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Physicians Cite Lack of Interoperability, Documentation Burden as Top EHR Pain Points

September 12, 2018
by Heather Landi, Associate Editor
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A recent survey of primary and specialty care physicians by Deloitte reveals that physician feedback on how to improve electronic health records (EHRs) is often overlooked as physicians continue to be frustrated with EHRs, particularly due to lack of interoperability and the burden of documentation.

Deloitte recently released a report about physician interaction with EHR technology based on the Deloitte 2018 Survey of U.S. Physicians, a survey of 624 U.S. primary care and specialty physicians.

With regard to EHR technology, the survey results suggest that at best, physicians perceive themselves as passive participants in EHR optimization efforts and, at worst, they feel ignored. Just one-third of physicians surveyed (34 percent) say their organization or EHR vendor sought their feedback on EHR enhancements; and this proportion is about the same for employed or affiliated physicians vs. independents. Primary care physicians are an exception: forty-four percent of them have been asked for feedback.

The survey results also point to a link between inviting feedback and sustaining engagement—half (51 percent) of physicians who were not asked for feedback say they are unaware of EHR optimization efforts within their organization or through their EHR vendor, but only 16 percent of physicians invited to provide feedback say so, the survey found.

The survey results indicate that lack of interoperability and ease of use continue to be big pain points with EHR systems. When asked what changes they would make to their current EHR system, 62 percent of respondents cited “making the current system more interoperable” and 58 percent would like to improve their EHR’s capability to easily add patient visit information.

What’s more, 39 percent of physicians want their EHR to be seamlessly available and accessible by mobile devices, 38 percent want their EHR to better support workflow management across the continuum of care and 37 percent see an opportunity to automate reporting to meet quality reporting requirements. Another 37 percent of respondents want EHR vendors to improve the capability to generate custom reports on their patient populations. Only 10 percent of physicians said they were satisfied with their EHR “as is.”

Documentation is the number one area where physicians see opportunities for efficiencies, according to the survey. Physicians also cited communication and care coordination (20 percent) as another area that could be completed more efficiently. Based on the responses, specific documentation tasks that could be done more efficiently include charting, capturing visit notes, data entry, and inputting boilerplate information to meet administrative requirements.

“The frequency and context of the mention of dictation tools in the survey responses suggest that physicians either underutilize them or find them subpar. Prior to the advent of EHRs, dictation was a common way to record notes. Though early generations of EHRs did not have the capability to convert dictated notes into structured information, the technology has evolved and new tools are becoming available to codify typed or dictated text,” the survey report authors wrote.

The survey report also notes that many healthcare organizations are experimenting with natural language processing (NPL) to unlock critical information from narrative reports, such as progress notes, discharge summaries and radiology and pathology reports to support patient care, administrative requirements and research. “Today, NLP technology is either expensive or requires considerable computer science expertise. As off-the-shelf NLP software becomes more accessible, organizations may discover additional documentation-related uses. Other technologies, such as artificial intelligence, robotic process automation, and blockchain, may support revenue cycle management activities that rely on EHR inputs,” the report authors wrote.

On the issue of interoperability, the report notes that organizations often face interoperability-related challenges at multiple level. As health systems have grown through mergers and acquisitions, different parts of the organization may be on different EHR systems. What’s more, multiple other information systems and clinical equipment may need to be connected to contribute to and/or extract data from EHRs. And as the number of connected devices grows, so does the need to ensure data security without inhibiting user experience.

Market dynamics, such as the Fast Healthcare Interoperability Resources (FHIR) standard, are helping to spur interoperability, however, solving the interoperability challenge can require multiple external and internal parties to collaborate and agree on common standards and governance, the report authors wrote.

“At a minimum, health systems and EHR vendors can share updates with their EHR users about important interoperability milestones achieved or functionalities added. Any interoperability improvement could support physicians in delivering care more efficiently,” the report authors wrote.

Survey respondents were asked what kind of EHR enhancements are underway at their organization or their EHR vendor. Fifty-six percent cited “improve/add capability to more easily input information about a patient visit” and 52 percent said current enhancement efforts are focused on making the current system more interoperable. Forty-three percent said enhancement efforts are focused on making the EHR seamlessly available and accessible by mobile devices and 41 percent said their organization and/or EHR vendor is working to improve the capability to generate custom reports on physicians’ patient population. Forty-percent of respondents said their organizations are working to automate reporting to meet quality reporting requirements to various payers and 37 percent said efforts are focused on better supporting workflow management across the care continuum.

