What’s the right formula for a dream EHR?

EHRs might well be a four-letter word given the negative passions they arouse.

The evidence has been anecdotal for years, but this month, some scientific evidence that electronic health records can be huge time sucks came to light. Earlier this month, the Annals of Internal Medicine published a study showing that ambulatory-practice physicians in four specialties spend 49.2 percent of their work days on “EHR and desk work” compared with just 27 percent of their in-office hours on “direct clinical face time” with patients.

Even when in the exam room with patients, the family practitioners, internists, cardiologists and orthopedics studied devoted only 52.9 percent of their time to patient face time, the American Medical Association-sponsored study found. These doctors were tied up with EHR and administrative tasks 37 percent of the time in the exam room, and patients frequently can feel ignored.

In an EHR satisfaction survey from Healthcare IT News a year ago, just one of the nine major vendors, Epic Systems, achieved an aggregate score of more than 7 on a scale of 10 in terms of support, interoperability and design. Common complaints about EHRs included complicated workflows, too many clicks, poor user interfaces and difficulty integrating with other health IT systems.

So what’s the formula for a dream EHR?

Activist patient Casey Quinlan, for one, thinks the current crop of EHRs are beyond repair.

“To improve EHRs, they need to get back to the drawing board,” Richmond, Virginia-based Quinlan said. The problem, according to the outspoken “Mighty Mouth” Quinlan, is that EHRs have their roots in billing and accounting systems.

“First, we must kill all the silos,” she said. “You really need to think globally on this.”

Her “nirvana” would be a system that brings in all available data on a given patient from multiple sources — primary care physicians, specialists, laboratories, pharmacies, convenience clinics, hospitals and, yes, payers.

“In the moment that it’s hit [with a record request], it would serve up exactly what the doctor asks for,” Quinlan said.

Further, for a given condition, the EHR should delineate treatment options — clinical decision support — and attach a dollar figure to each option based on the patient’s personal coverage so doctor and patient could develop treatment plans based on out-of-pocket cost.

“Why is that not happening?” an incredulous Quinlan asked.

Insurance information historically has not been part of the clinician workflow, but with high-deductible health plans and patients responsible for ever-escalating copays, it ought to be, Quinlan said.

Given that patients are, in Quinlan’s words, “still going to be a walking, talking medical history,” vendors and health systems alike need to recognize that patients know more about themselves than those inside the IT department.

“We need patients to be a part of the solution. No one group owns this, but we all own this,” Quinlan said.

Meanwhile an EHR vendor had his own idea of what a successful EHR should be.

“I don’t think doctors will hold EHRs in their hands in five years. I think they’ll be on Epocrates [a drug reference app owned by athenahealth] or some other app and they’ll call those records like you pull down a story on Audible or you pull down a movie to your device. So you stream it and then it goes back. You don’t keep it,” athenahealth CEO Jonathan Bush told MedCity News earlier this month.

He also, not surprisingly, plugged his own company.

“I believe records should be national networks like cable companies,” Bush declared. I think if I were a CIO, I would sign on to a national network like athenahealth and I would not attempt to build my own biosphere of clinical information.”

While that may resolve issues of data ownership and interoperability, a more down-to-earth approach for today’s EHR vendors is to focus on workflow improvements.

Dr. Charles Webster, owner of a Columbus, Ohio, consulting firm called EHR Workflow, cited four benefits of workflow-improvement technology: automation of mundane responsibilities; transparency in terms of being able to track the status of various tasks; flexibility; and systematic improvability, which is a product of the first three.

Webster said he researches every vendor in the guidebook of the Healthcare Information and Management Systems Society (HIMSS) annual conference. Five years ago, “workflow engine” was rarely mentioned. This year, more than a third of the 1,300 or so vendors did, so there has been some progress.

“There are BPM companies coming to HIMSS now,” Webster said. “If somehow the yoke of Meaningful Use lifts,you will see some of those come to the fore.”

Indeed, healthcare has become so attractive to companies such as Salesforce and SAP because this industry is so in need of BPM. This type of purveyor of “sophisticated” workflows from outside of healthcare is one of two types of entrants to the clinical IT market that Webster expects to see more of. The other is the startup community, including new companies offering patient-facing task management technology.

Ideally, a nonprogrammer should be able to modify the workflow within the EHR. Some commercial EHRs are not so flexible or easy to adapt to changing needs, Webster said.

“Most electronic health records are legacy technology, databases with interfaces slapped right on them,” Webster said. “It’s the opposite of ‘process-aware.'”

While that may be true, the University of Colorado Hospital in Aurora, Colorado, isn’t doing away with its Epic EHR anytime soon. Still, the Denver-area academic medical center has greatly improved its medication reconciliation by fixing workflows and customizing its software build.

The hospital last year turned on a single-click function in the EHR that allows physicians to add the indication of use when they write prescriptions. In May, this function became mandatory for all prescribing clinicians.

While helping to prepare the survey to renew the hospital’s Joint Commission accreditation, Kate Perica, medication reconciliation coordinator for the University of Colorado Hospital, noticed that the organization had not been providing an “indication of use” in medication reconciliation. The Joint Commission told the hospital the indication of use was mandatory for heart failure.

“It came from a heart failure finding, but it is an organizational finding,” Amanda Nenaber, manager of the hospital’s heart failure program, said. Rather than limiting the indication of use to heart failure, Perica and Nenaber decided to roll it out throughout the hospital.

While the EHR was capable of including the medical information on prescription labels, in medication lists and post-visit summaries, it was a more laborious process. When the IT department turned on the one-click function, clinicians were skeptical.

“There are a lot of non-meaningful clicks,” Nenaber said of EHRs. That made it a tough sell asking physicians to add a click at the time of prescribing with the promise of saving time hunting for information later.

But the ease of use — and the mandate — made the effort successful.

Post-implementation, two-thirds of physicians the hospital surveyed said it takes less than 5 seconds per prescription to include the indication. In the first four months of implementation, prescribers added indications to 336,000 prescriptions for 189,600 patients. Four months into the project, there is no evidence that it has improved outcomes, yet, but the hospital is going to study that.

“It was mostly getting the buy-in from providers,” Nenaber said.

For all the discussion of what  the right formula for a successful EHR is, in some quarters, the term itself leaves a bad taste in the mouth.

It’s “kind of tainted forever for doctors,” said Webster, the consultant, noting it may be time for a new name.

“It can’t be fixed,” he declared.

Photo: Peter Macdiarmid/Getty Images

CLARIFICATION: MedCity News has updated some of the information provided by Nenaber and Perica from an earlier version of this story.