Physicians are being hamstrung by the limits of current electronic health record systems, which are missing valuable opportunities to harness available data and predictive analytics to individualize treatment, while sophisticated advances in technology are going untapped.
That’s the conclusion of three Stanford University School of Medicine researchers who railed against the shortcomings of EHRs in a recent commentary in the Journal of the American Medical Association.
Although EHRs have many virtues, they contend that the systems have “not kept pace with technology widely used to track, synthesize and visualize information in many other domains of modern life.”
Donna Zulman, MD, assistant professor of medicine at Stanford and co-author of the article, believes that EHR systems should be used by physicians to improve clinical care and also maintain what’s fundamentally important—human interaction with the patient sitting in front of them. However, she and her colleagues complain that EHRs today have “clunky” interfaces that are not user-friendly, which only interfere with meaningful doctor-patient communication.
“The spectacular effects of computers in science and in the secular world are not reflected in the EHR, which for physicians remains burdensome, all-consuming and far from intuitive; this is not surprising, when the dominant EHRs are designed for billing and not primarily for ease of use by those who provide care,” states the article. “In fact, a measure of successful EHR evolution may be that physicians spend much less time with the EHR than they do now.”
Faced with “bloated records, devoid of meaning and full of cut-and-paste content,” Zulman and her colleagues recommend adopting a “less is more” strategy that prioritizes relevant information. “What we need to do is be much more strategic about the how EHRs are used at the point of care,” she adds. “We need to find ways to offload those sorts of time-intensive and tedious tasks, while freeing clinicians to be more present with their patients.”
According to the authors, “de-implementing the EHR could actively enhance care in many clinical scenarios” and “simply listening to the history and carefully examining the patient who presents with a focused concern is an important means of avoiding diagnostic error.”
They also lament the fact that EHRs generate a lot of alerts and reminders that are resulting in alert fatigue, which can have negative effects on patient safety as doctors simply block out the noise. They note that other industries have been able to minimize these types of frequent electronic interruptions.
“The airline industry limits pilots’ audible alerts to critical and life-threatening events, and financial software enables users to set investment goals without inundating their inbox at every price fluctuation,” argue the authors. “Better triage of EHR alerts and fewer workflow interruptions are needed so the physician can maintain situational awareness without being distracted.”
“Our intent was to describe the many frustrations that clinicians are experiencing now, but also to illustrate the many potential opportunities that we see for future growth,” says Zulman.
Another serious problem associated with EHR systems is information overload. “There’s a tremendous amount of information,” she observes. “We’re not suggesting that physicians should be turning off the computers.” According to the article, the solution lies in finding better ways to present the data.
“Advances in personal computing and the entertainment industry suggest immense possibilities for more thoughtful and valuable ways of depicting information,” state the authors. “When caring for a patient with a prolonged illness, such as a cancer that requires many cycles of chemotherapy and radiation, a single graphic could capture the clinical course, illustrating physiologic changes corresponding to new medications or acute events. The ability to visualize a patient’s clinical course in this manner could substantially improve physicians’ ability to rapidly synthesize historical events, communicate information to patients and families, and guide clinical decisions.”
At the same time, Zulman and her co-authors would like to see EHRs include social and behavioral factors that they see as critical to a patient’s treatment response and health outcomes.
“In this world of patient portals and electronic tablets, it should be possible to collect from individuals key information about their environment and unique stressors—at home or in the workplace—in the medical record,” they write. “The most sophisticated computerized algorithms, if limited to medical data, may underestimate a patient’s risk (e.g., through ignorance about neighborhood dangers contributing to sedentary behavior and poor nutrition) or recommend suboptimal treatment (e.g., escalating asthma medications for symptoms triggered by second-hand smoke). Advances in this area could provide clinical teams with information to more holistically approach patients’ needs.”
When it comes to personalized medicine, Zulman and her colleagues write that they believe that, despite advances in EHRs and predictive analytics, the technology is not addressing the patient at the individual level.
“While clinicians can calculate a patient’s likelihood of future myocardial infarction, risk of osteoporotic fracture and odds of developing certain cancers, most systems do not integrate these tools in a way that supports tailored treatment decisions based on an individual’s unique characteristics,” assert the authors. “Similarly, some algorithms (many developed by insurers) can identify patients at high risk for hospitalization, but evidence lags when it comes to using predictive analytics to deliver preventive care and services to targeted individuals.”
In addition, EHRs “have yet to seize one of the greatest opportunities of comprehensive record systems—learning from what happened to similar patients and summarizing that experience for the treating physician and the patient.”
With the advent of big data in healthcare, Zulman concludes that this information should be “at the fingertips” of clinicians who can analyze it and leverage the actionable insights for population health management.
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