At Northwell Health, IT Leaders are Revamping the EHR with AI, NLP and Voice Tools | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

At Northwell Health, IT Leaders are Revamping the EHR with AI, NLP and Voice Tools

July 5, 2018
by Heather Landi
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For physicians and clinicians, electronic health record (EHR) usability and the time spent box-checking and on data entry are oft-cited sources of frustration and stress. Numerous studies and surveys indicate widespread dissatisfaction among physicians with the time spent on EHR documentation and the impact on patient interactions.

A study published in the Annals of Family Medicine last fall found that primary care physicians spend nearly two hours on EHR tasks per hour of direct patient care. Another time and motion study published in the Annals of Internal Medicine in October 2016 found that, outside office hours, physicians spend another one to two hours of personal time each night doing additional computer and other clerical work. What’s more, a Mayo Clinic study linked EHRs with physician burnout.

Some of the biggest names in technology are working to tackle this problem, as well as innovative teams at many large health care systems, with a focus on developing “smart” EHRs using artificial intelligence and voice recognition technology. As recently reported by CNBC, Google is exploring ways to use AI and voice recognition to improve patients’ visits to the doctor. CNBC reported that four internal job openings at Google describe building the "next gen clinical visit experience" and using audio and touch technologies to improve the accuracy and availability of care.

The project falls under the healthcare group on Google Brain, part of its Google AI division, and is sometimes referred to internally as "Medical Brain,” according to CNBC. “The project would likely take advantage of the complex voice technologies Google already uses in its Home, Assistant, and Translate products,” CNBC reporters Jillian D’Onfro and Christina Farr reported.

Last fall, Stanford Medicine and Google Research announced a pilot project to study the use of a digital-scribe to replace a human scribe in order to save the physician time on data entry and improve physician-patient interaction. The digital-scribe system uses speech recognition technology and machine learning tools to automatically enter the information from the office visit into an EHR system.

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Earlier this year, Microsoft announced a collaboration with the University of Pittsburgh Medical Center (UPMC) on its Intelligent Scribe platform, a virtual AI assistant that “listens in” during a doctor’s visit and takes notes. The application analyzes a doctor’s conversation with a patient and then makes suggestions in the patient’s electronic health record.

Back in April, Vanderbilt University Medical Center unveiled a voice assistant for VUMC clinicians to interact with the hospital’s EHR system, developed by VUMC’s biomedical informatics and health information technology innovations division. Using natural language processing (NLP) and AI, the EHR Voice Assistant is designed to understand and fulfill verbal requests from clinicians and other hospital staff.

Additionally, startup companies like SayKara and Notable are also developing solutions in this space. SayKara developed an AI-powered scribe for doctors and Notable developed what it calls “voice powered healthcare” using AI to automate and structure patient-physician interaction.

At Northwell Health, a New York City-based health system with 23 hospitals, clinical and IT leaders collaborated on an innovation project, called EMRbot, that allows physicians and nurses to “talk” with a patient’s medical record. The technology enables users to interact with EHRs using voice, natural language text messages and an adaptive user interface using chatbots, according to the project’s leaders, Vishwanath Anantraman, M.D., Northwell’s chief innovation architect, and Michael Oppenheim, M.D., the health system’s chief medical information officer.

Northwell Health’s IT department plans to begin pilot testing the technology at several hospitals by the end of the summer.

The EMRbot was developed as part of Northwell Health’s third Innovation Challenge, which rewards innovative employee-led projects. The team behind the EMRbot project and another winning project team each received $500,000 to bring their concepts to market.

“EMRbot will completely revolutionize how clinicians interact with patient data and will restore the human `face-to-face’ interaction that EHRs have slowly eroded,” Dr. Anantraman said in statement when the Innovation Challenge winners were announced back in May.

In developing the EMRbot technology, the project team sought to solve an ongoing challenge in healthcare: physician and patient dissatisfaction with how much time doctors spend with computers during the patient visit. “Computers have become very disruptive to the workflow that physicians and nurses want to have, which is at the patient bedside or talking with the patient, more face-to-face interaction. Physicians and patients want interactions that are more natural,” Anantraman says.

“The second problem we’re trying to solve is that, most of the time, there is too much information available in the EHR, and every time you want to find one piece of information, you have to click through several screens before you can find it. It’s time consuming, it can be highly dependent on how much training you’ve had in the EHR, and, often, it doesn’t give you the information you want quickly,” he says.

The project team focused on building a user interface on top of the EHR using chatbots, NPL and voice recognition technology.