Interestingly, as noted above, physicians who were not asked for feedback on EHR enhancements were less aware of those enhancement efforts. For instance, 17 percent of respondents who had not been asked for their feedback said their organizations were currently working to make their EHR systems more interoperable, while more than double (39 percent) of physicians who had been asked for their feedback were aware of interoperability enhancement efforts underway at their organizations.

The report also recommends a number of steps that healthcare organizations leader can take to improve clinicians’ experience with EHRs.

  • Proactively seek physician feedback. Direct feedback combined with other data can help the informatics team understand the goal of an optimization request and identify the best method to achieve that goal.
  • Optimize workflow. When using an EHR, how one team member uses it can affect how others do their work. Organizations may realize that a solution to a problem may not always involve changing the system but rather ensuring that all users adhere to the correct and standard workflow.
  • Communicate progress. Fully addressing certain EHR issues (such as interoperability) may be a lengthy process. Communicating the progress and attainment of interim goals can signal continued commitment to resolving the issues that vex users.
  • Stay abreast of new technology and the vendor landscape. Many emerging technologies are in the early stages of development, but the landscape is changing, with some technologies and use cases quickly approaching maturity.

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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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Veritas Capital, Elliott Management Acquire athenahealth in $5.7B Deal

November 12, 2018
by Heather Landi, Associate Editor
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Private equity firm Veritas Capital and hedge fund Elliott Management will acquire athenahealth, the Watertown, Massachusetts-based electronic health record (EHR) and practice management vendor, for $5.7 billion, according to an announcement released Monday.

Veritas and Evergreen Coast Capital, a subsidiary of Elliott Management, will pay $135 per share for the health IT company, which represents a premium of approximately 12 percent over the company's closing stock price on Friday. The deal also represents a premium of approximately 27 percent over the company's closing stock price on May 17, 2017, the day prior to Elliott Management Corporation's announcement that it had acquired an approximate 9 percent interest in the company.

The deal concludes a six-month acquisition process and a tumultuous period for athenahealth and its leadership. Elliott Management, the sometimes-activist fund run by billionaire Paul Singer, has put pressure on athenahealth leadership to take the company private or explore a sale since the hedge fund acquired a 9-percent stake in the company in 2017.

Following the deal’s closing, Veritas and Evergreen expect to combine athenahealth with Virence Health, the GE Healthcare value-based care assets that Veritas acquired earlier this year. The combined business is expected to be a leading, privately-held healthcare information technology company with an extensive national provider network of customers and world-class products and solutions to help them thrive in an increasingly complex environment, the companies said in a press release.


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“After a thorough strategic review process, we have decided to enter this agreement with Veritas, which we believe maximizes value for our shareholders and accelerates our goal to transform healthcare," Jeff Immelt, executive chairman of athenahealth, said in a statement. Immelt was appointed to that position after company founder and CEO Jonathan Bush stepped down back in June. “Combining with Virence will create new opportunities for collaboration and growth. Operating as a private company with Veritas's ownership and support will provide athenahealth with increased flexibility to achieve our purpose of unleashing our collective potential to transform healthcare.”

This past May, Elliott Management made an all-cash takeover offer to buy athenahealth, at a valuation of $6.9 billion. The investors sent a letter to athenahealth’s board proposing to acquire the company for $160 per share. In the letter, the investors criticized leadership at the electronic health record (EHR) vendor for failing to make the changes necessary “to enable it to grow as it should and to create the kind of value its shareholders deserve.”

The story continued to take turns throughout the summer, particularly following the resignation of CEO and President Jonathan Bush in June. Bush’s resignation came just a few weeks after Elliott Management’s takeover bid, and just a few days after reports surfaced that the athenahealth chief had allegedly assaulted his ex-wife more than a decade ago, and also created a “sexually hostile environment” at the company.   

Following the news, various companies, both inside and outside of healthcare, were brought up as possibilities to buy athenahealth, including the Kansas City-based EHR giant Cerner Corp. According to a report in the New York Post  published in early September, Elliott Management was cited as the favorite to win the athenahealth takeover bid, reporting that Cerner and UnitedHealth declined an opportunity to acquire the health IT company.

The transaction is expected to close in the first quarter of 2019, subject to the approval of the holders of a majority of athenahealth's outstanding shares and the satisfaction of customary closing conditions and regulatory approvals. The athenahealth Board of Directors has unanimously approved the merger agreement and intends to recommend that athenahealth shareholders vote in favor of it at a Special Meeting of Stockholder.

