EHRs in 2019: Still a source of frustration, but getting better bit by bit

For years now, health IT professionals have been speaking of the post-EHR era. And indeed, for most hospitals and health systems, that's where they are.

The basic blocking and tackling of electronic health record implementation now behind them, they've pivoted toward a future of advanced analytics, population health, telemedicine, connected devices and artificial intelligence.

Nonetheless, EHRs are still here. And, for many clinicians, they're a daily annoyance – a reminder that, for all its potential to improve quality and improve safety, health information technology can also contribute to frustrating workflow impediments, alert fatigue and burnout.

But EHRs are not the enemy. Or shouldn't be, at least, as long as they're designed and deployed correctly.

The EHR may have become the "epithet to hang everything on," as HIMSS Chief Clinical Officer Dr. Charles Alessi noted earlier this year, but rampant dissatisfaction among so many clinicians has a wide array of contributing factors.

The epidemic of clinician burnout has lots to do with suboptimal user experience yes. A recent Mayo Clinic study has shown some strong correlations between those two phenomena.

But it also stems from onerous federal documentation requirements, the pains of prior authorization malpractice fears and more. Ultimately, said Alessi, it's about "loss of control."

Luckily, efforts were afoot in 2019 to both to improve EHRs themselves and help give back a sense of control and ownership to the physicians and nurses who have to use the technology every day.

A study published in the Journal of Clinical Informatics this spring from KLAS' Arch Collaborative polled more than 72,000 clinicians at more than 150 hospitals and health systems nationwide about their EHR use and experience.

The topline findings were unsurprising: "Despite decades of effort and billions of dollars of investment, the EHR has not lived up to its potential to improve care, reduce costs, or revolutionize the experience for caregivers."

But UX is only part of the problem, and not the biggest. Arch Collaborative researchers found "critical gaps in users' understanding of how to optimize their EHR."

Despite some clinicians' ingenuity at coming up with creative (but perhaps not quite safe) workarounds to deal with EHRs' limitation, most still could use some education on how to make the software work better for them.

"We as an industry have an opportunity to improve EHR adoption by investing in EHR learning and personalization support for caregivers," researchers said. "If health care organizations offered higher-quality educational opportunities for their care providers – and if providers were expected to develop greater mastery of EHR functionality – many of the current EHR challenges would be ameliorated."

The fixes can be large: This year the American Medical Association announced its new Practice Transformation Initiative, designed to help fill some of those knowledge gaps and  evidence-based best practices. Participating health systems will use validated assessment tools to field test workflow improvement tools, applying research methodology to evaluate their impact and sharing best practices within an AMA-facilitated learning community.

Or they can be small: One 2019 study from Health Affairs discovered that tweaks to EHR messaging– new strategies for managing how in-basket alerts are generated and presented, could go a long way toward boosting job satisfaction for frontline staff.

'How do we make it better?'

In 2019, EHR vendors also showed that they're paying more attention to the key role they play in all of this. Epic and Cerner continued to lead the pack in market share, and leaders from both those companies evinced a growing sense of responsibility for designing their products in a way that will address clinician burnout.

At HIMSS19 in Orlando this February, Healthcare IT News interviewed Epic CEO Judy Faulkner. She pointed to the KLAS/Arch Collaborative research mentioned above as evidence that EHR dissatisfaction doesn't correlate as tightly with clinician burnout as some say.

"KLAS asked physicians two questions, among others," said Faulkner. "One was, how much you like your job? One was, how much you like the electronic health record? And what they found was that there are a lot of people who were satisfied with their job, and who liked the electronic health record. And a lot of people who were satisfied with their job but didn't like the EHR. A lot of people who weren't satisfied with their job but did like (the EHR). And by far the smallest number was those who didn't like both. And from that, they concluded that there isn't a whole lot of correlation. There's a little bit, but not a whole lot."

That said, Faulkner noted that at Epic, "the need to constantly be working on how to make it as wonderful as possible for physicians is there. And we keep working on that all the time. We send our programmers out to customer sites all over the U.S. ... to see, how can our software do better? How do we make it better? How do we get feedback from them? Those are called immersion trips, and all of our programmers do that."

Cerner too highlighted new investments in usability and UX at HIMSS19 – many of the new features designed to improve clinicians satisfaction with help from AI.

"Cerner has set out to make the physician experience easier with our AI technology," said Dr. Jeffrey Wall, director and physician strategy executive at Cerner. "Some physicians express feelings of fatigue, frustration and disempowerment."

The vendor has been innovating uses of analytics and real-time feedback to continuously optimize systems for a more person-centered user experience, he said.

"With hundreds of millions invested in research and development, we’re evolving the EHR to deliver a more personalized and intuitive design," Wall said. "Continued investment in AI-enabled workflows, machine learning solutions and natural language processing are key ways we’re committed to ensuring the EHR remains a tool that helps physicians do their jobs and deliver the best care."

Indeed, AI looks to be a major way forward for improved EHR usability.

Earlier this year, Mayo Clinic CIO Cris Ross gave a speech at Health 2.0 in which he assured the audience that "This artificial intelligence stuff is real." He touted "small AI and big AI" tools that, applied deliberately and judiciously across clinical workflows, can help revamp existing IT systems to improve the experience of clinicians.

That's already happening at health systems such as Vanderbilt, which has developed a voice assistant for its EHRs that can give verbal summaries back to providers using natural language processing. VEVA – the Vanderbilt EHR Voice Assistant– uses natural language processing from Nuance to help interpret voice requests, and HL7's SMART on FHIR standard to pull pertinent data and provide relevant summaries.

And at Northwell Health, a longtime customer of Allscripts, that vendor is helping co-develop a new AI-powered EHR: a cloud-hosted, voice-enabled system, designed and built with close input from clinicians and IT staff, that's being billed as a next-generation electronic health record.