“We’re layering the technology on top of several EHRs that will allow the user to use voice and text messaging effectively to get back answers to questions that they have about the patient,” he says. “It also uses several techniques to contextually provide the correct information. You can ask a question and get an answer, but if the program knows the context of the question and why it’s being asked, then it can give you a more meaningful answer, and can learn your own individual preferences. That’s the AI piece in the whole thing.”

He adds, “Technology now is moving so fast, particularly with natural language interactions and AI, and that gives you the ability to be more tailored and more specific to what every single provider wants.”

Anantraman acknowledges that the project is in early stages, and has not yet been pilot tested, but the goal is to eventually build specialty-specific modules. “There is a lot of variation in how providers interact with the systems and there is variation among specialties. The kinds of questions an obstetrician may have are very different from the questions asked in a general unit or an outpatient setting. This is not an easy problem to solve. But, over the next couple of months, we want to build out those specialty areas.”

When pilot testing begins, the project team plans to study targeted outcomes in terms of patient satisfaction and physician satisfaction and the team plans to conduct time and motion studies to study the impact on productivity, he says.

“Being at Northwell is a big benefit for us because we have 23 different hospitals, everything from community hospitals to large academic medical centers, specialties to general practices, and from inpatient settings to outpatient settings, so we can pilot test this is different scenarios; it’s not a one trick pony. We want to try to use Northwell to roll out different modules, and to roll it out in different settings, before we take this outside,” he says.

Ultimately, the goal is to use the EMRbot technology to create a more seamless patient experience. “We want to build these collaborative tools that will allow physicians and nurses to get the information they need quickly and collaborate with each other more effectively,” Anantraman says.


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VA, Cerner Leaders Detail Progress on EHR Implementation, Interoperability Efforts

November 14, 2018
by Heather Landi, Associate Editor
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The U.S. Department of Veterans Affairs (VA)’s new $16-billion-dollar Cerner electronic health record (EHR) system will use open application programming interface (APIs) and Fast Healthcare Interoperability Resources (FHIR) standards to enable interoperability with the private sector, according to a Cerner executive, which potentially positions the VA as a leading force to drive interoperability forward in the healthcare industry.

The ability of the VA’s healthcare system to seamlessly share patient data with the U.S. Department of Defense (DoD) as well as health systems and physicians in the private sector continues to be a top concern among Congressional leaders as the VA is now six months in to its implementation of a new Cerner EHR, and the topic dominated a House oversight subcommittee hearing on Wednesday.

Congressional leaders pointed out that interoperability between VA and DoD and between VA and community providers would be key to the success of the VA electronic health record (EHR) modernization effort. “If you can’t make that step work, then this won’t work,” Rep. Phil Roe, M.D., (R-Tenn.) chairman of the House Veterans Affairs committee, said.

During the hearing, members of the House Veterans Affairs' technology modernization subcommittee reviewed the electronic health record modernization (EHRM) program’s accomplishments, to date, and questioned VA and Cerner leaders about implementation planning, strategic alignment with the DoD’s MHS Genesis project, as DoD also is rolling out a new Cerner EHR, as well as interoperability efforts.  

The VA signed its $10 billion contract with Cerner in May to replace VA’s 40-year-old legacy health information system—the Veterans Health Information Systems and Technology Architecture (VistA)—over the next 10 years with the new Cerner system, which is in the pilot phase at DoD. The VA project will begin with a set of test sites in the Pacific Northwest in March 2020.

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In October, the U.S. Secretaries of the VA and DoD signaled their commitment to achieving interoperability between the two agencies by implementing a single, seamlessly integrated EHR, according to a joint statement both agencies issued. VA Secretary Robert Wilkie and Defense Secretary James N. Mattis signed a joint statement Sept. 26 pledging that their two departments will “align their plans, strategies and structures as they roll out a EHR system that will allow VA and DoD to share patient data seamlessly."

However, subcommittee chairman Jim Banks (R-Ind.) noted during the hearing, “Community provider interoperability has always been the elephant in the room. VA-DoD interoperability is very important, but VA is further behind in exchanging records with its community partners. There are helpful tools, such as health information exchanges (HIEs), but no out-of-the-box EHR system completely solves this problem.” Banks added, “Community interoperability is a very real problem, and for $16 billion, VA had better solve it.”

It is estimated that up to a third of VA patients receive care in the private sector.

