User-Focused EHR Design Needed to Drive Care Improvement

According to an article published in JAMIA, future EHR systems must become more user-focused to enable providers to deliver improved care.

A panel sponsored by the American College of Medical Informatics (ACMI) at the 2021 AMIA Symposium addressed the question: “Are Electronic Health Records dumbing down clinicians?” The panel gave examples of how EHR use can worsen clinicians’ performances along with important benefits.

One clinician-panelist noted that end-users are hesitant to question clinical decision support from EHR platforms. Too many false positive alerts can limit clinicians’ abilities to respond to rare critical alerts.

Another panelist detailed the adverse effects of EHR use on nurses. A concern is that EHR use obscures the nursing narrative about each patient.

“Current EHRs emphasize and encourage nurses to enter data via flowsheets which contain hundreds of data entry cells which are time-consuming to complete, require significant scrolling, may not be relevant to the current patient, and do not easily summarize the overall, coherent story of what happened,” the JAMIA authors wrote.

Another burdensome aspect of nursing EHR documentation discussed by panelists is the excessive number of reminders, many of which are unnecessary. Of 739,000 interruptive EHR-generated alerts at one institution over three months, only 4 percent were considered valid.

The panelists also noted that a long-lasting adverse EHR effect on clinicians is less detailed documentation. Two authors said that a decades-old, standalone diagnostic aid used previously at their institution contained 1,800 possible descriptors for history and physical examination (H&P) findings.

A 2017 analysis of the H&P note templates at the same organization revealed that the templates facilitated the entry of a maximum of 360 possible descriptors, suggesting that exam results were less detailed.

“Although clinicians could painstakingly add information, those additions would be hidden from subsequent routine view by default and would require extra effort to uncover or reuse,” the authors wrote.

“This trend produces clinical documents with less information granularity potentially lacking the richness necessary for clinician-users to fully understand what is happening with their patients,” they continued.

Proposed improvements to EHRs fell into four categories:

• Institutional and end-user readiness and competency
• EHR design and capabilities
• Regulatory policies and closer healthcare system-vendor partnerships
• Decoupling clinical documentation from billing and regulatory requirements so that clinical notes contain only the information necessary to care for the patient.

The panelists suggested that a wide range of stakeholders must design and revise future EHR systems, including healthcare providers, informaticians, educators, health system operations, EHR vendors, and policymakers like ONC.

“Greater readiness and competency for future EHR users includes better EHR training,” the authors noted. “Simulations can play a key role. For example, teaching about EHR downtimes using simulations could be critical in preparing for actual events, especially with more frequent prolonged downtimes hospital ransomware attacks increase.”

Additionally, EHRs need improved documentation tools, the panelists said. Academic researchers could also develop metrics to demonstrate the efficiency and breadth of clinical documentation.

“Ultimately, EHRs must have more efficient mechanisms for data capture and extraction,” the authors wrote. “Several prototypes now exist whereby patient records are created unobtrusively as a byproduct of care delivery.”