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One Medical Researcher’s Take on EHR Usability and the Impact on Patient Care

July 11, 2017
by Heather Landi
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While it’s no secret that physicians have complaints about electronic health records (EHRs), the co-author of a new medical study about hospital-based physicians’ perceptions of EHRs says the study findings illustrate that EHR usability should be addressed as a quality of care issue.

As reported by Healthcare Informatics, an analysis by researchers at Brown University and Healthcentric Advisors, and recently published in the Journal of Innovation in Health Informatics, found that hospital-based physicians and office-based physicians generally perceive EHRs, in their current design, negatively altering patient interactions, however, hospital-based physicians cited different reasons than their office-based counterparts. Hospital-based physicians commented most frequently that using EHRs takes time away from patient contact; office-based physicians commented on EHRs worsening the quality of their patient interactions and relationships.

The analysis is based on the open-ended answers that 744 doctors gave to this question on a Rhode Island Department of Health survey in 2014 on health information technology: “How does using an EHR affect your interaction with patients?”

According to the study, one hospital-based physician commented, “We spend less time at bedside and more time interacting with our computers.” The study found that the second most common theme among hospital-based physicians was the negative impact of EHRs on the quality of interactions with patients and therefore physicians’ relationships with patients. One hospital-based respondent commented, “My nose is now burrowed deep into my computer interface, leaving markedly reduced time to make eye contact and actually interact one on one with my patient.” The study also found that hospital-based physicians report benefits from using EHRs, ranging from better information access to improved patient education and communication.

The study authors contend that this particular analysis is novel for its relatively large sample size and its incorporation of both hospital and office-based physicians. And, the findings add to the prior literature, which focuses on outpatient physicians, and can be used to shape interventions to improve how EHRs are used in inpatient settings, the study authors stated.


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The study was led by Rebekah Gardner, M.D., an associate professor of medicine at the Warren Alpert Medical School of Brown University and a senior medical scientist with Healthcentric Advisors; Kimberly Pelland of Healthcentric Advisors and Rosa Baier, associate director of the Center for Long-Term Care Quality and Innovation and an associate professor of the practice at the Brown University School of Public Health.

Healthcare Informatics Associate Editor Heather Landi recently spoke with Gardner about the implications of the study findings, the issue of EHR software usability and the potential impact on quality of care.

What motivated you and your fellow researchers to examine this issue of EHRs and the impact on physician-patient interaction in hospitals?

The Rhode Island Department of Health has been administrating this health IT survey since 2008, and every year there’s a box at the end that says, ‘If you have any additional comments, please leave them here.” It’s a standard survey box, and we were struck by the anguish that came through in the comments that people chose to leave and we really noticed quite a common theme where people said, ‘We get it, EHRs aren’t going away and they do add value, but here are the things that really make it so hard for us.’ After reading these comments year after year, we thought we needed to get at this in a more scientific way. So, we specifically included a question about the patient interactions and devoted time to doing an actual qualitative analysis, which is different than reading through comments and getting a general sense. In 2014, we invented that particular question [used in the study] and we wanted to take a more scientific approach to echo what we had been hearing for years, but hadn’t really fully captured by the usual use of multiple choice questions.

What is unique about this study compared to previous research about physicians’ use of EHRs?

Most of the research has been done in the office-setting, mostly around primary care physicians and family physicians. Those physicians are all unified in way because there is a commonality across the doctors who see the same patients time and time again; they have a longitudinal relationship with patients. They are usually using a computer in the exams room. That’s a particular type of doctor-patient relationship, and a particular use of the computer. We really noticed an absence in the literature of inpatient physicians. I practice medicine, personally, both in the office and in the hospital and reflecting on that, the way we use the computer in the hospital is quite different. Usually the computer is outside the exam room; we go in and have a conversation with the patient that we’re meeting for the first time that day and may never see again. Then, I go and document later in the chart without the patient being there. The way the computer is part of the physicians’ day is quite different and the relationship between the patient and the physician is quite different. We wanted to get a sense of whether the computer is even an issue, honestly, for inpatient doctors, and it turns out, it was.

