JAMIA recently published an article titled “The complex case of EHRs: examining the factors impacting the EHR user experience,” which provides a look at the many factors that impact clinician experiences with electronic health records. Join the discussion to learn more about this multi-factorial issue and explore what various stakeholders across the industry can do to improve the experience physicians and care team members have when using their EHRs.
Get physician input pre- and post-implementation, provide real-time training, and measure productivity by physician to identify those needing more assistance. Continue to monitor EHR use metrics to identify best practices/opportunities for improvement.
Agree. Physician input early and often is key to ensuring these systems provide the necessary functionality necessary to provide efficient, safe, quality patient care.
Testing the system pre and post implementation is key. There are many generic test cases that vendors provide to test system functionality, but they may not be specific to what you see or have seen in the local environment. Developing rigorous test cases can help ensure the system protects patient safety and improves physician efficiency. Last year, the AMA, MedStar Health, and Pew Charitable Trusts developed a framework for improving EHR Patient Safety including sample test cases that can be leveraged and/or used as a reference by practices/health systems and/or vendors.
Collaboration among many stakeholders will be integral in making strides towards a better end-user experience with EHRs. Not only will it require physicians, health systems & practices, governing bodies, and vendors to come together, but it will also include patients as well as technology developers that are making software solutions to help address some of the problems clinicians face with their EHRs. If these stakeholders work as adversaries vs. together, we won't be successful at achieving optimal EHR use.
Health insurance providers also recognize that they can play a role in simplifying the physician/health system user experience with EHRs through collaboration. For example, the Core Quality Measure collaborative seeks to align measures through public and private payers reducing the number of measures that need to be documented, collected and reported on through the EHR.
A number of good suggestions are available at STEPS Forward. See the Electronic Health Record Optimization: Strategies for Thriving that includes strategies to help health care organizations maximize the benefits and minimize the burdens of the EHR. edhub.ama-assn.org/steps-forwa...
One important thing practice administrative leadership and the C-Suite can do is listen to the ultimate end-users of the EHR, including physicians, nurses, medical assistants, etc. They are the ones who will be in and out of the EHR multiple times throughout the day, and who will have to bear the burdens of inefficient EHR workflows, excessive clicks and confusing navigation (i.e. not being able to find the test or medication they want to order because it is buried on a screen that isn't intuitive). The more the EHR stands in the way of end-users providing high quality patient are, the more it will be viewed as a challenge to providing good patient care rather than a facilitator.
Dr. Chen - I couldn't agree more. In my previous experience as practice administrator, clinicians on the "front lines" are seldom included in any evaluation, selection, and/or implementation of EHRs (or any new technology for that matter). Physicians, nurses, APPs, MAs, etc. have the exact experience, perspective, and expertise needed to ensure EHRs function in a way that allows for efficient, effective, and quality patient care.
While I recognize the cost of purchase and implementation is extremely high (which is often why features/functionality get cut or training is light), I've often wondered that if EHRs were implemented the right way the first time around (i.e. clinicians were at the table early on, necessary features/functionality were purchased and turned on, workflows were looked at up front, and training was adequate, thoughtful, and ongoing), would health systems be required to invest as much as they do in outsourcing consultants to optimize these systems 1 and 2 years post-implementation?
We believe the fact that there's such a large implementation burden for setting up EHRs points to a fundamental weakness in the design of these systems. Customer service is very important, but, in an ideal world, EHRs wouldn't require so much setup or ad hoc configuration.
In addition to optimizing the implementation of existing EHRs, we think incumbent EHR vendors need to dedicate additional attention towards designing better, more user-centered software. Unfortunately, this is unlikely, since implementation fees account for a large percentage of EHR vendor revenue. Given the status quo, these companies actually have a disincentive the provide better software.
The competitive dynamics of the EHR market make innovation challenging. Despite well documented frustration from users, EHR vendors have very strong loyalty from their customers, since IT leadership is often disconnected from physicians and other users.
