A presentation focused on the "next phase" of EHR use, which involves optimizing usability and utility across the clinical enterprise

1. EHR “v2.0”: Optimizing
Usability and Utility
Michael Hogarth, MD, FACMI, FACP
Clinical Research Information Officer, and
Director of Biomedical Informatics, Altman
Clinical Translational Research Institute
University of California San Diego Health

2. Challenges with current EHRs
• EHRs are a source of clinician dissatisfaction
– Is there a ‘perfect’ EHR?
• Understanding the source of frustration –
assessing and improving usability
– Measuring use: Clicks, notes, time in the system
– Optimizing usability
• Interoperability was done to satisfy
regulatory requirements in HI-TECH
– Data exchange between EHRs is far from ‘good’
• EHR Optimization is expensive
– Continuous training
– Optimization “sprint teams”

3. Is there a problem with EHRs Today?

4. Physicians are not the only ones dissatisfied!

5. Can EHRs Have an Impact on Physician Satisfaction?

6. EHRs and Professional Satisfaction
Mayo Clinic Proceedings 2016 91, 836-848DOI: (10.1016/j.mayocp.2016.05.007)

7. 2014 American Academy of Family Practice Survey
73% would not
purchase the EHR
system they had
– they are all
dissatisfactory

8. 2013 RAND/AMA Study
• Multiple factors, in combination, determine
“physician satisfaction”
• Surveyed 30 practices across 6 states (small:
<9; medium 9-49; large:>50)
• 28/30 had an Electronic Health Record
system; 14 different products
• 108 in-person interviews, 447 written
responses
• Did not initially include the adoption of an
EHR by the practice as a contributing factor,
but after the first 6 practices, they included
EHR use.

9. An Important Point: Physician Satisfaction is a
*balance* of multiple factors – the EHR is just one

10. Key Drivers of EHR Dissatisfaction
• 9 Key Drivers of physician dissatisfaction with EHRs
1. Time-consuming, cumbersome data entry
2. User interfaces do not match the workflow in the practice
3. The computer interfered with face-to-face patient care
4. Insufficient health information exchange with other systems
with patient data
5. Information overload
6. Mismatch between meaningful use criteria and clinical practice
7. EHRs threatened practice finances
8. EHRs required physicians to perform lower-skilled work
9. “Template” notes degrade clinical documentation quality

11. Why?

12. An unrelenting *fact*:
EHRs must deliver/source a lot of information!

13. As a result, EHRs user interfaces are complex

14. Why are EHR user interfaces so complicated?
• There are hundreds of things (actions) the system must allow a user to perform
• Physician adoption is improved if the systems adapt to their workflow
• Physicians have their own workflows – so one must provide ”many choices” at
each screen so you can jump to the point in the workflow you want
https://uxpa.org/jus/article/usability-electronic-medical-records

15. The American Journal of Emergency Medicine 2013 31, 1591-1594DOI: (10.1016/j.ajem.2013.06.028)
EHR Workflows Require Many Clicks:
4,000 mouse clicks in an ER shift (10hrs)
ED practitioner overall time allocation

16. The financial impact of “clicking”
$223/hour x 400hours = we are paying $89,200 per ED
physician annually for them to click!!

17. A US-specific challenge – The burden of lengthy documentation

18. Primary Care Doctors spending more time with EHRs that with patients

19. Another Issue: Doctors find computers ‘dehumanize’ the
relationship with patients – and they have a good point…

20. Should one really give up on EHRs and go back to paper??

21. EHRs with CPOE Improve Safety

22. EHRs do have an overall benefit to patients and the healthcare
delivery process… but not much for the clinician
https://www.healthaffairs.org/doi/10.1377/hlthaff.2011.0178

23. Situational Awareness – another benefit from having EHRs
“You can’t improve it if you can’t measure it” (W. Deming)

24. Should you “Rip and Replace” your EHR?

25. Costs Associated with “Rip&Replace”
• Loss of productivity - $$$
• Data migration from previous EHR - $$$$
• Can you ‘rip/replace’ all at once or do you need legacy access - $$
• Re-implementation of any integrations - $$$
• Replacing hardware (often) -$
• Unanticipated costs – 20% of the total budget.

26. Are you really getting something better?
https://healthitanalytics.com/news/can-big-data-analytics-data-governance-restore-joy-to-medicine

27. Should you consider using multiple EHRs?
• Benefits:
– Perceived flexibility by providers
– “best of breed”
• Challenges:
– More difficult to standardize
processes/workflows to improve patient
safety
– Viewing integrated data is difficult – hard to
characterize practice trends/metrics across
both EHRs
– Must have helpdesk that has an in-depth
knowledge of all the EHRs being used
– Training materials are more expensive and
difficult to maintain – 100% increase per EHR

28. Optimizing the EHR Experience
• 3 Key Initiatives to improve EHR
experience
– Redistribute tasks to the healthcare
team, including patients
• integrated questionnaires – physicians
are reviewing not entering it
themselves
– Refine workflows in the EHR with the
goal to limit clicks
• Maximize the use of dictation-to-
transcription and voice recognition
• Narrative text can be processed enough
with NLP for meaningful data used in
metrics
– EHR training and workflow coaching
• Track clicks by providers and
improve/optimize their use of the HER
• ”home by 7” program

29. Optimization “Sprints”
• Sprint intervention
– Trained clinicians 1-on-1 on
existing EHR features
– Redesign workflow within the
clinic to optimize use of EHR
– Build new specialty-specific
EHR tools
– 186 providers so far
• Sprint team
– 1 physician
– 4 EHR trainers
– 4 EHR analysts
NPS = Net Promoter Score

30. How about Health IT in other countries?

31. A Fundamental Problem with Today’s EHRs
• Electronic Health Record systems today
have been designed to only replace a
paper chart
(only created a digitized paper chart)
• The US EHR design has to also optimize
support for revenue capture/claims
(billing)
• The Result:
Prevailing commercial EHRs today have
not been designed to primarily
*facilitate* good medical practice….

32. Key takeaways
1) Today’s EHRs are only replacements for paper records
– They do not primarily “facilitate” medical practice
– They are primarily focused on clerical tasks, which now physicians perform
– Increased documentation burden
2) Dissatisfaction with computerized medical records is common (and predictable)
among physicians
– EHRs today do not “assist” physicians – they increase work without much value
– EHR user interfaces must be complex due to the nature of what they must provide and the variation
in workflow required for acceptance
– Train,train,train – EHR training is a key to optimizing the use of the EHR
3) Physician practice satisfaction in due to multiple factors – the EHR is a factor but not
the only one
– Obstacles to providing high quality care was a major source of dissatisfaction
– Autonomy, control over pace were factors in satisfaction
– EHR optimization can improve satisfaction – Sprint teams targeting specific practices.

33. Where we need to go:
EHRs need to evolve to ”EHR 2.0”
• Next generation EHRs need to:
– Focus on user experience (UX)
– Reduce focus on “billing” and required documentation
– Become *assistive technology* for the practice of medicine
• ”smart” aggregation of relevant data for the case at hand (minimize
information foraging in the chart)
• Interoperability to gain access to other records on the patient
– Automated seeking of external data from other EHRs with records on the patient at
hand
• Support medical decision making in an intuitive and unitrusive fashion

34. Q&A
Lake Tenaya, Yosemite National Park
https://en.wikipedia.org/wiki/Tenaya_Lake