The Promise And Pain Of EHRS

EHRs have provided faster access to patient data and billing information, but workflow disruptions have prevented many providers from realizing efficiency and patient care benefits from the technology.

While the majority of hospitals and doctors — spurred by federal regulations and incentive programs — are now using EHRs, the software systems still present user interface, cost, and interoperability obstacles that are making it difficult for providers to experience the clinical benefits the technology has promised.

As of 2013, according to the ONC, 59 percent of hospitals had adopted an EHR system, a five-fold increase over 2008. Furthermore, the ONC reports that in 2013, eight in 10 physicians were using or planning to adopt an EHR, and 82 percent of EHR adopters were using a Meaningful Use (MU)-enabled solution. However, the majority of those physicians (62 percent) were primarily motivated by incentive payments rather than the software’s capabilities.

In our survey of nearly 170 healthcare providers, it was clear EHRs simplified the process of accessing patient records, but many respondents reported they still struggle with day-to-day use of EHRs. Many clinicians see the EHR as a productivity drain that disrupts clinical workflow, and interoperability among solutions remains a challenge. Likewise, although a record number of hospitals and physicians are now using EHRs, user interface and problems with interoperability have prevented them from realizing anticipated benefits in efficiency and outcome improvements.

“Right now, clinicians are constrained in how they enter data into these systems,” says Dr. Donald Voltz of the Department of Anesthesiology at Aultman Hospital in Canton, OH. “Every system has a different way to document, and the industry has not stepped back to ask, ‘Is there a better way to interact with the solution in the normal workflow that physicians are accustomed to?’ The system should figure out where the information needs to go. Right now, the clinicians have to figure out where to enter data.”

The rapid adoption of these solutions throughout healthcare could potentially help providers increase visibility into patients’ records and address the challenges of improving the quality of care and care coordination, as well as reducing certain administrative challenges. To fulfill that promise, many of the providers we surveyed feel fundamental changes to how EHRs work need to be made.

EHRs Provide Data Access, Billing Improvements
The majority of respondents (55.88 percent) to our survey represented a hospital or IDN, 15.88 percent represented a group practice, 5.89 percent represented a long-term care provider or home health provider, and the vast majority of the remaining 22.35 percent were either in private practice or identified themselves by specialty.

The biggest single strength of EHRs, by far, was their allowing quick and simultaneous access to patient records — 38 percent listed improved records access as a key benefit. Electronically capturing data for billing purposes was second at 12.43 percent.

“When I’ve talked to doctors about these issues, they actually like EHRs and even enjoy using them,” Voltz says. “They see the potential of these solutions. We just need to find ways to address some of the complexity issues that affect workflows.”

Other benefits, such as improving quality of care, simplifying data exchange, reducing paperwork, or streamlining clinical ordering processes, were each cited as an EHR’s biggest strengths by less than seven percent of respondents. One key commonly touted benefit of EHRs, reducing medical errors, was cited as a strength by only 3.55 percent of respondents.

In other words, some of the key benefits of EHRs are not necessarily emerging at hospitals and practices that have deployed them, in part because of interoperability challenges.

At Girgis Family Medicine in South River, NJ, for example, there were issues in getting the patient portal to go live. “Our website and EHR system simply were not able to create an interface, and we had to change Web hosts after 12 months of struggling,” says Dr. Linda Girgis, practice owner. “Many vendors are not willing to work together to create interfaces, and this creates problems.”

EHRs provide access to large amounts of valuable patient data, but easily parsing and viewing the data in a way that is useful can be challenging in some systems. According to Voltz, most EHRs provide limited customization options, and there is no way to tailor the types of information clinicians view regarding day-to-day care of the patient.

“There is a great deal of data coming to us, but it is out of context, and there’s very little consistency in how the data is presented,” Voltz says. “One of the big disruptions in our workflow is that we are required to search for information manually, and we have little insight if a piece of information is missing or might be contained somewhere else in the system.”

The data presented to patients is likewise presented out of context. “Most facilities with MU have implemented a single-vendor system, and you are pretty tied to whatever that vendor brings to the table with respect to patient engagement,” Voltz says. “You can give the patient access, but the data in isolation will be difficult for them to understand. The customization available is minuscule compared to what we need. I can’t design a data representation or access solution that would best engage the patients.”

So although electronic records have made it easier to access chart data, the types of efficiency and visibility clinicians hoped would come with EHR adoption is not always apparent.

EHRs Cause Workflow Disruptions
There has been a shift in perceived EHR weaknesses since our last survey. In 2014, the top weakness cited by respondents was the lack of interoperability/ integration with other solutions (30.4 percent of respondents), followed by clinical workflow disruptions (28.6 percent) and overall cost and expense (12.6 percent).

In this year’s data, clinical workflow disruptions topped the list, but with a smaller percentage (24.7) of respondents. Interoperability issues dropped to second place (20.6 percent), and cost and expense concerns stayed third but increased from 12.6 to 18.2 percent of respondents.

Clinical workflow issues are a common complaint. For physicians used to dictating notes, entering information on multiple screens or having to switch between different applications can be a drain on productivity.

“An EHR should match a doctor’s workflow,” Girgis says. “When I see a patient, I don’t need to see all their demographic information. That just takes up space and can be left on another screen rather than the encounter note. Vital signs should be on the same screen, as well as a problem list and medication list. Also, it would be helpful to be able to e-prescribe directly from the medication list, which should be displayed on the encounter note page.”