Fable - Agree that switching costs in the EHR space are very high. How do we drive innovation to benefit patients and physicians?
The most successful EHR companies recognized from the outset that their customers are those who administer revenue-driven, widget-based health financing systems, what physicians refer to as "the perfect EHRs for the CFOs." Physician incentives became aligned with maximizing revenues rather than providing value in exchange for higher compensation, and clinicians have been burdened over time with increasing demands for documentation by the payers, while office-based physician-centric billing codes have discouraged delivery redesign to more efficient effective team care.
Until we understand how care must be re-designed to optimize value instead of revenue, what such care needs to look like, and how reimbursement needs to support value and the work of change, how can we determine what EHRs will then need to look like? For now they are perfectly designed to support the unacceptable status quo.
In the meantime, independent IT apps should be developed to support care teams and disease population management independent of the EHRs that are not designed for these purposes, IMHO. This essential product development and testing has been discouraged by the notion that EHRs can and should provide these functionalities, and health system administrators' failure to understand and provide for the needs of their care givers and patients at the points of service in outpatient medical practices.
Michael - We realize that EHRs as we know them are here to stay, and we think innovation opportunities exist for creating auxiliary tools that help users better access and record EHR data.
For example, a modern user-centered charting tool, that reads data from, and writes data to the EHR could really help reduce the time physicians spend in front of the computer.
EHR companies often promote their developer programs (eg: Epic App Orchard, Cerner's code, Athena MDP) as examples of innovation, but egregious pricing and other overbearing terms make these programs unappealing to software developers.
The technology for this sort of innovation exists, what's missing is more collaboration, both in between providers, and also between providers and forward-thinking healthcare software companies.
Harvesting data from EHRs to analytic apps is how most physicians and experts see it working. Unfortunately, this intuitive data flow is brand specific and expensive, as Fable suggests. Entering purposed data into analytic apps like chronic disease population disease activity measures and attaching individual patient PDF reports to encounters in the EHR is efficient, inexpensive, and works across all brands. Of course the EHR vendors want to build these functionalities into their own products and make them elegant. Simple and counter-intuitive is superior for practices and integrated health systems.
As many have mentioned on this thread, a complete overhaul of EHRs (and the current market leading vendors) isn't likely. With that said, as an industry, we can call for vendors to enhance transparency. This includes transparency around costs, available functionality, and implementation and training needs for users. If health systems, practices, and physicians were more aware of these aspects of the EHR, there could be improvements in end-user experience.
My hospital has outsourced IT to Cerner, just as they have outsourced the running of the cafeteria and many other services. The hospital's CTO is an employee of Cerner as is the entire IT staff and Cerner has the final authority over all IT issues (EHR, phone system, patient portal, etc). Physicians make suggestions for improvements but, in the end, Cerner decides what features get added, when, how and the GUI. Is this happening in other community hospitals?
Most physicians have no impact on the design and development of EHRs and relatively little on vendor selection by their hospital or health system. While they may be invited to vendor demos the great majority do not attend and those that do- do not have the expectation that their input will be large in terms of what EMR is finally chosen. But where they do stand to have an impact is that of being a "super user" for their organization and providing at the elbow support for colleagues and input for their IT departments post go-live. A problem is most places though is that of compensation for these super users as these tasks obviously pull them away from seeing patients, teaching, or doing research. Have any of you come up with a workable solution to this?
Hospital IT would work better (and there are objective examples) if the person who has the ultimate authority over all EHR design/implementation decisions:
1. is required to use the EHR on a daily basis
2. has deep knowledge about clinical medicine
3. has some experience in computer programming
4. has an in-depth understanding about information technology and
5. is committed to evidence based medicine while acknowledging its limitations.
