In 1991, the National Academies of Sciences, Engineering and Medicine declared that computer-based patient records were an essential technology for health care. The new records would not only support patient care but would actually improve it, and health care professionals would become more productive: These were just two of the Academies’ many ambitious expectations. Yet today, says Kevin Johnson, MD, MS, it is clear that electronic health record (EHR) implementation in the US has failed to live up to such high hopes. Dr. Johnson and co-author William W. Stead, MD, of Vanderbilt University, set out the important problems and suggest solutions in a new JAMA viewpoint article.
Take, for instance, the basic need to learn the medical history of a new patient. “This is one of the most burdensome clinical processes,” Dr. Johnson points out. “Clinicians spend time reviewing the entire EHR to put together a synopsis of the patient. Ideally, that work could be streamlined using computational approaches that summarize the data and present it to the clinician. There would be less time spent ‘foraging’ the record.” The process could also pull information from other sites, he adds, using health-information-exchange technologies to streamline the creation of the record — before the patient has even met the practitioner.
Rather than improving the cognitive processes that are foundational to practicing medicine, write the authors, today the EHR is proving to be a distraction. Given that it does not effectively capture a patient’s record and does not function within established practice workflows, even the term electronic health record is a misnomer, they assert. “The EHR is really quite a bit broader than what any single health system might own. It includes other systems that manage data, such as document management systems, radiology systems, and even data about a patient in remote clinics or settings,” Dr. Johnson says. The gaps in how this information comes together can compromise medical safety, he adds.
The EHR has many stakeholders: physicians, health system executives, educators, regulators and patients. Yet in the US, the authors write, it’s the administrative requirements — for reimbursement, regulatory compliance and workflow automation — that often take precedence over all else.
The recent Centers for Medicare & Medicaid Services final rule recommending that hospitals assess their healthcare information technology using the SAFER (Safety Assurance Factors for EHR Resilience) Guides is an important first step, they write. To lighten practitioners’ cognitive load, they recommend three more: First, debunk myths about what clinicians must document; use collaborative documentation where users identify individual contributions, confirmations and differences in perspective. Second, avoid interrupts in clinical workflows unless they are time critical. Third, align decision support to role and task; consider strategies such as bundling preventive care recommendations into an ad hoc guideline available to all care team members.
Most important, the authors call for maximizing EHR cognitive support — making EHRs SMARTER. Their “SMARTER” guide might include: Synthesizing information and supporting goal-oriented search; Monitoring care decisions, taking patient data and care setting into account, and suggesting better alternatives; Automating routine tasks; Recognizing trends toward or away from idealized patient models; Translating important user actions into documentation; Exposing contextually relevant data; and Reliably and consistently performing these functions.
And maximizing EHR cognitive support is only one part of the job, says Dr. Johnson. A record that serves patients effectively and efficiently is another unattained goal: “That is critical work in which we need to engage,” he emphasizes.
Read the article in the Journal of the American Medical Association.