The combined company is expected to operate under the athenahealth brand and be headquartered in Watertown, Massachusetts. The company will be led by Virence chairman and CEO Bob Segert and an executive leadership team comprised of executives from both companies. Following the completion of the transaction, Virence's workforce management business will become a separate Veritas portfolio company under the API Healthcare brand.

Athenahealth got its start in the health IT space as a developer of practice management systems for physician practices and has steadily expanded its suite of network-enabled services for revenue cycle management and medical billing, electronic health record (EHR) systems, patient engagement, care coordination, and population health services. The company ranked at No. 13 on the Healthcare Informatics 100 list for 2018, with $1.2 billion in revenue.

For the past 20 years, the company’s culture was driven by its outspoken CEO, Bush, and many athenahealth customers have said they like the strong culture and the company’s service business. It remains to be seen how this deal with impact new and existing customers.

In an interview back in June, Erik Bermudez, senior research director at Orem, Utah-based KLAS Research, said he had spoken with a number of key athenahealth customers about the potential for new management. “What I heard is, because of athenahealth being who they are and because of the strong culture that they have built, they are less worried about athenahealth than they would be if it were another company. And, they indicated that it might be a good thing.”

He continued, “It’s been a public company and it’s really hard to serve two masters, Wall Street and customers and other stakeholders. Customers I talked to indicated that a sale would bring in new ownership and perhaps bring in a different set of priorities, and that could really help athenahealth get back to their roots and back to the culture they had when they began. I think there’s still a lot of excitement, and there’s some hesitancy as well.”

In Monday’s announcement about the deal, Ramzi Musallam, CEO and managing partner of Veritas Capital said in a statement, “athenahealth is a market leader and a natural and strategic fit with Virence. Virence and athenahealth have differentiated and complementary solutions, deep relationships with their respective customer bases and a shared culture of commitment to innovation. We look forward to leveraging our expertise in the sector, as well as the capabilities and solutions across both companies to provide superior value to customers, and create exciting growth opportunities for both sets of employees as Bob and the team build the future of healthcare IT.”

Veritas, a government and technology focused investor, has been adding health IT companies to its portfolio in the past few years. The investor bought Truven Health Analytics from Thomson Reuters for $1.25 billion in 2012 and then sold Truven to IBM Watson for $2.6 billion in 2016. Veritas acquired the healthcare business (now known as Verscend Technologies) from Verisk Analytics for $820 million, in 2016. The investment then bought GE Healthcare’s value-based care division for $1 billion in April 2018, followed a few months later, in June, with Veritas-backed Verscend Technologies buying Cotiviti, a provider of payment accuracy and analytics driven solutions, for $4.82 billion.

Bob Segert, chairman and CEO of Virence, said in a statement about the athenahealth deal: “We are excited by the opportunity to partner with athenahealth, one of the largest and most connected provider networks in the nation, to drive outcomes that matter the most to our customers. athenahealth and Virence have complementary portfolios and highly-talented people, and this combination expands our depth and reach across the continuum of care. I'm looking forward to combining our mission-driven cultures to create an even stronger healthcare IT company.”

Elliott Management Partner Jesse Cohn said, “We are pleased to support this transformative transaction combining athenahealth and Virence, which we believe represents an outstanding, value-maximizing outcome for athenahealth shareholders.”

 Upon completion of the transaction, Elliott's private equity subsidiary, Evergreen Coast Capital, will retain a minority investment stake in the combined company. Evergreen Managing Director Isaac Kim said, “We look forward to taking part in this unique opportunity. Under Bob's leadership and with Veritas' strategic oversight and strong track record of value creation, we believe the combined company will be a true leader in healthcare IT, ideally positioned to improve outcomes and reduce the cost of care.


Related Insights For: EHR


Seven Best Practices for Optimizing EHRs Clinically and Financially

November 7, 2018
by Dan O’Connor and Joncé Smith, Industry Voices, Stoltenberg Consulting, Inc.
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You can make the most of your EHR system with these seven tips for two-pronged optimization

Healthcare professionals today face numerous competing daily tasks beyond patient care appointments. With the constant strain, healthcare facilities struggle with knowing if they are using their electronic health records (EHRs) to the full potential. To alleviate the confusion and optimize your EHR for combined clinical decision making and operational effectiveness, use the following seven tips.

Clinical Optimization Tasks

End-user education, data collection and system usability are the main areas of focus when initially assessing your EHR from a clinical standpoint. Are you collecting the correct information in the appropriate form? Are workflows efficient? Do clinicians have the appropriate tools, and are they using the EHR effectively? These questions can help as you conduct a comprehensive assessment, reviewing your EHR system and processes from patient registration to final billing.