Part of the above is excerpted from
Physician input is crucial in making the EHR work for us and not for it. While it may be true for a lot of physicians that they were not able to make the EHR vendor decision or to make huge changes in the way the EHR software functions, there are ways to be impactful at your organization's final design. We have physician advisory groups that help guide decisions on layout and changes to the system. We try to have a variety of specialties represented for providing feedback. Most physicians in that group are volunteers and attend these meetings virtually before office hours begin. We are lucky enough to have organization support to begin granting some dedicated time for select physicians for additional input into our EHR design. We also provide feedback to our vendor for future changes of the software of things that could be improved. They do listen and often times there is a positive change, but it can be slow because of competing priorities for changes in the system. Lastly, there are physicians working at the EHR vendor aiding in design. Giving feedback to them can be helpful as well.
My experience with our Physician Advisory Group was dismal. The vendor frequently said "we can't do that" (which the MDs believed) but what they meant was "we won't do that." I have done a lot of coding (I wrote ComChart EMR www.ComChart.com) and I know the difference between "can't" and "won't".
Very good point. Having the knowledge of what is possible makes a big difference. Some organizations have started using "physician builders" (go through their EMR vendor's course on how to build things in the EMR) can make a big difference in knowing what is possible. Often times analysts think something is not possible, and these physician builders can show them that it is!
Very interesting. I had not heard of this level of outsourcing (including CTO).
Does your C-suite advocate for front line physicians? The opportunity for physicians to have meaningful impact on the EHR deployed in their organization depends on C-level leaders. With their support, physicians can have many opportunities for impact. We redesigned our EHR UI and navigator specific to each specialty after initially being told it couldn't be done. It was so successful that other physicians in our system who were not part of our group began using them once they discovered they were available.
As a healthcare IT company, we are very interested in addressing the widespread frustration that physicians have with their EHRs and using clinician input to design software to improve the charting process.
We don't expect to supplant large EHRs since those systems are so heavily embedded in health systems, but we do see opportunities to build auxiliary tools to provide a better UX for charting and other time intensive activities that are encumbered by the poor design of EHRs.
We'd love to hear any feedback from physicians about the need for these sort of tools as well as any potential interest in collaboration.
I think the lack of physician engagement on this topic is probably a reflection of the fact that the physicians are "burnt out" on health information technology issues and are no longer willing to waste their time discussing a problem they have tried to fix innumerable times, without success.
I personally believe that the problem is a result of the fact that physicians and their organizations (including the AMA, MMS, ACP and others) have allowed the healthcare system to be taken over by corporations who see physicians as vendors.
I too do not believe the current system can be solve unless today's healthcare overlords are replaced by practicing physicians.
This is a good point. As described in the recent article by the moderators of this group, governance decisions made by healthcare organizations often cause physicians to spend more and more time in the EHR.
The most common frustrations we've seen involve too many extraneous required fields, and concern about incomplete reporting leading to 'note bloat' which makes it difficult to find important details in patients' clinical histories.
Having more physicians in leadership will definitely help address some of these issues related to governance, and we'd hope would also provide more opportunity for innovation in this space.
Having a well-optimized EHR is definitely a large step ahead of where most providers are right now, but even the most well implemented version of Epic/Cerner is still a Windows 98-style click-fest.
Many EHRs were originally designed and implemented with revenue cycle functions in mind vs. the impact that they could/would have on patient care. Over the years, I think there has been some progress in leveraging physicians for input into these systems, but we still have a long way to go. That physician input that is being sought today often happens to be that of vendor-employed physicians or physicians in leadership roles (i.e. CMO, CMIOs), which isn't representative of the physicians that are providing patient care full-time (and using these systems all day, everyday). It's those physicians (and clinicians) that should have a key role in the evaluation, selection, and implementation of EHRs to ensure they are successful in the patient care environment.
I hadn't either, Michael! I also think it's an interesting model to consider, but in my experience, there is extreme value in having an internal IT team that is experienced with all IT systems across the organization and the IT staff are able to build relationships with care teams that foster trust and engagement. It continues to surprise me to see IT roles/resources be some of the first cut when we're in a time where technology is leveraged more than ever across the industry.
While each individual physician, or even group, may not have much sway with the behemoth EHR vendors, a unified physician voice through the AMA can enhance the impact and sway ONC to make wide-scale changes through the Certified Electronic Health Record Technology (CEHRT) requirements.
