction problem, which is tied to metrics such as EHR use, cost controls and readmission rates, etc. Forty-seven percent (compared to 43 percent in the 2016 survey) of physicians have their compensation tied to quality/value, but when physicians were asked if they believe that value-based payments are likely to improve quality of care and reduce costs, 57 percent either disagreed or strongly disagreed that this is the case, while only 18 percent either agreed or strongly agreed that it is.

As one responding physician put it: “We are no longer in the business of healthcare delivery, we are in the business of ‘measures’ delivery.” More than 13 percent of physicians are not sure if they are paid on value.

What’s more, the research found that 88 percent of physicians have reported that some, many or all of their patients are affected by social determinants. Conditions such as poverty, unemployment, lack of education, and addictions all pose a serious impediment to their health, well-being and eventual health outcomes. Only one percent of physicians reported that none of their patients had such conditions.

Additional notable findings from the research included:

  • 18.5 percent of physicians now practice some form of telemedicine
  • 80 percent of physicians report being at full capacity or being overextended
  • 40 percent of physicians plan to either retire in the next one to three years or cut back on hours—up from 36 percent in 2016
  • 32 percent of physicians do not see Medicaid patients or limit the number they see, while 22 percent of physicians do not see Medicare patients or limit the number they see
  • 46 percent of physicians indicate relations between physicians and hospitals are somewhat or mostly negative

Coupled altogether, 78 percent of physicians said they have experienced burnout in their medical practices, according to the survey’s findings. And the results show that one of the chief culprits contributing to physician burnout is indeed the frustration physicians feel with the inefficiency of EHRs.

“The perceptions of thousands of physicians in The Physicians Foundation’s latest survey reflect front-line observations of our healthcare system and its impact on all of us, and it’s sobering,” Gary Price, M.D., president of the Foundation, said in a statement. “Their responses provide important insights into many critical issues. The career plans and practice pattern trends revealed in this survey—some of which are a result of burnoutwill likely have a significant effect on our physician workforce, and ultimately, everyone’s access to care.”

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Brigham Health’s 3-Pronged Approach to Reducing EHR’s Contribution to Burnout

September 18, 2018
by David Raths, Contributing Editor
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Focus is on individualized training, reducing unnecessary clicks, voice recognition tools

Research studies have found that “burnout” is nearly twice as prevalent among physicians as among people in other professions.  Physician surveys have found that 30 to 60 percent report symptoms of burnout, which can threaten patient safety and physician health. With EHR documentation ranked high among aspects of their work physicians are dissatisfied with, Brigham Health in Boston has taken a three-pronged approach to reducing the pain.

Brigham Health, which is the parent organization that includes Brigham and Women’s Hospital, Brigham and Women’s Faulkner Hospital and the Brigham and Women’s Physicians Organization, rolled out its implementation of Epic in 2015. In a Sept. 18 presentation that was part of the Harvard Clinical Informatics Lecture Series, Brigham Chief Information Officer Adam Landman, M.D., said the organization’s initial EHR physician training was eight hours of classroom training on where to find things in the EHR instead of focusing on workflows and how to use the EHR to support it.  “Our experience was not the best,” Landman admitted.  They followed up with tip sheets, a help desk and a swat team to do service calls, but providers only rated those interventions as somewhat helpful, so Brigham informaticists re-doubled their efforts to:

• Improve the EHR;

• Provide one-on-one training in the clinical setting; and

• Offer voice recognition software and training.


Mastering the EHR: How Optimization Services Foster Quality Documentation & Physician Satisfaction

We know the goal of the electronic health record (EHR) is to create an optimal work environment that allows providers to maintain a healthy work/life balance while efficiently capturing critical...

Landman said IT teams at Brigham feel a sense of urgency about reducing the burden of EHR documentation. “Burnout is an epidemic, and the EHR is a component of this,” he said, adding that the changes are not just a one-year cycle but must involve continual iterative improvements. “We need to be more aggressive about making changes,” he said.

He described some efforts to reduce notifications and remove clicks from the medication refill process. They also removed a hard stop when discontinuing a medication. Those three changes alone reduced the number of clicks per month by 950,000 across the health system.

They also worked to reduce clinical decision support alerts with very low acceptance rates by turning them off. Three alerts with very low acceptance rates were turned off. “If we thought they were important, we would fine tune them to increase the acceptance rate,” Landman stressed. “That is part of clinical decision support lifecycle management. But we will continue to iterate to reduce the number of unnecessary clicks.”

A year and a half ago, Brigham also created a one-to-one support program, in which an expert trainer would meet the physicians in their practice and help them with their work flow. A pilot project involved four specialties, including general surgery. Each session was 90 minutes to two hours long, and providers were offered one or more follow-up sessions, as well as optional training on speech recognition. After seeing some negative feedback on their initial classroom training, the one-to-one sessions were met with a very positive response. Almost 95 percent said it was valuable, and 95 percent said they thought their efficiency with the EHR would improve following the training. Based on that early success, the training effort is now being rolled out to much larger groups of physicians at Brigham and across the Partners HealthCare network.

In another attempt to improve documentation turnaround time, Brigham has made voice recognition tools and training available to physicians. They made two-hour training sessions mandatory for those interested in adoption, with additional personalization sessions also available. Informaticists partnered with departments to build department-specific order sets. (Brigham also started offering 15-minute e-learning sessions for residents.) More than 90 percent of surveyed physicians said the training met expectations, and 70 percent said they would be willing to have additional training, Landman said. Currently 5,000 physicians across Partners are trained to use voice recognition tools with the EHR.

Landman also cited a study that compared U.S. and international use of Epic that saw a huge disparity in length of documentation notes. The U.S.-based users’ notes were nearly four times longer on average than those of their international counterparts. Epic users overseas tend not to complain about the burden of documentation, he noted. This has to do with how the provider notes are used in billing, he said, adding that CMS is working on proposals to change billing requirements that may alleviate some of the documentation burden for physicians.

In closing, Landman urged informatics colleagues to think about working on EHR optimization research and studying the impact of policy and technology changes. “New technology tools can seem fun and exciting, but for physicians who see up to 100 patients per day, they can be quite overwhelming,” he said. “We don’t want physicians spending half their time doing administrative work.”






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