  1. Conduct clinical end-user interviews– Begin by reviewing daily end-user operations. Ask employees what they think needs to be improved and what is working well. Then assess end users’ system utilization. Is user knowledge an issue? How often is end-user education provided, and does it align with system upgrades or application transitions? Do new hire EHR education modules include simple and clear documentation and real practice examples? One easy way to improve system knowledge is to partner new employees with an EHR superuser mentor to help them quickly become comfortable with system use. Having a good understanding of providers’ perception of how the system is functioning is a good starting point prior to looking at the specifics of system use, workflows, information storage and providers’ direct interactions with the system.
  1. Assess data collection processes– How information is collected impacts everything from direct patient care decision making to triggering clinical care best practice alerts appropriately. Can you trend information for research? Are you able to run historical reports based on cohorts of patient or diseases? These are just a few questions to consider when determining how data is collected, how it is stored and what data is being pulled from previous patient visits. Ensuring that the correct data is collected in the correct form is important, but making sure the workflow facilitates the provider’s view of aggregating data is just as critical. This is directly related to observing providers interacting with the system.
  1. Perform a usability study– Review how clinicians interact with the EHR including the hardware and clinical tools that correlate. Are providers documenting at the bedside, or are they using scribes? Do they effectively navigate the system? Do they document in real time or after patient contact? Evaluate how these observations line up with the initial end-user interview process. Are there gaps or discrepancies? Are there bottlenecks in the workflows or limitations due to equipment or space? These critical factors can significantly impact system usability. For clinical optimization post assessment, look for documentation points where data should be changed from either discrete to free form or free form to discrete. Work this into clinical workflows to alleviate end-user system frustration.

Financial Optimization Tasks

With clinical optimization assessment considerations in hand, concurrently look at revenue cycle management (RCM) concerns. Provider practices typically have limited staff fulfilling business office duties, with most juggling multiple hats. Bottom line: financial representatives must utilize more efficient workflows. Follow these financial optimization steps to save staff time and improve their ability to create clean claims and reduce denials.

  1. Create a list of authorization numbers per major health plan–Request a list of procedures that require authorization numbers from your payer representatives. During the appointment booking process, flag those procedures to prompt staff to call the payer for an authorization number and create a report to list those without one during nightly processing. Within the final financial clearance process, establish a step to check for an authorization number. If the A/R follow-up sees a new denial for a procedure not listed, it can easily be added to the list. By reviewing for the presence of an authorization number, you can minimize preventable denials.
  1. Ensure consistent copay collection– Health systems with multiple clinic locations often experience inconsistent copay collections over time. To regain lost traction, create quick reference sheets with standardized documentation of proper copay workflow, noting particular transaction codes for correct system postings. Make sure you participate in and assess monthly reports on the rate of copay collection per clinic location. Such reports hold each clinic accountable by direct comparison to peers and national benchmarks for copay collection, which is 98 percent of all scheduled appointments.
  2. Evaluate common claim denials– Do a deep data dive on your top 10 denial codes and identify the payer for each. Identify the root causes of each denial and correct faulty processes or overlooked administrative or business office steps. If poor coding is a root cause, provide additional education for providers. If procedure authorization is not routinely obtained, business office staff may need additional training on payer requirements.
  3. Reduce charge entry lag time– Using data from the EHR, create a weekly report with the following fields:
  • Patient ID– system’s unique patient identifier
  • Encounter number– system’s number for a specific care episode
  • Encounter start date– the date of admission for an inpatient care episode or the date of the visit for an outpatient care episode
  • Charge entry date– the actual date the charge was successfully posted (may not equal the charge entry date due to edits)
  • Service or procedure date of service– the date the procedure or service was rendered to the patient
  • Service department– the name of the ancillary department that performed the service/procedure

From this data set, calculate the lag time between the date of service for the procedure/service and the charge entry date. Sort by service department and calculate the range and average per department. Then, meet with the appropriate representative of the service department to discuss any entries that exceed five days. Ensuring departmental charges are posted within five days of the service greatly decreases the risk of lost charge revenue.

You can make the most of your EHR system with these seven tips for two-pronged optimization. Over time as technology evolves, it’s important to approach EHR optimization as a continuous process improvement effort. Keeping an open line of communication with key stakeholders and superusers across both clinical and financial areas, revisiting implemented changes to evaluate their effectiveness, and making data-driven adjustments throughout the process will help your organization get the most from your EHR investment.

Dan O’Connor, vice president of client relations, Stoltenberg Consulting, Inc.

Joncé Smith, vice president of revenue cycle management, Stoltenberg Consulting, Inc.

Both can be contacted at

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