You’re so correct. It should be total engagement on the part of those charged with implementation, unfortunately it does not come with the standard contract with the EHR and often requires extra investments. Often times the superuser providers continue with there day to day office operations, and are asked to much to sacrifice for total engagement.
A best practice for policy makers could be to measure the time costs for compliance with a proposed regulation.
Standard setting organizations could establish it as an organizational best practice for organizations to regularly measure and respond to EHR-use metrics.
Federal policy is a major driver in EHR system design. We continue to highlight that federal reporting requirements (e.g., the Quality Payment Program’s [QPP] Promoting Interoperability measures) are significant determinations in how EHRs look and feel to physicians. Simply put, EHR design is based on federal reporting demands. Program requirements are too focused on physicians reporting use of EHRs as opposed to whether EHRs are useful to physicians and the care they provide to their patients. Unless changes are made, EHRs will continue to burden physicians.
Policymakers can take a variety of steps to make EHRs work better for end users. They could (1) allow for the use of health information technology beyond certified EHRs to count towards the Promoting Interoperability performance category under the QPP; (2) permit reporting by attestation to move to a more outcome-focused care (rather than rely on burdensome numerator/denominator calculations); and (3) leverage EHR vendor-generated information to reduce physician burden and to meet the federal government’s needs to collect data on EHR usage. EHR vendors already track and record many data points used for Promoting Interoperability reporting, so there is no need to continue to use physicians as reporting intermediaries.
Good points Paul. Do you think we are going to see improvements in regulations coming? Where is the certification requirements/program headed?
Great questions! The Centers for Medicare & Medicaid Services (CMS) and the Office of National Coordinator to Health IT (ONC) are both focusing on interoperability and improved patient access to health information as opposed to burdensome, prescriptive data capture, and measurement policies. In the recent proposed rule for the Hospital Inpatient Prospective Payment Systems, CMS proposed only requiring a 90-day reporting period in 2021 for the Promoting Interoperability program, making the reporting for the optional querying of PDMP measure be by attestation, and removing the verifying opioid treatment agreement measure from the program because it was complicated, burdensome, and didn’t promote interoperability. I hope to see similar proposals in the forthcoming physician fee schedule/quality payment program proposed rules. While great steps, in AMA’s comments back to CMS, we highlighted the issues I laid out up above and also responded to the seven RFIs that CMS had on the future of the Promoting Interoperability program.
The recent ONC proposed rule touched upon a variety of topics from updating the 2015 Certified EHR standards to implementing the information blocking provisions of the 21st Century Cures Act that applies to providers, developers (like EHRs), networks, and exchanges. There’s a lot to impact (our comment letter was over 125 pages!) but of relevant note is that we supported ONC’s proposal for certified health IT developers to adopt and implement new requirements around application programing interface (API) design, function, and use. We believe that this will enhance interoperability and reduce implementation complexity and cost.
HHS is mandated in the 21st Century Cures law to establish a goal, develop a strategy, and provide recommendations to reduce EHR-related burdens that affect care delivery. Collectively, we need to keep the pressure on HHS to deliver actionable next steps. healthit.gov/topic/usability-a...
And do current vendors provide it or will this come from new entrants?
A good experience should be "delightful" and surprise the user with ease of use. A good experience should make the user a better doctor or nurse--allow more time for direct face time with patients, more rapid situational awareness, less cognitive workload.
A good EHR experience should enhance the physician-patient interaction, providing the physician with a succinct summary of the patient prior to entering the exam room, including what is unique about that patient, support the physician by anticipating the next question in the history, providing Dx and Rx recommendations, with a user interface that highlights what is important for that patient and that specialty. At the end of the encounter it should provide a progress note and pended orders for the physician to review, dramatically decreasing the data entry burden.
And, it should facilitate team care, allowing all support staff and the patient to enter pertinent information.
With this kind of support, we can dramatically improve the experience for patients, support staff, and physicians alike.