Where you surprised with the study’s findings, or did the findings resonate with what you have experienced?

I would say the outpatient data was not at all surprising to us; it reinforces what’s been shown in other studies. This was a fairly large data sample compared to other qualitative studies, which have been more focus groups and the nature of that study design limits the number of study participants. It was gratifying to see that we certainly reinforced findings that have been found elsewhere, and we were able to show that across specialties as well, which is different, and that was not surprising but it was validating. For us, the inpatient findings were surprising in that computers really do bother inpatient physicians a lot, but for different reasons. Thinking about it, it makes sense. But we didn’t typically get ad hoc comments from inpatient physicians about their distress. Reading those comments and seeing their perspectives was interesting and, we feel, hadn’t been shared before.

What are the implications of these study findings, for physicians, for technology vendors and even for health IT policymakers?

Certainly, reading this makes you think about, ‘Okay, now what, what do we do with this?’ I would say there may be different answers in the different settings. There are folks, especially at the University of Chicago, who are doing great work on how outpatient physicians can better incorporate the EHRs into the patient visits. They have models where they instruct physicians; when you walk into the exam room, don’t turn on the computer, greet the patient, make eye contact, do what’s called ‘honoring the golden minute’ and have that face-to-face conversation before turning on the computer and also narrate whatever you’re doing on the computer as you do it and face the screen so that it’s also facing the patient. And these are all strategies to engage the patient, bring the patient into that computer experience, so the patient doesn’t feel so ignored. There is some merit to those strategies to really bring the patient in and try to improve the relationship, as it stands. It will be interesting when they take those studies to the next step and measure what patients think of that, that will be helpful to see.

In the inpatient setting, that’s not the issue we found, so we think the solutions there may be different. In the inpatient setting, we’ve heard loud and clear about the documentation burden and, certainly, outpatient physicians will be the second loudest voice on that. And what we’ve heard is that there is so much in the documentation requirements for quality measures, for billing, for public reporting; the EHR is there to serve so many different masters. It’s really not just a chart for clinical care. The way we use the EHR and the process of reporting information about a patient visit really reflects the fact that we’re trying to serve so many masters at one time.

So, most inpatient and outpatient doctors would say, ‘Look, we have to reduce the documentation burden,’ and then in a similar vein, most outpatient and inpatient physicians, particularly inpatient, would say that if the user interface is so clunky and the way we enter data is not in keeping with how we think through a patient case and how we do a patient history, that we suffer slowdowns just with the data entry piece, even if we’re good typists, just the data entry part of it is so non-intuitive and disjointed.

Many healthcare leaders advocate the use of medical scribes to ease the physician documentation burden. What are your thoughts on the use of scribe to address this issue?

The use of scribes is really interesting. There’s two models for scribe use—one, which is more common, is the fly on the wall model. The scribe is recording everything the physician is saying. I see the point of that, but it’s weird to have that other person in the exam room, but the doctors I know who use scribes have them find them to be a lifesaver. The other model is treating the scribe as a member of the healthcare team, so a nursing assistant, and they may participate in the visit too, so they are not just silently typing things. They might do the visit wrap-up or other things related to the visit, and that may feel a little more organic for the patient. Scribes are ultimately a symptom of a larger problem, which is that the EHRs are not useable in a way that is supportive of physicians. It’s a way of treating a symptom, but not curing the problem.

What do you think needs to be done to address the usability issue?

