Introduction
Electronic medical records and electronic health records (EMR and EHR) are digital records of medical information. Electronic medical records are, essentially, digital patient charts which are used by hospitals and clinics to collect notes and data about patients which are then used by providers to inform diagnoses and treatment. Electronic health records are broader than EMR and encompass information from all the healthcare providers involved in a particular patient’s healthcare.[1] EHR can also be shared across platforms between the different medical centers that provide care to a single patient, although the way this is currently carried out leaves much simplicity to be desired. EHR and EMR have been technologies that the US healthcare system was (and to some extent, still is) slow to adopt. In 2009, however, as part of the Health Information and Technology for Economic and Clinical Health (HITECH) Act, the US federal government set aside $27 billion in incentive money that would be awarded to hospitals and other healthcare providers that made the switch to digital health records. While this certainly did cause many US providers to switch to digital records, the money incentive forced this switch to happen nearly overnight. The extremely rapid transfer to EHR and EMR from standard paper records may be to blame for the many issues that these digital platforms are currently experiencing.
Theoretically, EMR and EHR could be extremely powerful for capturing and aggregating mass amounts of patient information and data to illustrate new patterns and trends in public health, diagnostics, and prognoses. However, the US healthcare system has seen less than optimal use of these tools and there is some data which suggests that these electronic tools may even be doing more harm than good. In fact, 70% of the physicians surveyed by a 2014 study responded that “implementing an EHR system was not worth doing” and roughly two thirds of the 1000 physicians involved in the survey said that if they were given the chance to buy it again, they “would not [use] their current EHR system… due to high costs and poor functionality.” [2] In order to fully understand the challenges that digital health records are facing, we must first understand what EMR and EHR are, how they’re currently implemented, and how they impact patient health and other aspects of the healthcare workflow.
Theoretically, EMR and EHR could be extremely powerful for capturing and aggregating mass amounts of patient information and data to illustrate new patterns and trends in public health, diagnostics, and prognoses. However, the US healthcare system has seen less than optimal use of these tools and there is some data which suggests that these electronic tools may even be doing more harm than good. In fact, 70% of the physicians surveyed by a 2014 study responded that “implementing an EHR system was not worth doing” and roughly two thirds of the 1000 physicians involved in the survey said that if they were given the chance to buy it again, they “would not [use] their current EHR system… due to high costs and poor functionality.” [2] In order to fully understand the challenges that digital health records are facing, we must first understand what EMR and EHR are, how they’re currently implemented, and how they impact patient health and other aspects of the healthcare workflow.
How do electronic medical records interact with
and impact patients and providers?
EMR has potential to be useful for a variety of healthcare workers but particularly physicians. EMR makes medical records portable and easy to access and allows medical records to be easily viewed throughout a single medical institution. They also have the potential to be seen by multiple doctors in different clinics around the world in a split of a second and also greatly facilitate the tracing of a patient's medical history. While this technology seems to have a variety of utilities, often times, a patient has different medical records in several different clinics which is where the complications begin. While it would seem that gathering all these records would be far simpler electronically than on paper, many times it becomes a monumental task to accomplish as many of the digital record systems around the country have a difficult time communicating with one another, though the issues that EMR and EHR pose are explored in more depth in the next section.
Ideally, with a detailed medical record of their patients in hand, physicians are able to do more than just diagnosing and treating patients based on current observations. These digital records facilitate the tracking of a patient's health data over time and can greatly reduce the burden put on human personnel for scheduling checkups and administering diagnoses. Physicians should be able to easily check how their patients are doing on certain health indices over time; parameters such as blood sugar, heart rate, and vaccinations ought to be tracked such that abnormalities are easily identified. EHR and EMR could also potentially empower physicians to be able to monitor and improve the overall quality of care within a practice and give guidance to future visits.[3] Despite all the usefulness that electronic health records have to offer, their utility is nowhere near optimization and even still, there are many healthcare providers that have opted out of EHR/EMR adoption.
The barriers associated with the wide adoption of EMR are numerous among physicians. Many healthcare organizations are reluctant towards digital healthcare records due to concerns about the high cost and insufficient return; despite EMR and EHR being touted as efficient ways for clinics and hospitals to cut costs, it has turned out to be financially burdensome for many healthcare organizations. In addition to EMR softwares being pricey, they also require further investments past the initial purchase, with just one such cost being the fact that all healthcare providers within an institution need to receive training to learn to properly use the system. In addition, it is also reported that the technology might be not meeting the needs of rural health centers or federally qualified health centers (FQHC), catering instead to only large healthcare facilities in major urban areas[3]. Let's dive into more of these issues a bit deeper.
