Answer: There have been multiple barriers to successful deployment and adoption of EHRs. While there has been progress, many of these barriers remain as significant obstacles to future success and innovation.
• Cost. EHRs are expensive to deploy and maintain. Direct costs include licenses, hardware, training and support. Indirect costs involve lost productivity due to a steep initial learning curve and ongoing inefficiency if the workflow is awkward or training is not adequate. Government subsidies helped offset some of the initial costs and clearly stimulated the widespread adoption of EHRs. While a few organizations have been able to demonstrate a return-on-investment (ROI), most have either not measured or failed to find well documented ROI.
• Changes to Workflow. By design, EHRs cause (or invite) major changes in clinical workflow and have significant impact on both who does the work and how work gets done. In theory, this presents an opportunity to carefully plan and redesign key workflows to improve quality, safety and efficiency. This requires a “go slow to go fast” approach and substantial upfront effort to identify and reach consensus on workflow changes. In practice, few organizations make significant efforts to really change workflow and, as a result, they miss out on the opportunity and simply “pave the cow path.” This has a negative impact on efficiency and user satisfaction. It often results in prolonged and expensive efforts to “optimize” – i.e., to go back and fix broken or inefficient workflows.
• Poor User Interface/User Experience. For the most part, todays EHRs represent the first generation of a new technology. They are more like the Model T than a sleek, self-driven sports car. User interfaces are complex and too often do not make use of basic human factors engineering principles. The user experience is typically negative and frustrating due to a combination of elements including poor design and configuration choices, lack of attention to workflow (as described above), or over-engineering (too many screens, clicks, or alerts). This contributes to dissatisfaction, inefficiency and errors. These problems are being addressed through optimization efforts, a growing recognition of the importance of human factors, and the emergence of the next generation of third-party applications that supplement or replace core EHR functions.
• Interoperability. The ability to share information between and across EHRs remains a huge problem and one of the biggest barriers to success and innovation. For example, many people are surprised to learn that moving data between two instances (deployments) of the same brand of EHR is difficult. This goes far beyond simple record portability. Interoperability is the foundation for the innovation health IT desperately needs. A thriving “application economy” (think Apple’s App Store) cannot exist without robust interoperability. Application Programming Interfaces (APIs) have had a dramatic impact on interoperability in other industries (finance, retail, etc.) and are now poised to do the same in healthcare.
Question: What are the ways in which EHR is best used?
Answer: Based on the limited data available, the widespread deployment of EHRs has had mixed results. Some tasks and workflows take longer than they did in the pre-EHR world. Examples include ordering a single medication or completing routine documentation. Some are faster, such as finding information or using an order set to place a group of related orders all at once. Legibility has also improved and basic error checking (like drug-drug or drug-allergy checks) is in place, both of which have likely reduced medical errors.
Deploying EHRs has resulted in a more (but not completely) comprehensive “source of truth” for clinical, research, and operational activities. But, the potential is still not fulfilled and there are many opportunities – short and long-term – to extract increased EHR value. We needed to digitize medicine as a first step, now we need to harvest the “digital dividend.”
The overarching goal should be to provide actionable information. This means the right information is presented in the right way to the right person (or group, and this includes patients and families, too!) at the right moment and that they can act on the information in an efficient and effective way. Measured by that standard there is much, much more work to be done.
Question: Describe how EHR is helping doctors diagnose conditions.
Answer: As noted above, EHRs give clinicians a more comprehensive “source of truth” and incorporate the first-generation decision support. It is reasonable to believe additional information will result in better diagnosis and treatment – though outcomes studies remain inconclusive about this. Clinical Decision Support (CDS) has the potential to improve accuracy and speed of diagnosis and to improve outcomes by making it “easy to do the right thing, hard to do the wrong thing.” One common area of focus is reducing the rate of “failure to diagnose” errors. For example, CDS can suggest additional diagnoses to consider or testing that could rule-in/rule-out a particular diagnosis.
It is important to note that we are at the beginning of this journey. There are still many opportunities to deploy and improve CDS. And, there is much to learn about how to make CDS more effective and less intrusive or annoying to end-users.
Question: Outline opportunity areas for EHRs. In a few years, what will EHR be able to do that they can’t now?
Answer: Robust interoperability for both records portability and third-party application development will emerge as a key enabler of better communication, data exchange, and enhanced applications. We will see “app store”-like functionality and options for both clinicians and patients.
Greater focus on human factors coupled with the emergence of robust interoperability will lead to better user interfaces and user experiences. This will be seen in both the basic design of screens and workflow. It will also be the result of deploying basic, “Siri-like” Artificial Intelligence (AI) that supports workflow and decision making. Refined approaches and more powerful analytics will enable increased CDS effectiveness and consistent delivery of actionable information.
Predictive analytics, which have transformed the retail and finance sectors, will begin to impact medicine. Additionally, ‘sEHRs and related technology will become mobile and more pervasive. We are mostly still in the “desktop” stage of health IT. Expect to see an increase in mobile platforms, devices, and the interoperability needed for them all to connect and collaborate.
We will also see greater patient-facing functionality. Platforms that provide transparency (pricing, outcomes, availability) and useful transactions (result retrieval, appointment scheduling, self-care, and other basic information) will become widespread and will further empower patients, enhance the “customer experience,” and be the basis of competition and differentiation between health care providers.
David Levin, MD, Chief Medical Officer, Sansoro Health – David Levin, MD is a physician executive with over 25 years of experience in healthcare information systems, clinical operations and enterprise strategic planning. Prior to joining Sansoro Health, he served as Chief Medical Information Officer (CMIO) for the Cleveland Clinic Health System (CCHS), where he led the Clinical Systems Office. Dr. Levin has founded several healthcare IT startups and served as an advisor to many more. He is a nationally recognized speaker and has appeared in academic, industry and consumer media. He currently serves on multiple industry and venture capital advisory boards and non-profit governance boards. Dr. Levin received his MD and his BA from Brown University.
About Sansoro Health
Sansoro Health solves health care IT’s most pressing challenge today – achieving secure, seamless data exchange between electronic health records (EHRs) and leading-edge administrative and clinical applications. Health IT innovators leverage Emissary®, Sansoro Health’s award-winning software platform, to install swiftly, deliver robust functionality and slash integration resources. To learn how Emissary creates agile integration, visit www.sansorohealth.com.