I think the problem is the documentation burden, the usability of the EHRs and making those more intuitive, and, this may be pie in the sky, trying to separate out the billing pieces. The way we do billing is very challenging and requires documentation in certain fields and certain phrases and all those these things are not harmonious with how doctors think and talk and would like to record information about patients. So, I think separating out the billing somehow, and figuring out ways to measure quality that doesn’t require documentation in certain fields, all those things are very challenging. I think the tech industry is up for it, but there hasn’t been much motivation for them to do anything differently, because people are getting paid, quality measures are being reported, and so not everyone is so interested in doctors’ complaining. We otherwise have it pretty good. I think there is not so much sympathy. I think the real issue is that there is growing data and evidence that stress around EHR usage leads to physician burnout, and that is a quality issue, that is a workforce issue and so that may be a place where physicians’ voices may be more compelling.




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Research: Physician Burnout is a Public Health Crisis; Improving EHR Usability is Critical

January 18, 2019
by Heather Landi, Associate Editor
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Physician burnout is a public health crisis and addressing the problem requires improving electronic health record (EHR) standards with a strong focus on usability and open application programming interfaces (APIs), according to a new report from leading healthcare researchers.

The report is a “call to action,” the researchers wrote, “to begin to turn the tide before the consequences grow still more severe.” The researchers also recommend “systemic and institutional reforms” that are critical to mitigating the prevalence of burnout.

The result of collaboration between researchers with the Massachusetts Medical Society, the Massachusetts Health and Hospital Association, the Harvard T. H. Chan School of Public Health, and the Harvard Global Health Institute, the report's aim is to inform and enable physicians and health care leaders to assess the magnitude of the challenge presented by physician burnout in their work and organizations, and to take appropriate measures to address the challenge, the researchers say.

The report also offers recommended actions for healthcare leaders to take, which the researchers acknowledge are not exhaustive, but “represent short-, medium-, and long-term interventions with the potential for significant impact as standalone interventions.”

The authors of the report include Ashish K. Jha, M.D., the K.T. Li Professor of International Health at the Harvard T. H. Chan School of Public Health, and director of the Harvard Global Health Institute; Andrew Iliff, lead writer and program manager, Harvard Global Health Institute; Alain Chaoui, M.D., president of the Massachusetts Medical Society; Steven Defossez, M.D., vice president, clinical integration, Massachusetts Health and Hospital Association; Maryanne Bombaugh, M.D., president-elect, Massachusetts Medical Society; and Yael Miller, director, practice solutions and medical economics, Massachusetts Medical Society.

In a 2018 survey conducted by Merritt-Hawkins, 78 percent of physicians surveyed said they experience some symptoms of professional burnout. Burnout is a syndrome involving one or more of emotional exhaustion, depersonalization and diminished sense of personal accomplishment. Physicians experiencing burnout are more likely than their peers to reduce their work hours or exit their profession, according to the report.

By 2025, the U.S. Department of Health and Human Services predicts that there will be a nationwide shortage of nearly 90,000 physicians, many driven away from medicine or out of practice because of the effects of burnout.  Further complicating matters is the cost an employer must incur to recruit and replace a physician, estimated at between $500,000-$1,000.000. 

“The growth in poorly designed digital health records and quality metrics has required that physicians spend more and more time on tasks that don’t directly benefit patients, contributing to a growing epidemic of physician burnout,” Dr. Jha, a VA physician and Harvard faculty member, said in a statement in a press release accompanying the report. “There is simply no way to achieve the goal of improving healthcare while those on the front lines – our physicians – are experiencing an epidemic of burnout due to the conflicting demands of their work. We need to identify and share innovative best practices to support doctors in fulfilling their mission to care for patients.”

The beginning of the physician burnout crisis can be traced back to several events, according to the researchers, including the “meaningful use” of electronic health records, “which transformed the practice of many physicians, and was mandated as part of the 2009 American Reinvestment and Recovery Act.” Going back further, the 1999 publication of the Institute of Medicine’s “To Err is Human” highlighted the prevalence of medical errors, brought new attention to quality improvement and the value of physician reporting and accountability, the report states.

