Dr. Nick van Terheyden: EHRs are like junk drawers — but there's a way to declutter them

Searching for patient data in an EHR is rather like rummaging in that catch-all drawer most people have in their kitchen. You know the one — it's where everything goes that doesn't have a designated place or somehow doesn't get put where it belongs. That drawer has many useful items in it. All those jumbled bits and pieces may be useful someday, but you don't need them right now.

An EHR is a lot like that drawer. It has plenty of useful data in it, and a lot of other bits and pieces that, with the right integration tools and the right analytics, will be useful someday. The problem is that right now you need a specific piece of patient data, and to find it you end up rummaging through a lot stuff that isn't of any help at the moment.

Worse yet, the data you need can be a test result that is locked up in another system. It's like knowing that you have a small screwdriver that is perfect the task at hand, but you loaned it to your neighbor. You could go knock on the door and ask for it, but they might take forever to answer the door, and then they'd have to rummage through their catch-all drawer to find it, and you just don't have time to mess with it. So you buy a new one.

Like that screwdriver, the data you need is often locked up in another nearby system, and you could get it if you asked for it, but you don't have time to knock on the digital door and wait around for the other system to find it and send it to you. So you order a new test.

A new, better way to rummage in the digital data drawer

To take the analogy a bit further, imagine that you hire an organizational assistant to sort all the stuff in the catch-all drawer, pull out the bits that are currently useful and place them on a shelf, neatly organized and easy to find. And the assistant sets up a network with your neighbors that tells you exactly where all their useful bits are, and places those useful bits in a place you can access easily. And then he sets ups a drone system to bring those useful bits to you whenever you needed them.

That would be pretty amazing, don't you think?

It is possible to create a digital organizational assistant to rummage through the EHR and present you with the data you need just when you need it. There are several developers working on new interfaces for EHRs, which would treat the EHR like a relational database rather than a clinical user interface.

The new interface would gather data from the EHR and send data back to it, but would present the physician or other caregiver with an interface specifically designed for that clinician and his view of patient care. Currently, EHRs are gathering all sorts of data that is useful for billing, analytics, population health risk stratification and other purposes. But often that data isn't useful for real-time patient interactions, and the interfaces are less than ideal.

It's no secret that physician dissatisfaction with EHRs is high (there's even a rap song about it). But with billions invested in existing applications, it's unlikely that hospitals, health systems and physician practices are going to make a major change any time soon. And EHR vendors don't have any real incentive to do the kind of overhaul of their applications that physicians really want.

This "digital assistant" approach will eliminate much of the frustration of dealing with EHRs, while making good use of the existing investments. And if the right integration tools were incorporated into this interface, it could conceivably rummage through other EHRs, pharmacy systems, emergency department systems and other clinical applications in real time to find all the useful data and present them to you in a way that is relevant to the patient and the clinical decision-making process.

Here's an example of how that would work.

Let's say you are a primary care physician and you have a diabetic patient, Mrs. Johnson, who goes to the ED on the weekend because of a fall. If your digital assistant sorted through the EHR systems of all local EDs daily and pulled information about your patients into your system, you would know that Mrs. Johnson had an incident that could be related to poor blood sugar control. Did she fall due to dizziness or faintness? Is she having issues with her arthritis? Is she developing a heart condition?

If your digital assistant also pulled in Mrs. Johnson's blood glucose readings, you could review the information quickly. That would give you the chance to adjust her medications, if need be, and coach her on ways to keep her glucose in tighter control. Or perhaps you'd have the chance to confirm that the diabetes was actually under good control, and do a proactive review to address other issues that may put her at risk for a major medical event.

If your digital assistant routinely pulled in pharmacy information, you could see if Mrs. Johnson was filling her prescriptions on schedule. If she isn't, you could find out why and help her solve the problem. A study published in 2014 in the Annals of Internal Medicine found that nearly a third of all new prescriptions weren't filled within nine months; a survey by the group Prescriptions for a Health America (a coalition of physicians, patients and pharmacy and healthcare industry groups) found that approximately 60 percent of patients don't take medications as they are prescribed. The group also found that better medication adherence resulted in significant reductions to other medical costs.

And how about co-morbidities that result in visits to specialists? You could be alerted if Mrs. Johnson fills a prescription from a cardiologist or rheumatologist or an orthopedist or any other physician. That's important information, because you want to be sure that any new medications won't interact negatively with the medications she is already taking. And you want to know if she has other health problems that she might not have mentioned to you. If those other physicians also had a digital assistant that mined the pharmacy system, they'd be alerted to what medications you are prescribing. That would help all of Mrs. Johnson's caregivers provide higher quality medical services, and possibly provide Mrs. Johnson with a better quality of life at a lower cost overall. It would also offer her an opportunity to see, use and share her own medical record and information with her care team and family.

A new standard for data will help

To make all this rummaging in the data easier and more accurate, HL7, the international group working on interoperability issues, has a new standard and application programming interface (API) called Fast Healthcare Interoperability Resources, also known as FHIR (pronounced like fire). This new standard is just beginning to be used, and one of its goals is "to facilitate interoperation between legacy healthcare systems, to make it easy to provide healthcare information to healthcare providers and individuals on a wide variety of devices from computers to tablets to cell phones, and to allow third-party application developers to provide medical applications which can be easily integrated into existing systems."

FHIR should greatly advance development of the kind of interfaces we need to make EHRs easier to use and more clinically useful. Physicians can aid that advancement by insisting that any new applications or tools adopted are based on these standards.

If vendors get on board and use these standards, we'll see a revolution in how physicians, nurses and other caregivers interact with EHRs. The good news: Vendors seem to like the new standards, and they are quickly moving to use them.

Nick van Terheyden, MD, is CMO of Dell Healthcare & Life Sciences. He previously served as CMIO of Nuance Communications. Dr. van Terheyden is a 25-year veteran of healthcare technology. He aided in the development of one of the first EMRs and served as a business leader in one of the first speech recognition Internet companies. He is a graduate of the Royal Free Hospital School of Medicine, University of London and has several professional memberships including HIMSS, mHealth Executive Committee, AMIA and AMDIS.

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