"I’m not ready to sound the alarm, but I’ve heard very little on the subject [interoperability with DoD and community providers],” Banks said, noting that a review by industry experts indicated that VA and DoD need to be on the same instance of the Cerner EHR in order to achieve seamless interoperability. “That means both departments have to pull patient data from the same database. The two implementations have to be joined at the hip. It raises the stakes. It’s important to put this reality out in the open, and early.”

During her testimony, Laura Kroupa, M.D., acting chief medical officer with the VA’s Office of Electronic Health Record Modernization (OEHRM), noted that interoperability with community healthcare providers was a challenge that VA and Cerner leaders were working together to address.  “Going on the Cerner platform will allow us to utilize national systems in place for interoperability. Our community care councils also look at all the different workflows for how patients get referred into and out of the VA to make sure that information is exchanged and put into the system, not just as a piece of paper or image, but actually the data itself,” she said. Kroupa said project leaders are working to utilize interoperability mechanisms that Cerner currently has as well as HIE initiatives already in place, such as Carequality and CommonWell, to ensure interoperability between VA and the private sector.

John Windom, who leads the VA’s EHR modernization project as the executive director of VA’s OEHRM program, said, “There are two issues—one is technology-based which is solved, the HIEs, CommonWell, Carequality, allow seamless exchange of information. But, there is also another piece, the information has to be put in, and so that information has to be made accessible by the people on those networks; we’ve got the technology piece solved.”

Travis Dalton, president of government services at Cerner, testified that Cerner would use open APIs and FHIR-based integration to enable interoperability between VA and healthcare providers in the private sector.

“We’ve committed to that contractually. It’s going to happen, it’s technically possible and feasible,” Dalton said, adding, “What will be powerful to the industry and commercial partners is if VA and DoD choose a common standard. That will move the industry forward because this isn’t always a technical issue, it’s a standard-based issue. The power of the DoD and VA to make that choice to move it forward will influence the commercial marketplaces. The tools exist, through HIE and Direct exchange; it’s a standards issue.”

Congress created the technology modernization comittee to provide more rigorous oversight of the project amid concerns about the project’s cost and alignment with the defense department’s electronic health record roll-out.

There have been ongoing questions about VA leadership, specifically with regard to the EHR modernization project, beginning with the ouster of the previous VA Secretary, David Shulkin, M.D., earlier this year, as well as other shake-ups, including the resignation of Genevieve Morris only two months after she was tapped to lead the VA’s EHR project.

An investigation by ProPublica, detailed in a report published Nov. 1, asserts that VA’s EHR contract with Cerner has been plagued by multiple roadblocks during the past year, including personnel issues and changing expectations. According to that report, Cerner rated its EHR project with the VA at alert level "yellow trending towards red.” To investigate the underlying factors that have contributed to the EHR project's problems, the publication reviewed internal documents and conducted interviews with current and former VA officials, congressional staff and outside experts.

In parallel, Rep. Banks has expressed concerns with the VA’s “apparent loss of focus” on innovation, specifically as it relates to open APIs. In a letter to acting VA Deputy Secretary James Byrne dated Oct. 10, Banks noted that two years ago the VA initiated an open-API gateway interoperability platform concept, called Lighthouse. Back in March, during the HIMSS Conference, the VA also announced an open API pledge, with the launch of a “beta” version of its Lighthouse Lab, which offers software developers access to tools for creating mobile and web applications to help veterans better manage their care, services and benefits. Banks wrote that these efforts seem to have “lost momentum.”

In the letter, Banks noted that the VA needs a flexible platform to translate data coming in from multiple EHRs and on which to build, and so its private sector partners can build, interfaces to and from medical practice billing systems, insurance companies, external applications, veterans’ devices and one day Medicare and Tricare’s systems. “The need to ‘future-proof’ the technology that VA is acquiring is very real. Moving forward with the open-API gateway and sustaining the open API pledge are important steps to do that,” Banks wrote.

Progress Made in the First 180 Days

During the hearing, Windom outlined the EHRM program’s accomplishments, to date, including the establishment of 18 workflow councils and current state assessments of the initial implementation sites. VA and Cerner project leaders also completed an analysis report to assess the DoD’s MHS Genesis system as EHRM’s baseline. The workflow councils are mostly comprised of clinicians in the field who provide input to enable configuration of national standardized clinical and operational workflows for the VA's Cerner EHR system, Windom said.

Dalton said the site visits of the initial implementation sites provided important insights into VA’s IT needs. “VA has a unique patient population, you’ve got an older, sicker population, with unique needs, such as behavioral health. Some areas that we uncovered that we need to focus on now include telehealth, behavioral health and reporting. These are big content areas,” he said, adding, “I expect the work that we do will help to lead us into the future in that area. We expect that as we work closely together to meet the needs of the agency that will help to makes us better commercially.”