Agree with all of the above from Drs. Sinsky and De Chant. A good EHR experience would be one that is virtually invisible to the patient while facilitating the physician-patient relationship and supporting physicians. It should also help to ensure high quality care by providing nudges, suggestions, decision support that is evidence-based, without being overly intrusive. It should allow the care team to share pertinent data without requiring duplicative data entry.
Agree with Dr De Chant, it is vital that systems be configured to have staff enter pertinent information. In our team-based care model at Bellin, we up train staff to do most EHR work. After working in that world for a few years, it becomes clear that to have physicians do data entry makes absolutely no sense. It is like your CEO taking minutes at meetings. Once the EHR data entry burden is lifted, the great strengths of the EHR emerge - it's incredible ability to gather data that optimizes population health work. The improvements others are talking about here are still really important, to make the EHR wor easier and more intuitive for staff
Dr. Jerzak and Bellin are getting it right. Bureaucrats and administrators have weaponized the EMR to fix a problem most do not understand and can not fix. The core problem is traditional, physician-centric care in the outpatient practices that manage chronic diseases. Most physicians were trained to do it all themselves in under-resourced academic clinics. This approach creates the widely documented waste, backlogs and care gaps, because physicians lack the appointment slots and time to do all of the necessary work this way.
Care teams can reassign about 2/3 of traditional physician work to others, Physicians are then liberated to see more new patients, and solve established patients' problems that they are best equipped to solve. Physicians no longer consume 50% of visits learning that the patient is doing well, while failing to optimally manage those who are not.
The key change that increases practice performance is separate nurse assessment visits to collect and document clinical data and to identify those patients with management needs within disease populations. This re-design increases practice capacity, reduces physician appointment bottlenecks, and provides pro-active care for more patients per physician at a lower per patient cost. Waste, physician shortages, and satisfaction improve.
EMRs are designed to document traditional care encounters for billing; independent simple disease population registries manage work, support improvement, and document team performance at the disease population level.
Physicians must buy into and lead in team building, and others must support them in doing so, especially by seed funding non-physician positions in outpatient practices. Once established, teams are self-funding.
A colleague and I have a book in press, Great Health Care Value: Chronic Diseases, Practice Teams, and Population Management, that describes these advantages based on 25 years of re-design experiences in exceptional practices, such as Bellin.
More clicks, less communication (less time with patients). Lack of control and customization of EHR tools. Unnecessary reminders or alerts (clinically irrelevant, untimely). Frequent and poorly-communicated changes to EHR structure.
It's complicated because there are so many at the surface and below the surface. While many are looking to better user interfaces (and they are needed), it won't solve the whole problem. Government regulation, quality reporting, organizational decisions, etc.
Details are best described in the JAMIA article "The complex case of EHRs: examining the factors impacting the EHR user experience" doi.org/10.1093/jamia/ocz021
I agree there are many. Unintuitive to use. Multiple clicks for simple tasks. Inappropriate alerting distracting from the appropriate ones. Difficulty of users keeping up with changes and being able to take advantage of changes. Organizations not willing or able to provide time for users to learn and personalize their views.
Short answer - no. EHR training is usually short, squeezed into already overloaded schedules, and happens once pre-implementation/go-live. There's also a "one-size fits all" approach, which doesn't account for learning styles, experience levels, or departmental specifics.
A few things that could improve training and set EHR users up for success:
1. Arrange for protected time during normal business hours for users (especially clinicians) to be able to receive training. Often there are reduced schedules for the first few weeks post go-live, but this could be consider pre as well to ensure clinicians have the time they need to be trained properly.
2. Pre-plan for ongoing training to continue to help users expand their knowledge, get more familiar with the system, and enhance their abilities to use the functionality and tailor the system for efficiency.
3. Personalizing the training experience could improve user engagement and ensure individual users are prepared with the knowledge unique to their role/department/etc. Also, by having an understanding of where EHR users are in their experience with tech can help provide tailored training to meet users where they are in the training process.