Electronic health record (EHR) systems have increased rather than decreased workloads, contributed to physician burnout, and returned little back to patients in improved healthcare quality, according to Penn Medicine’s Center for Health Care Innovation. However, researchers there say these systems can be reconfigured to achieve their original promises of efficiency.
For example, they say, today’s EHRs just replicate previous pen and paper records. But they can be restructured into platforms that allow doctors to “subscribe” to their patients’ clinical information to receive real-time updates when action is required, like social media feeds and notifications.
“When the first movies were made, they were really just plays made permanent on film. It took time before film editing and special effects turned the two-dimensional images on the screen into something more immersive than what could be performed on stage,” said senior author David A. Asch, MD, MBA, executive director of the Center for Health Care Innovation.
“Current EHRs haven’t taken the step they need to. They are still just putting plays on film,” Ash said. “Healthcare is suffering today in part because health records haven’t yet made the transformation that nearly all other industries have achieved as they have gone digital.”
“The same doctors who, on their way into work, are getting news feeds on their favorite sports teams still have to ‘go to the chart’ to check up on their patients,” said Katherine Choi, MD, a clinical innovation manager at the Center for Health Care Innovation. “If you can subscribe to feeds about a football team, why can’t you subscribe to Mrs. Jones in room 328?”
The researchers point to several examples implemented in the University of Pennsylvania Health System that reveal how record systems can be reconfigured into subscription services. For example, receiving patient information could depend less on physicians remembering to search the chart.
For safety reasons, Penn established automatic expiration dates for antibiotics and antiepileptics for inpatients, but the system initially required physicians to remember when to renew the expiring prescriptions. As a result, medications weren’t ordered 10% of the time because physicians didn’t check the chart in time or notice the need for renewal.
To address this, Penn developed a web application that, among other features, allowed residents to receive push notifications on their mobile devices. As a result, the number of missed renewals dropped by a third, and providers were relieved to have one more checklist item taken off their minds, the researchers said.
“When your record systems require that physicians go to the chart to learn important information, you are relying on the hope that they get there on time, see what they need to see, and then do what they need to do,” said Yevgeniy Gitelman, MD, a clinical informatics manager at the Center for Health Care Innovation. “You’re just creating opportunities for error and delay.”
“We need to move beyond passive engagement with the medical record to the approach people expect in other parts of their lives—that important information comes to them,” Choi said.
These push notifications, which are sent using a HIPAA-complaint messaging platform, can also shorten the lag time between when information becomes available and when it’s used. Not all information needs to be known as soon as it is available, though. The push notification services also can filter what’s important and relevant, reducing the risk of alert fatigue.
“And not everyone needs to know everything at the same time,” said Choi. “Of course, the primary team may be concerned with the whole picture, but the renal doctors only need to act on specific alerts relevant to the kidney function and only the important changes in that. Reimagining EHRs so that they are no longer only charts but are now seen as subscription services allows for the selective filtering of information.”
“When I read the newspaper, which I do in its digital form, I go for the top stories and the editorials,” Asch said. “I browse through the obituaries when I have the time. I completely skip the automotive section. In fact, the top stories are pushed to me without going to find them. Yet, we’ve been treating the electronic health record as a communal trough of information that we all have to sift through when we don’t do that in any other part of our lives.”
Beyond one-off intervention alerts, these notifications can manage panels of both inpatients and outpatients. One Penn program monitored the 30 patients with the highest use of care in one of its hospitals, using a dashboard to follow their needs, such as the best way to communicate with them, engage with their family, and next steps for setting up social services.
The multidisciplinary team covering the patients was automatically alerted to a patient’s arrival in the emergency room and pointed to the action plan in real time. One year after implementation, 30-day readmissions and total days in the hospital for this group of patients decreased by 67% and 56%, respectively.
The previous strategy of managing clinical data as static files that need to be retrieved only places outdated, unnecessary burdens on physicians, the researchers said, noting that most electronic systems and healthcare organizations have yet to make the shift.
The study was published by The New England Journal of Medicine.