Re-envisioning Electronic Health Records

Okay, so this “forward looking” image is somewhat self-serving.

Recently I was asked by a colleague, how would I size up current EHR’s: what are the major wins and major needed improvements? In about an hour, and off the top of my head, I wrote this list. It is neither comprehensive nor deeply reasoned. However, it IS a compilation of frustrations and grateful moments that come from having help design, implement and USE an EHR over the past 2 decades.

  1. See Youtube, from a Boston EHR interest group, CRICO: Provocative; I don’t agree with all of it, but it provokes a lot of discussion, see below.
  2. MAJOR win: engaging the patient using the portal: online communication, access to records, Open Notes, Open Results, is just the beginning of a needed improvement in information transparency. Anything that eliminates the telephone tag circus is good.
  3. MAJOR win: having the chart accessible ANYWHERE ANYTIME avoids missing data (medical errors from handoffs of care) and paper filing and paper shuffling costs. As one colleague wrote: PAPER KILLS. In the late 1990’s between 1/3 and 2/3 of patient appointments did NOT have the relevant paper chart pulled in time for me to see the patient. How embarrassing. This no longer happens. Also, our paper filing, despite a team of 50 in medical records, was always 2-3 weeks BEHIND. Even if you DID receive the paper chart, chances were good you did not see the recent report you needed.
  4. MAJOR win: improvements in legibility (sometimes at the cost of unreadability due to note bloat). How many times per day did used to I take a paper chart to a colleague or nurse and ask “what you think this says?”
  5. MAJOR win: easy narrative documentation using Speech Recognition, and increasingly, Natural Language Processing (detecting codified concepts using machine learning). We only just starting to see the fruits of these technologies. A typical physician’s cost for human transcription, per year is about $15,000. And the turnaround time can be days, resulting in missing data during that time. Speech rec is instant. AND NLP has the potential to create instant alerting and reminders.
  6. MAJOR win: reminders and alerts improve the frequency of doing the right thing at the right time more often (when well designed). This is the FLIP SIDE of of Alert Fatigue (see below). I love when my system reminds me to vaccinate, or screen for colon cancer, or screen for depression, particularly when I catch and prevent an illness that I would otherwise have missed.
  7. NEEDED IMPROVEMENT: alert fatigue: poorly designed, terrible signal-to-noise ratio of alerts. Enough has been written about this. Our Physician Informatics Group (PIG: yes, we don’t take ourselves seriously), constantly struggles to improve the SIGNAL to NOISE ratio of these alerts, and to reduce alerting. I consider it a personal failure if we have implement at “Best Practice Alert” that stops a doctor’s work, instead of designing a smarter EHR that “guides” and “nudges” a doctor’s behavior, so that we make the RIGHT THING EASY.
  8. NEEDED IMPROVEMENT: Better ways of capturing physician-patient interaction (see #1), maybe full video recording instead of typing out a history, and having the machine collate into a timeline, concise narrative.
  9. NEEDED IMPROVEMENT: user interface design: (see #1), why can’t the electronics disappear into the wall until it is needed and then pop in with reminders and context-sensitive help just-in-time?
  10. NEEDED IMPROVEMENT: how to eliminate communication barriers and snafu’s based on nurse-physician-patient ping-pong messages.
  11. NEEDED IMPROVEMENT: an appreciation from clinical leaders that an EHR is NOT THE SOLUTION: instead, need to focus on a clinical re-invention that uses an EHR as tool to create better teamwork and communication. How to get that across? Our biggest successes come from clinics that realize this one fact. See previous posts on SPRINT  EHR Sprint team: work hard, persevere, sometimes you get to build a dream team and TRANSFORMATION Politico (and HuffPo): The Doctor of the Future (with stuff about us, and Care Redesign at UCHealth!)

CMIO’s take? Send me a message! What’s missing? What would you take issue with? Let’s craft a message to our EHR vendors and demand innovation and something better. I’m convinced we’re in version 20 of something that will need 50 versions to get right.

Author: CT Lin

CMIO, University of Colorado Health; Professor, University of Colorado School of Medicine

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