Dalton said the VA Cerner are committed to applying commercial best practices, as well as any lessons learned from our DoD experience, to the VA’s EHRM program.

“We learned some hard lessons with the DoD experience,” he said. “Transformation is always difficult. We’re doing things a lot differently—we’re engaging with sites early and often. We’re also doing more workshops up front, so it’s more of an iterative process.” And, he added, “This is a provider-led process. We have the 18 councils that are assisting us with validation of the workflow.”

 


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EHR Usability Issues Impact Pediatric Patient Safety, Research Finds

November 13, 2018
by Rajiv Leventhal, Managing Editor
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In an analysis of 9,000 pediatric patient safety reports from three healthcare organizations, researchers found that 36 percent of the reports were related to EHR (electronic health record) usability issues.

The research, published in the November issue of Health Affairs, and led by Raj Ratwani, Ph.D., director of the National Center for Human Factors in Healthcare, Washington, D.C.-based MedStar Health, and others, aimed to further understand the specific issues around why pediatric populations are uniquely vulnerable to the usability and safety challenges of EHRs particularly those related to medication.

To understand specific usability issues and medication errors in the care of children, the researchers analyzed 9,000 patient safety reports, over a five-year span, from three different healthcare institutions—two stand-alone pediatric institutions and one adult and pediatric institution that used Epic and Cerner EHRs (two institutions used Epic, and one used Cerner)—that were likely related to EHR use.

Of the 9,000 reports, 3,243 (36 percent) had a usability issue that contributed to the medication event, and 609 (18.8 percent) of the 3,243 might have resulted in patient harm, the researchers found.

“The general pattern of usability challenges and medication errors were the same across the three sites. The most common usability challenges were associated with system feedback and the visual display. The most common medication error was improper dosing,” the research revealed.

The researchers noted in the study that pediatric patients are uniquely vulnerable to EHR usability and safety challenges because of different physical characteristics, developmental issues, and dependence on parents and other care providers to prevent medical errors. For example, they offered, lower body weight and less developed immune systems make pediatric patients less able to tolerate even small errors in medication dosing or delays in care that could be a result of EHR usability and safety issues.

Although the Office of the National Coordinator for Health Information Technology (ONC) has policies to promote usability—such as requiring system developers to incorporate feedback from clinicians into software design and development and mandating the testing of twelve high-risk EHR functions that are primarily related to medication—the researchers noted that these policies have not made a distinction between adult and pediatric populations. However, the 21st Century Cures Act of 2016 requires ONC to establish new voluntary criteria unique to EHRs used in the care of children.

For this research, the 9,000 reports—3,000 from each site—were reviewed to verify whether the events were related to the EHR and medication; determine whether EHR usability contributed to the event and, if it did, identify what the specific usability challenge was; identify the type of medication error; and identify whether the event reached the patient.

Of the 9,000 patient safety event reports that were collected, 56 percent were confirmed as being related to both the EHR and medication. Of these 64 percent had a usability issue as a contributing factor to the safety event, which amounts to 36 percent of the total 9,000 reports analyzed.

Of the 3,243 reports (36 percent) that had usability as a contributing factor, 19 percent reached the patient. Of these, 33 percent did not cause harm and did not require monitoring, 18 percent required monitoring or an intervention to prevent harm, 3 percent resulted in temporary harm, and the consequence was unknown for 46 percent, the researchers revealed.

One example of a usability issue that caused some harm was when a when a physician ordered five times the recommended dose of a medication without receiving an alert from the EHR, although the prescribed dose was outside the recommended range. Both vendor design and development, as well as implementation and customization, may be contributing to the challenges associated with system feedback, the researchers stated.

“To address this systemic problem, vendors and providers should consider developing more comprehensive design guidelines and use generalizable tools to assess usability and safety. The Leapfrog [computerized provider order entry simulation] tool, which assesses clinical decision support functionality, is one example of the types of tools that could improve the safety of implemented EHR products,” they said.

The researchers concluded, “To better prevent usability-related medical errors, the ONC could include safety as part of the voluntary certification criteria of EHRs for use with children and implement usability-related measures to assess EHR performance. Vendors and providers should use rigorous test-case scenarios based on realistic clinician tasks. Finally, the Joint Commission should assess EHR safety as part of its hospital accreditation program. The implementation of approaches such as these is needed to reduce patient harm related to EHR use.”

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