Clinical Perspectives and Building a Better EHR
By Matt Phillion
We live in an age where incredible amounts of data are available to us all the time. But in healthcare, the challenge can be finding the right data, at the right moment, to achieve the best outcomes for patients. EHR technology has been game changing, but it’s also led to practitioner frustration: While EHRs can present all the data available about a given patient, they’re not always good about surfacing precisely what a physician needs.
As the industry moves toward value-based care models, clinicians have an even greater need to optimize their patient care through access to high-value information. According to physicians like Bill Hayes, MD, CMO at CPSI and a member of the HIMSS Electronic Health Record Association (EHRA) Executive Council, now is the time for stakeholders to improve EHR system functionality, and for EHR designers to enable input from clinicians and thereby ensure the most clinically relevant information is available at the point of care.
“There’s no perfect EHR out there,” says Hayes. “I was a practicing cardiologist, and I felt I was delivering quality care. Along came the computerized world, and if we ask the rhetorical question ‘What was the most important change to healthcare?’ to me it’s the integration of information technology.”
That integration had a wide-reaching impact. “All of a sudden, we installed a system and when I came into work, how I delivered care was drastically changed,” says Hayes. But electronic information technology brought unique challenges alongside its benefits, and some of those challenges linger even today. For example, EHRs still aren’t universally delivering on their promise of faster, easier, better management of patients.
“An EHR is a direct healthcare delivery tool and can save lives, but it has the potential to be so much better at doing that to greater extents,” says Hayes. “I also found myself frustrated by it, as it wasn’t how I cared for my patients, as I could not find information that I needed.”
Healthcare and silos
“As a physician, perhaps I’m partially responsible” for the particular way healthcare information is siloed, Hayes says. “When vendors came along to build these systems, they were originally built on transactions and billing, which works great in the business world, but that’s not the clinical world.” The encounter-driven, single-transaction business perspective doesn’t match up with clinical needs—for example, the multiple interconnected visits and longitudinal care required over the course of a pregnancy.
Ironically, Hayes says, as a partner in his practice, he paid for the system that made him work harder rather than smarter. “When they came to us 20, 30 years ago, these brilliant engineers asked us what do we need, and we gave them all these sections and silos. They built these modules and apps to perform the functionality we listed,” he says. “EHRs have a bar or column with 40 or 50 applications. Silos of allergies, meds, orders, lab results. That’s great, except it has nothing to do with the workflow needed to care for the patient in the best manner.”
While the engineers delivered on the requested EHR model, it turns out they’d been tasked with the wrong job. The real issue, says Hayes, wasn’t converting paper charts into digital—it was creating a clinical workflow. “That doesn’t take advantage of the computer, because health IT is the interaction between the human and the computer,” he says. “But on the other hand, really, healthcare is the interaction between myself and the patient, with the computer there to help me. We don’t want to be distracted by the computer. We’re not data clerks. But now the workflow had changed.”
A change of perspective
A conversation with his wife led Hayes to get more involved in improving how EHRs interact with physicians. “I have a very pragmatic wife. She’s the COO of a company. And I said, ‘I’m paying for this, but it doesn’t improve my care.’ She said, ‘I don’t believe in people who complain—I believe in people who do something about it.’ ” This led Hayes to delve into where he as a practicing physician could provide feedback and perspective to improve the EHR.
By this point, the majority of practices were using an electronic system, but in Hayes’ opinion, those systems weren’t improving quality and efficiency. “The ultimate goal to me as a physician,” he says, “is that the exchange of data should be irrespective of vendors and should be patient-centric—clinicians should have the right information available to care for those patients.”
For example, Hayes says: If someone lives in Tampa, Florida, but goes on a ski trip in Vail, Colorado, and crashes into a tree, they may not know important details about their medical history and might not have anyone present to advocate for them before an emergency surgery. Their medical records in Tampa might show a significant allergic reaction involving previous surgery that no one in Vail would be aware of.
“No exchange of data could lead to a lot of trouble in a situation like this for the patient. The providers wouldn’t do anything intentionally, but they [don’t] have the relative high-value clinical information needed in that moment,” says Hayes. “When we talk about safety, and the data exists in Tampa but not in Vail, that strikes home for me.”
Conversations are happening about the best way to prevent these gaps in knowledge. “I’m on calls with the EHRA executive committee; they’re all for interoperability and the exchange of data,” says Hayes. “Let’s figure out how to best information share.” (There’s a distinct difference between data and information, he notes. “Both have huge value.”)
Another example: A patient should have access to all their data, but if they’re about to undergo anesthesia for abdominal surgery, the anesthesiologist doesn’t need to know the patient had a bunion in 1987, he says.
“If you exchange all the data that’s available in the system, let’s go further: The surgeon can’t go through all that data,” says Hayes. But computers can, and quickly. If the computer is trained or programmed correctly—say, to look for allergies or reactions to anesthesia and surface information that’s relevant to the surgery the patient is about to undergo—having it comb through the data becomes invaluable.
“That could save the patient’s life,” says Hayes. “I am all for interoperability. I want patient-centric, longitudinal systems. I don’t want to look at or need all the data because I can’t go through it all, so I may miss something. It’s mostly siloed and takes a long time to review, and even if all the data is there I may not get what I need or want at the point of care.”
He continues, “The ability of technology to draw the high-value clinically relevant information at the point of care from the cumulative data is a huge benefit at the bedside. If that information can be found for you, it could really be a safety and quality improvement mechanism. This type of workflow is not application-driven, it’s problem-driven.”
An industrywide improvement
The EHRA is a voluntary trade organization made up of 30 companies in the EHR space. “The government has a very good idea regarding interoperability, and we need to find the best way to help them help us and work together,” says Hayes.
The ultimate goal, he says, is to examine what the EHR should be to ensure patients receive the safest, highest-quality care. Accomplishing this involves working with groups of doctors and nurses, getting their perspective at the table.
“My company has volunteer physicians who help us get to where we should go, what we want to pursue with the EHR, and how to build the products that help them deliver healthcare,” says Hayes. Without this feedback, the systems can’t deliver valuable information at the point of care.
“I kid my company engineers that if I go to buy a truck, they don’t tell me it’ll be brown, have four doors, and won’t have a trailer hitch without asking me what it is I need for the work I’m trying to do,” says Hayes. “You can’t put it in a box. It’s unique for every patient.”
Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.