Ideally, with a detailed medical record of their patients in hand, physicians are able to do more than just diagnosing and treating patients based on current observations. These digital records facilitate the tracking of a patient's health data over time and can greatly reduce the burden put on human personnel for scheduling checkups and administering diagnoses. Physicians should be able to easily check how their patients are doing on certain health indices over time; parameters such as blood sugar, heart rate, and vaccinations ought to be tracked such that abnormalities are easily identified. EHR and EMR could also potentially empower physicians to be able to monitor and improve the overall quality of care within a practice and give guidance to future visits.[3] Despite all the usefulness that electronic health records have to offer, their utility is nowhere near optimization and even still, there are many healthcare providers that have opted out of EHR/EMR adoption.
The barriers associated with the wide adoption of EMR are numerous among physicians. Many healthcare organizations are reluctant towards digital healthcare records due to concerns about the high cost and insufficient return; despite EMR and EHR being touted as efficient ways for clinics and hospitals to cut costs, it has turned out to be financially burdensome for many healthcare organizations. In addition to EMR softwares being pricey, they also require further investments past the initial purchase, with just one such cost being the fact that all healthcare providers within an institution need to receive training to learn to properly use the system. In addition, it is also reported that the technology might be not meeting the needs of rural health centers or federally qualified health centers (FQHC), catering instead to only large healthcare facilities in major urban areas[3]. Let's dive into more of these issues a bit deeper.
What are the problems with
digital Health Records?
In 2015, the American Medical Informatics Association (AMIA) commissioned a comprehensive investigation of the current status and future directions of EHR in the US.[4] We will begin with a brief summary of this article as it serves as a good place for us to start understanding the challenges facing digital health records. The goals of incorporating EMR in the healthcare system are to increase the accessibility of patients’ data, increase the efficiency in querying and comparing patients’ data, facilitate communication between healthcare providers and physicians and consumers, and support innovation and research that will ultimately benefit patients. Since the HITECH act was announced in 2008, there has been early success in the adoption of EHR systems in improving patients’ health outcomes and healthcare quality which meet some of the expectations of EHR adoption. However, there’s substantial room remaining for improvement in leveraging EHR and thus accomplishing future goals. The adoption of these new technologies and EHR have also brought some unintended consequences that require corresponding risk-mitigating strategies and solutions. The Report of the AMIA EHR-2020 Task Force proposed the future direction of improvement for adoption and revision of the current EHR system from five perspectives with ten different recommendations. The report evaluates the current EHR system in terms of the healthcare givers’ workflow and behaviors for data entry, regulations and incentives for EHR stakeholders to improve the system, and its potential in supporting the innovation in research and development. In the following sections, we will summarize some problems with EHR and review some of the recommended solutions mentioned in the AMIA EHR-2020 Task Force Report.
Issues around documentation
It may be surprising to know that the time physicians spend on documenting the care patients receive has doubled in the past 20 years, especially with the implementation of EHR. Physicians, arguably the most valuable role in the healthcare team, the extended time they devote to documenting and their elongated working hours have impaired not only the quality of care patients receive but also the working quality that physicians experience. The issue of copying/pasting clinical notes from previous documents by physicians increases the risk of medical errors while they are addressing the annoyed documentation tasks. The more attention drawn by entering and looking for the data through electronic devices, the less time doctors are able to spend consulting and communicating with patients which lowers the healthcare quality they are able to deliver.
The recommended solution is to shift the burden of documenting and data entry to other actors along the healthcare process. Much of the information that is created during diagnosis results from laboratory tests but information about a patient's medical history can be captured by other healthcare givers or even patient’s themselves. Furthermore, some information could be effectively captured and stored through devices or information systems automatically. The behavior associated with entering data in combinations with the predefined template that captures data create discrete observation with few narratives that fail to capture the nuances of patients’ unique conditions. The artifact designed to document patient visits should be able to accommodate users’ preferences. At the same time, advances in natural language processing can support the extraction of meaningful information in clinical narratives in a machine-readable format which reduces physicians’ reliance on templates and facilitates the communication between providers.
The recommended solution is to shift the burden of documenting and data entry to other actors along the healthcare process. Much of the information that is created during diagnosis results from laboratory tests but information about a patient's medical history can be captured by other healthcare givers or even patient’s themselves. Furthermore, some information could be effectively captured and stored through devices or information systems automatically. The behavior associated with entering data in combinations with the predefined template that captures data create discrete observation with few narratives that fail to capture the nuances of patients’ unique conditions. The artifact designed to document patient visits should be able to accommodate users’ preferences. At the same time, advances in natural language processing can support the extraction of meaningful information in clinical narratives in a machine-readable format which reduces physicians’ reliance on templates and facilitates the communication between providers.
Issues around regulations, certifications, and transparency
The early years of the EHR Meaningful Use Incentive Program has successfully stimulated the widespread adoption of EHR. However, a 2014 revision of the certification program’s requirements (with the change in vendors and providers) negatively impacted the progression of EHR innovation and improvement. Among the most salient complaints is the overly strict certification requirements which result in diverting vendors attention away from improving quality and safety.
