How Hartford Health is limiting redundancy, improving its EHR: Q&A with CMIO Dr. Spencer Erman

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Spencer Erman, MD, chief medical information officer at Hartford (Conn.) Healthcare, discusses how the health system is alleviating physician burden when it comes to the EHR as well as the areas of healthcare he thinks need innovating.

Responses have been lightly edited for clarity and length.

Question: How has your role as CMIO evolved over the past two to three years? How have your responsibilities changed since you took on the role?

Dr. Spencer Erman: When I started in this role in 2016, 90 percent of my time was focused on the design, build-out and implementation of our EHR, which we did in a phased rollout. Phase 1 focused on ambulatory and primary care, while phase 2 focused on different hospitals. That consumed most of my time over the past three years. We still have one more hospital to go live — that will happen in October 2019 —and another acquisition that we will do in 2020.

Now we're focused on other technologies. EHR still plays a big part —upgrades, etc. —but now we're spending a lot of time with users and provider personalization and ensuring that the technology is working for them, rather than a situation where they are working for the technology.

Another area of focus is implementing and optimizing third party functionality — electronic prescribing of controlled substances and secure communications as well as single sign-on. I'm also executive sponsor of our system's opioid council, which has a prescribing arm and a treatment arm. We're looking at monitoring, education and helping providers prescribe appropriate medications in appropriate amounts. We use EPCS to monitor how they're prescribing and where they're sending their prescriptions. And we're using EHR and best practice alerts to help guide the providers in appropriate prescribing.

Q: What tasks take up most of your time?

SE: Our treatment arm is really focused on addiction, getting patients into treatment and pairing them with the right coaches using our match program. That's taking a lot of my time now.

The third area of focus is our provider resilience and wellness program, which we've implemented here because providers are burning out at record rates. Anywhere from 40 percent to 60 percent of a provider's time is spent documenting. That needs to change, and a lot of places are looking at ways to assist.

Q: What do you consider your No. 1 priority as CMIO? How do you ensure you're successful?

SE: My number one priority now is to keep the clinical focus in technology.

The EHR and other peripherals have developed into a catchall — using EHR for billing, coding, etc. — and not just for clinical. That's why it's gotten so out of hand. Over the past few months, CMS has changed documentation requirements, which allows us to take advantage of EHRs. We're working on ways to improve it locally — getting rid of the redundancy and the unnecessary steps when ordering specific tests. A lot of the departments require you to fill out this whole big questionnaire. We're going back to the department saying why do you need this information — height, weight, etc. — it's already in the chart and re-entering would be redundant work.

We're building links to bring it right in, so the imaging centers see the information already exists. We don't need to type it in again and spend that time. Same thing with prior authorizations — it used to be 'in the paper world' that a nurse could do the call in. Now, because providers are doing the ordering, all that information must be inputted in real time during the order placement. We're looking for ways to streamline that process so providers don't have to and can spend more in-person time with patients.

Q: How do you feel about the use of voice recognition technology, such as Amazon’s Alexa and Google Assistant, in healthcare? Is there a place for its use within the EHR?

SE: We're using Dragon and Nuance products now, and providers that use them like them a lot. Although they work well and save time, they don't do everything you need. You still have to go into the EHR and click the boxes and do the signatures. I'd like to see further development in
'complex commands.' Nuance does have some of those. If I'm documenting a patient who needs to go in for preop for a hernia repair, for example, it would be valuable if I can say into my voice recognition software: 'Preoperative repair,' etc. —and it opens the order. And it's ready to offer my signature so I can change anything while the computer still understands that this is my usual preop.

'Virtual scribes' or 'voice assistants' are emerging, but they are not quite there, in my opinion, and I can't see it working for most providers. There's also the growing use of a live person offsite who listens through a microphone and documents patient-provider discussions. Patients have expressed some concerns about having scribes or a third party in the room doing the typing. I can only imagine what they think of their voice going out over a telephone or computer line to someone in another location. I don't know that Alexa or Google Assistant has been used in healthcare for that purpose yet. I can see typing voice commands into the EHR, but I don't know if it exists where you ask for information and it comes up instead of having to type it in.

Q: Where do you see the biggest need for innovation to improve the healthcare system in the future?

SE: One area in need of innovation is to let the providers be providers — they shouldn't be data entry clerks or coders. Innovation must help us develop teamwork and a team-based approach so that everyone can operate to the top of their license. That means, for example, having a nurse enter a prescription that providers can quickly sign, or having a clerk start the prior authorization paperwork. I'd also like to see innovation that helps us better utilize the data we have. Right now, we have a tremendous amount of data but we're not using it to its full advantage — and it's not national. Epic has started benchmarking and providing that data nationally, which is helping, but we need more on the national level.

The other future areas of need include: virtual care, telehealth and remote monitoring using patient devices that can be worn or used at home to collect data. But we must be careful; just because we can do it doesn't mean we must do it now. It's helpful if a patient has a Fitbit and it shows that she is doing exercise every day. But do patients want a device sharing that data with the provider? And does the provider really need to know how many steps their patient walks? There might be indications where they do but not in general. Therefore, we must be careful with collecting too much information that is of little clinical usefulness.

Biometric solutions are coming, and they will help with security. Palm and retinal scans offer both security and time savings potential. Patients may hesitate to have their fingerprints or palm prints on record, but it can certainly help in cases of fraudulent identity sharing. If a person tries to use, for example, his brother's insurance card or driver's license to enter a hospital, palm scanning or fingerprinting can identify that fraudulent attempt. Biometrics will also help speed a patient through the registration process. Solutions are available but have yet to be widely adopted.

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