The researchers note that the primary impact of burnout is on physicians’ mental health, “but it is clear that one can’t have a high performing health care system if physicians working within it are not well. Therefore, the true impact of burnout is the impact it will have on the health and well-being of the American public,” the researchers wrote.

The researchers note, “If we do not immediately take effective steps to reduce burnout, not only will physicians’ work experience continue to worsen, but also the negative consequences for health care provision across the board will be severe.”

And, while individual physicians can take steps to better cope with work stress and hold at bay the symptoms of burnout, “meaningful steps to address the crisis and its root causes must be taken at a systemic and institutional level,” the researchers wrote.

According to the researchers, the primary drivers of physician burnout are structural features of current medical practice. “Only structural solutions — those that better align the work of physicians with their mission — will have significant and durable impact,” the researchers wrote in the report.

To that end, the researchers’ immediate recommendation is for healthcare institutions to improve access to and expand health services for physicians, including mental health services.

In the medium term, technology can play a large role. Addressing physician burnout will require “significant” changes to the usability of EHRs, the researchers wrote, including reform of certification standards by the federal government; improved interoperability; the use of application programming interfaces (APIs) by vendors; dramatically increased physician engagement in the design, implementation and customization of EHRs; and an ongoing commitment to reducing the burden of documentation and measurement placed on physicians by payers and health care organizations.

New EHR standards from the Office of the National Coordinator for Health IT (ONC) that address the usability and workflow concerns of physicians are long overdue, the researchers state. One promising solution would be to permit software developers to develop a range of apps that can operate with most, if not all, certified EHR systems, according to the report. The 21st Century Cures Act of 2016 mandates the use of open APIs, which standardize programming interactions, allowing third parties to develop apps that can work with any EHR with “no special effort.” There already have been efforts on this front, such as Epic’s “App Orchard,” the researchers note, but more work remains to be done.

To expedite this critical process of improvement, the report recommends physicians, practices, and larger health care delivery organizations, when seeking to purchase or renew contracts for health IT, adopt common RFP language specifying and requiring inclusion of a uniform health care API.

The researchers also say that artificial intelligence (AI) can play a promising role as AI technologies can support clinical documentation and quality measurement activities.

Long term, healthcare institutions need to appoint executive-level chief wellness officers who will be tasked with studying and assessing physician burnout. Chief wellness officers also can consult physicians to design, implement and continually improve interventions to reduce burnout, the researchers wrote.

“The fundamental challenge issued in this report is to health care institutions of all sizes to take action on physician burnout. The three recommendations advanced here should all be implemented as a matter of urgency and will yield benefits in the short, medium, and long term,” Jha and the research team wrote.


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GAO Report: Patient Matching Efforts Can Be Significantly Improved

January 17, 2019
by Rajiv Leventhal, Managing Editor
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The report did conclude that no single effort would solve the challenge of patient record matching

There is a lot that can be done—such as implementing common standards for recording demographic data—to improve patient matching, according to a new Government Accountability Office (GAO) report that closely examined the issue.

The 21st Century Cures Act included a provision for GAO to study patient record matching, and in this report, GAO describes (1) stakeholders' patient record matching approaches and related challenges; and (2) efforts to improve patient record matching identified by stakeholders.

The 37 stakeholders that GAO interviewed, including representatives from physician practices and hospitals, described their approaches for matching patients' records—comparing patient information in different health records to determine if the records refer to the same patient.

The respondents explained that when exchanging health information with other providers, they match patients' medical records using demographic information, such as the patient's name, date of birth, or sex. This record matching can be done manually or automatically. For example, several provider representatives said that they rely on software that automatically matches records based on the records' demographic information when receiving medical records electronically.

Stakeholders further said that software can also identify potential matches, which staff then manually review to determine whether the records correspond to the same patient. They said that inaccurate, incomplete, or inconsistently formatted demographic information in patients' records can pose challenges to accurate matching. For example, records don't always contain correct information (e.g., a patient may provide a nickname rather than a legal name) and that health IT systems and providers use different formats for key information such as names that contain hyphens.