With reasonably flexible, clear, and transparent certification requirements, the certification program would better foster the implementation and improvement of EHR rather than add complexity to the whole supply chain. The certification should have a positive impact on facilitating the improvement in interoperability, clinical quality measures, safety, and security, and these regulations should shift the focus of documentation from billing purposes to patient-center outcome measures. Furthermore, the transparency of both certifications and regulations may result in constructive competition between vendors, empower consumers, and stimulate innovation.
With reasonably flexible, clear, and transparent certification requirements, the certification program would better foster the implementation and improvement of EHR rather than add complexity to the whole supply chain. The certification should have a positive impact on facilitating the improvement in interoperability, clinical quality measures, safety, and security, and these regulations should shift the focus of documentation from billing purposes to patient-center outcome measures. Furthermore, the transparency of both certifications and regulations may result in constructive competition between vendors, empower consumers, and stimulate innovation.
Issues around innovation and
Patient-centered care
As more and more academic centers choose to use EHR provided by commercial vendors, it becomes harder for innovators and researchers to access EHR data because most of these commercial products are closed-source, meaning that the data within is kept safe with high-level encryption that prevents users from modifying or even copying/pasting any and all parts of the coding. If EHR vendors can be more open to both allowing the extraction of data from the system and allowing the interaction between external applications and EMR systems, researchers and innovators will then have the opportunity to utilize valuable information and knowledge lying in the EHR. Although, this is a difficult goal to achieve given that EHR systems contain sensitive patient data that is intentionally kept highly private. Another issue hindering the exchangeability and accessibility of EHR data revolves around data standards and open-source APIs (application programming interfaces). Data standards are crucial for interoperability such that standards allow researchers and, most importantly, machines to have the same common language in communicating and exchanging data. Public APIs can be imagined as the waiters who deliver information between two applications or machines. Public APIs with consensus standards discussed among vendors and researchers would reduce the burden in mapping and facilitating the interoperability for different EHR systems and between EHR and other clinical laboratory machines.
As changes in healthcare span the spectrum from molecular data for precision medicine to population level health data, EHR should also evolve in the same pace. The information covered by EHR should also not be limited to clinical diagnosis, but start to integrate with the social, environmental, and functional contextual patient data that give physicians a sense of patients' living context and experience in assisting the diagnosis.
As changes in healthcare span the spectrum from molecular data for precision medicine to population level health data, EHR should also evolve in the same pace. The information covered by EHR should also not be limited to clinical diagnosis, but start to integrate with the social, environmental, and functional contextual patient data that give physicians a sense of patients' living context and experience in assisting the diagnosis.
our role in solving the problems
Reading the AMIA report that evaluates current EHR problems from five different perspectives encourages thinking about what we can contribute to the improvement for the recognized problems and enact the recommendations in the report from a biomedical informatics perspective. Interestingly, the AMIA biomedical informatician competency constructs come to mind when this problem is approached. It seems that the issue around physicians’ workflow and behaviors regarding the use of health IT, EHR, and design of documentation artifacts are qualitative in terms of social and behavioral science. Much like the study of NLP in extracting information from clinical notes, data standards and public APIs are related to information science and technology, whereas the coverage of personal health data to population and societal data is about health information and science. Overall, there is much to be considered when implementing improvements to EHR but one thing is certain: there are improvements to be made.
WANT TO LEARN MORE?
HERE ARE SOME REFERENCES WE USED TO WRITE THIS ARTICLE
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[1] Alberto Coustasse, DrPH, MD, MBA, MPH; Pete Andresen, MS; Michelle Schussler, MS; Kyle Sowards, MS; and Craig Kimble, PharmD, MBA, MS, BCACP. “Why Physicians Switch Electronic Health Record Vendors.” Perspectives in Health Information Management (Spring 2018): 1-13.
[2] “Electronic Health & Medical Records.” Health IT Buzz EMR vs EHR What Is the Difference Comments, www.healthit.gov/buzz-blog/electronic-health-and-medical-records/emr-vs-ehr-difference.
[3] “Electronic Medical Record Systems.” Electronic Medical Record Systems | AHRQ Digital Healthcare Research: Informing Improvement in Care Quality, Safety, and Efficiency, digital.ahrq.gov/key-topics/electronic-medical-record-systems.
[4] Alberto Coustasse, DrPH, MD, MBA, MPH; Pete Andresen, MS; Michelle Schussler, MS; Kyle Sowards, MS; and Craig Kimble, PharmD, MBA, MS, BCACP. “Why Physicians Switch Electronic Health Record Vendors.” Perspectives in Health Information Management (Spring 2018): 1-13.