Thomas Jefferson University Hospital in Philadelphia is in the process of migrating its EHR platform to a new solution, in part because of these workflow and usability issues. Andrew Miller, associate CMO at Thomas Jefferson’s Methodist Division, says he hopes to see an improvement in user friendliness when it comes to order entry and entering daily notes. “EHRs could also be much more institution friendly when it comes to extraction and manipulation of data for research or population health measures,” he says.

Miller thinks voice or speech-to-text capabilities could potentially improve the interface. Being able to enter information with fewer clicks is another improvement he’d like to see, in addition to making it easier to move back and forth between old and new records within the application. As other respondents indicated, switching back and forth between screens can bog down data entry for clinicians.

According to Girgis, the documentation requirements associated with MU remain an underlying problem that has exacerbated the poorly designed interfaces. “The amount of documentation required to comply with this program is quite onerous and actually meaningless for many physicians,” she says. “I think it is time for those forcing the MU requirements on us to actually sit down and talk with front-line doctors so they know what is truly meaningful for improved patient outcomes. The rest is just mindless data recording that I tend to leave until the end of the day.”

Another thing Girgis would like to see is a way to automatically capture some of that MU data that wouldn’t require manual data entry.

Integrating data from different EHR solutions remains a function falling largely on providers because software vendors haven’t developed solutions that can easily exchange data. “EHR solutions are not uniform in the U.S., and I think even the largest vendors struggle with interoperability issues,” Miller says. “If you are in a large metro area, not everyone is going to be on the same system. If a patient comes across town, you may not be able to communicate very easily with the VA system, for example.”

“Without interoperability, the whole push for EHR and MU breaks down,” Girgis adds. “Hospitals in our area cannot interface with our EHR. We have to go to so many sites to download reports and upload them into the EHR that it is much easier just to receive a fax and scan it in.”

Voltz cautions that simply being able to exchange data is only half the problem. “The problem with interoperability is that we reduce everything down to the data and assume that the same data is going to lead to the same conclusions everywhere,” Voltz says. “The use of the data is even more important. It’s the interpretation of that data and making sense of it as it flows across the continuum of care.”

Providing automated messaging and communication capabilities would help, and eliminating the manual processes that clinicians have to undertake to search for data would add even more value.

“For that to work, documentation has to change,” Voltz says. “There are systems that don’t allow physicians to put in the note for a follow-up. They are designed around coding and taxonomy. We need to be able to see the interpretations of this data to flesh out their meaning as the patient progresses, so that another professional can see those interpretations. That doesn’t happen right now with many EHR systems.”

Although workflow and interoperability complaints top the list, the percentage of respondents citing those items as weaknesses has declined as vendors work to address their concerns. Costs, and not just the upfront software purchase, have become an issue for more providers than in last year’s survey.

In addition to the initial purchase, there is also staff training, maintenance, ongoing support and upgrade costs, and the cost of downtime during the implementation to deal with. “Organizations were enticed by reimbursements to install these solutions, and nobody realized how high maintenance and upgrade costs would be,” Voltz says. “If you ask a lot of hospitals if they’d consider changing systems if they found something better, I have a feeling a lot of them would tell you they can’t afford to rip and replace at this point.”

That leads to a significant amount of manual workarounds in the background to maintain the performance of EHRs that are not otherwise performing to expectations. Other common complaints such as privacy risks, poor patient identification, alert fatigue, or increased medical errors were cited as weaknesses by less than four percent of respondents.

Users Want Streamlined Data Entry, Standardized Systems
When it comes to improvements providers want to see, usability again topped the list. Requiring fewer clicks and less clinician data entry was the most required change cited by 30.6 percent of respondents. Twenty-two-and-a-half percent wanted to see more interoperable solutions based on open data or unified standards. Interestingly, only 10.65 percent of survey respondents said the change they’d most like to see would be a reduction in cost.

While other items were cited by six percent or fewer of respondents, they still indicate some of the deficiencies in current solutions, including vendor support, mobile capabilities, stronger security protocols, transparency and patient interaction, or the inclusion of a true patient identifier.

Some clinicians think reducing mouse clicks or adding voice capabilities would ease the data entry burden, but Voltz feels the underlying problems would still remain. “It doesn’t matter how we enter data. We don’t know what the best way to electronically enter information is yet,” he says. “That doesn’t matter until we have an interface that allows us to interact across all of the different EHRs.”

Upgrades are an issue Miller would like to see improved. “I’d like to see more ideal servicing and updates of the software,” Miller says. “We need updates that are more seamless and less disruptive and that result in less downtime.”

Voltz has been pushing for more open systems that would allow third-party developers to create middleware products to help improve the way that clinicians interface with EHRs. “It would allow platform development that would meet the needs of clinicians as well as other stakeholders such as the administrative side or for government reporting agencies,” Voltz says.

The American Medical Informatics Association EHR 2020 Task Force in its 2015 report also emphasized greater openness and transparency to allow for more innovation in the EHR space. That would allow developers to create new software that would connect to multiple EHRs and provide the types of data entry, access, and utilization improvements that they seem to want.

“Right now, we’re constrained by what the individual vendors allow in their systems,” Voltz says. “If we can distribute this type of middleware solution across EHRs, that’s when we will see a return on investment in these platforms. I think we’ll get there.”