Those who GAO interviewed identified recent or ongoing efforts to improve the data and methods used in patient record matching, such as the following:

  • ·         Several stakeholders told GAO they worked to improve the consistency with which they format demographic data in their electronic health records (EHR). In 2017, 23 providers in Texas implemented standards for how staff record patients' names, addresses, and other data. Representatives from three hospitals said this increased their ability to match patients' medical records automatically. For example, one hospital's representatives said they had seen a significant decrease in the need to manually review records that do not match automatically.
  • ·         Stakeholders also described efforts to assess and improve the effectiveness of methods used to match patient records. For example, in 2017 the Office of the National Coordinator for Health Information Technology (ONC) hosted a competition for participants to create an algorithm that most accurately matched patient records. ONC selected six winning submissions and plans to report on their analysis of the competition's data.

Those who were interviewed said more could be done to improve patient record matching, and identified several efforts that could improve matching. For example, some said that implementing common standards for recording demographic data; sharing best practices and other resources; and developing a public-private collaboration effort could each improve matching.

Stakeholders' views varied on the roles ONC and others should play in these efforts and the extent to which the efforts would improve matching. For example, some said that ONC could require demographic data standards as part of its responsibility for certifying EHR systems, while other stakeholders said that ONC could facilitate the voluntary adoption of such standards. Multiple stakeholders emphasized that no single effort would solve the challenge of patient record matching.

To this end, a recent report from the Pew Charitable Trusts outlined several key themes related to patient matching, while also suggesting recommendations to improve matching and the infrastructure needed for more robust progress in the medium and long term.

Related Insights For: EHR


Montana Senator to VA CIO: “EHR Modernization Cannot Fail”

January 14, 2019
by Rajiv Leventhal, Managing Editor
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Senate VA (Department of Veterans Affairs) Committee Ranking Member Jon Tester has urged new VA CIO James Gfrerer to avoid past failures as he helps to move forward the department’s EHR (electronic health record) modernization project.

Gfrerer, an ex-marine and former executive director at Ernst & Young, was recently confirmed by the Senate to serve as assistant secretary of information and technology and CIO (chief information officer) at the Department of Veterans Affairs.

One of Gfrerer’s top tasks will be helping to update hospitals’ infrastructures as the VA continues to work on replacing the department’s 40-year-old legacy EHR system, called VistA, by adopting the same platform as the U.S. Department of Defense (DoD), a Cerner EHR system. That contract was finally signed last May and the implementation project is scheduled to span over 10 years.

In a letter to Gfrerer, Tester, a Montana senator, noted that while many of the responsibilities for the implementation of VA’s new EHR fall to the recently created Office of Electronic Health Record Management, the CIO’s role “is critical to ensure that we do not repeat the mistakes of the past.”

The office that Gfrerer now leads, VA’s Office of Information and Technology, will still be in charge of managing infrastructure needs for both the patient care facilities that have received the EHR upgrades and those that have not, Tester stated. “This task will require significant resources and robust oversight as VA manages a decade-long rollout,” he said.

Tester further wrote, “EHR modernization cannot be allowed to fail, and your leadership is essential if VA is to ultimately achieve a truly interoperable health record for veterans.”

In regard to “past failures,” it’s possible that Tester is referring to media reports that have outlined some of the significant issues that the DoD has had with its own Cerner rollouts. In reports throughout 2018, the initial feedback on the four military site EHR rollouts has been less than ideal. A Politico report first detailed the first stage of implementations noted that it “has been riddled with problems so severe they could have led to patient deaths.” Indeed, some clinicians at one of four pilot centers, Naval Station Bremerton in Washington, quit because they were terrified they might hurt patients, or even kill them, the report attested.

Providing an update on Cerner’s progress with the DoD EHR implementations, a company executive recently noted that he is seeing “measurable progress” at the DoD’s initial operational capability (IOC) sites.

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