[5] Understanding Health Policy: A Clinical Approach. Thomas Bodenheimer, Kevin Grumbach. 7th edition online. McGraw Hill, New York, NY. Accessed April 2020.
[2] “Electronic Health & Medical Records.” Health IT Buzz EMR vs EHR What Is the Difference Comments, www.healthit.gov/buzz-blog/electronic-health-and-medical-records/emr-vs-ehr-difference.
[3] “Electronic Medical Record Systems.” Electronic Medical Record Systems | AHRQ Digital Healthcare Research: Informing Improvement in Care Quality, Safety, and Efficiency, digital.ahrq.gov/key-topics/electronic-medical-record-systems.
[4] Alberto Coustasse, DrPH, MD, MBA, MPH; Pete Andresen, MS; Michelle Schussler, MS; Kyle Sowards, MS; and Craig Kimble, PharmD, MBA, MS, BCACP. “Why Physicians Switch Electronic Health Record Vendors.” Perspectives in Health Information Management (Spring 2018): 1-13.
[5] Understanding Health Policy: A Clinical Approach. Thomas Bodenheimer, Kevin Grumbach. 7th edition online. McGraw Hill, New York, NY. Accessed April 2020.
Personal Perspectives
Oliver |
While I was reading the article, I tried to think about the problem we are facing and the recommendations article proposed to what we have learned so far. I think the implementation of EHR is to solve some parts of the quality and satisfaction problems both for the physicians and patients in the healthcare system. Despite the early success in the widespread use of EHR, it is not surprising that the implementation of EHR will at the same time create new problems that need to be solved. Thus, we as the informaticians are the innovators and researchers to keep the wheel rolling. In the summary of the AMIA report, I categorize the solutions by AMIA competency constructs but how will the recommendations align if we think about the “STEEEP” framework for measuring health care quality improvement? I find out that usually one recommendation will fulfill more than one domain in the framework. For example, the redesign of documentation artifacts will improve the safety issue because it better captures the patient's condition that will assist physicians in diagnosis. The redesign of artifacts also supports the communication between physicians to be more effective and efficient. Another example is the incorporating of molecular and environmental data into EHR which is aligned to the patient-centered domain in the framework. One question I haven’t figured out is how we are supposed to improve the equality aspect of healthcare as informaticians. It seems to me that none of the recommendations mentioned in the report fit the equality domain in the STEEEP framework.
|
Weipeng |
The failure of the EMR system is interesting to me. Although I outlined a number of reasons people refuse to adopt EMR systems, the most important reason might just be EHR is taking the role of EMR. The reason I think the outlined disadvantages are not the most deadly is that these problems exist in almost every medical system, including EHR. However, different from EMR, EHR flourishes in the United States. It seems to me that EHR has a much wider adoption in the United States that EMR. The market of EMR and EHR and highly overlapped. And today, when EHR is already widely used, there doesn't seem to be a place for EMR.
I also thought about the success of EHR and why EHR wins the market over EMR. We know that EMR and EHR both had a similar start point, yet EHR won the market. I think that it is because EHR follows the historical trend correctly. EMR focuses on the internal exchange of information between physicians while EHR takes a step further, involving also patients and laboratories in the information sharing cycle. This might just be the correct direction of healthcare. We used to consider physicians as the absolute center of health care but the success of EHR indicates that both physicians and patients should be considered. Of course, this is already the mainstream view today but seeing it from the history of EMR/EHR is another angle. |
Dakota |
In reading about EHR and EMR it is disappointing but sadly unsurprising that the execution of these digital healthcare platforms is severely lacking. I recall back when I had just moved to Portland, OR for college and was setting up primary care with a new clinic, I experienced many of the difficulties cited in the readings and supplemental articles that we cited. In order to give my new primary care doctor access to my prior medical records, I had to contact each of my 3 offices individually by phone and make a formal request which resulted in... well... nothing. After several weeks, my new doctor still had not received my medical records. Upon inquiring again, one out of the three records managed to make it's way to the new clinics software but the other two were still missing. Contacting them again and talking to numerous administrators in those clinics proved fruitless and I eventually had to request each of these clinics to scan paper copies of the records and email them to me so that I could share them with my new office. Even then, only one of the clinics came through. It turned out that the other provider had left that practice and joined a clinic in another country. Nobody at the clinic was able to tell me how to contact her and I was never actually able to obtain a copy of my patient data from that provider; my new primary care doctor just had to take my word for all the care I was reporting to her.
It is absolutely wild to me that these electronic healthcare records have the potential to be enormously powerful and potentially even save lives but still to this day, the execution leaves much to be desired. If these electronic patient records are designed to save time, money, and lives, why does it seem that they're doing the opposite of that in nearly every case? Surely there must be some hospitals or clinics around the world that have managed to successfully implement intelligent and useful EHR systems so who are they, and what are they doing differently? |