healthcaretechoutlook

Don't Give Up on Electronic Health Records Yet!

By Adrian Zai, Clinical Director, Population Informatics, Laboratory of Computer Science, Massachusetts General Hospital

Adrian Zai, Clinical Director, Population Informatics, Laboratory of Computer Science, Massachusetts General Hospital

In recent years, electronic health records (EHRs) have taken a beating. Clinicians have criticized them for being overly complicated to use, while IT vendors have complained about their lack of interoperability. When fee-for-service was in full swing over a decade ago, we didn’t have this problem. EHRs were mostly systems used for tracking revenue cycles and documenting clinical care, just as we used to do with our old paper charts. The current basic design of an EHR user interface still mirrors our old paper charts. EHRs were great and fulfilled their intended purpose.

"I believe healthcare organizations will need to incorporate research and innovation initiatives to become highly competitive"

However, that honeymoon period came to an end in 2011. Our country adopted value-based care, as commonly seen in programs like Accountable Care Organizations, Medicare Shared Savings Programs, and Meaningful Use. With these fundamental changes, the focus is no longer only in caring for those who show up at the clinic. Rather, it is now about optimizing cost-effectiveness of care across entire patient panels, regardless of their attendance record at the clinic. Suddenly, we are left with EHR systems designed for a bygone era.

EHRs need to address four critical areas if they are to tackle value-based care. First, EHRs need to search across tens of thousands to millions of records at a time to manage at-risk populations. Second, EHRs need to enter external data such as payer and social determinants of health data as part of that search to better understand the population risk pool. Third, EHRs need to develop algorithms to stratify population risk, to understand population denominators better, and accurately determine links between patients and providers. Finally, EHRs need new tools to implement non-visit-based interventions to impact those patient populations.

Addressing these issues is not easy because the EHR’s underlying transactional framework does not technically allow it. Despite that, the sobering reality is that EHRs have to evolve rapidly to keep up with this transition. Meanwhile, clinicians’ frustration is growing because they are asked to meet the needs of a value-based care environment using EHR technology designed for a fee-for-service environment, thereby contributing to an unfortunate new trend: physician burnout.

Fortunately, not all is gloomy. EHR vendors are rapidly stepping up to the plate. According to KLAS reports, the three top EHRs–Epic, Allscripts, and Cerner–are ranked among the top 10 population health solutions. These solutions include sophisticated patient-provider linkage algorithms, as well as risk-stratification algorithms for various populations. Judy Faulkner, Epic’s CEO, announced at HIMSS17 that she is homing in on social determinants while working on creating truly “comprehensive” platforms that capture data beyond the walls of a healthcare institution. Furthermore, Faulkner is also highlighting "One Virtual System Worldwide," an initiative Epic launched in January 2018, aimed at making it easier for Epic shops to exchange data and encourage collaboration around it. The concept is to make it easy to view patient data across multiple institutions in a single merged view.

In terms of interoperability, the three top EHR vendors revealed in March 2017 they were working to make their EHRs more open, embracing APIs to enable third-parties to write software and apps that run on their platforms. While EHR vendors are doing their part to improve interoperability, I am even more excited to see what blockchain technology can do to finally make medical records truly patient-centered.

Usability is likely to be one area that will remain an ongoing challenge. However, this is not an isolated EHR issue. It’s a challenge tightly linked to optimizing clinical workflow to support a value-based care model. If a legacy fee-for-service-based workflow is used to solve a value-based issue, all stakeholders are bound to be frustrated. The solution lies in creating innovative approaches to patient population care that combine new clinical workflows supported by new user interfaces. EHRs have been working on creating tools to support custom care pathways and registries with batch ordering capabilities. The tools are coming, but to work at peak efficiency, they need to be tailored to align with value-based care workflows.

Ultimately, I believe healthcare organizations will need to incorporate research and innovation initiatives to become highly competitive. These initiatives will push hundreds of small usability research pilots through rapid cycles of quality improvement to achieve peak efficiency. Today, I am cautiously optimistic about next-generation EHRs. EHRs have evolved significantly over the past few years, but there is still significant work to be done, especially with regard to usability and provider burnout. I am truly excited about what the future will bring us, and look forward to playing a small part in the ever-changing healthcare IT landscape.

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