Electronic health records (EHRs) have numerous advantages over paper-based records, such as identifying potential medication-related interactions/allergies, facilitating best practice alerts, monitoring for potential adverse events, and supporting retrieval of patient information to aid in clinical decision support, to name a few. EHRs also have the potential to dramatically improve care delivery, quality, and outcomes as the health care industry moves toward an interoperable digital health information system. Nonetheless, barriers exist to achieving this goal in the long term, and a number of hurdles prevent physicians from efficiently capitalizing on the benefits of EHRs today.
The American College of Surgeons (ACS) Division of Advocacy and Health Policy staff has been working with the Office of the National Coordinator for Health Information Technology (ONC) and the Centers for Medicare & Medicaid Services (CMS) to inform these government agencies of ACS members’ concerns and to recommend means of reducing physician burdens associated with EHRs. This article summarizes a number of ACS members’ concerns.
Many ACS members have expressed frustration with the usability of EHRs. EHRs are intended to decrease practice variability, improve system reliability, and ultimately improve quality and patient safety. However, in reality, EHRs often are difficult to use efficiently in a clinically relevant manner and can result in documentation errors. Because of these design failures, many clinicians find themselves relying on automated processes, checkboxes, cut-and-paste options, and templates, which often negate the utility and potential value of EHRs. These workarounds result in notes so voluminous that they make it difficult for clinicians to find relevant information, and in some cases, data needed for patient care is obscured or the note itself is unreadable.
Another central concern is the inability to adapt EHRs to clinical workflow and the needs of a particular practice. EHR systems force clinicians to enter and represent data in a manner that prohibits the provider from making adaptations for specialty or individual practice patterns. An additional challenge for physicians is learning how to use multiple EHR software systems when training as a resident, then in practice in the office, and then when entering data at various hospital affiliates. The expense and education required for software upgrades, especially when the value of the upgrade is unclearly conveyed, is an added burden.
Members also report that compliance with the Health Insurance Portability and Accountability Act (also known as HIPAA) and data security requirements should be more aligned with clinician workflow. The effort of attempting to efficiently move through clinician work as computers time out, requiring the provider to reenter passwords, log on to sub-sites, and toggle between data entry and human interaction, is demanding. Moreover, the number of pop-up screens, some of which are unrelated to surgery, lead to alert fatigue. For example, with some EHRs, surgeons routinely see alerts that the patient needs a colonoscopy or needs to be screened for diabetes, even if a health care professional other than the surgeon provides these services.
Entering data into EHRs is another area of difficulty. For many physicians, this time-consuming process drastically limits time available for direct patient care, resulting in the need to hire medical scribes at extra cost to the practice. To improve ease of entering data into EHRs and also potentially reduce the need for scribes, voice recognition software should be a standard application in EHRs.
Documentation guidelines need modernization
Surgeons report that the CMS documentation guidelines are inefficient in a digital health care environment and have created a number of unnecessary burdens. The CMS evaluation and management (E/M) documentation guidelines, for example, were created after the initial five levels of E/M services came into use. CMS worked with the physician community to create the guidelines to add structure to the various levels of E/M services and a sense of equivalency of E/M services across the multiple clinical specialties. In a digital EHR era, health care providers are more likely to over-document by cutting and pasting, both to increase compliance and to avoid CMS audits.
Consequently, use of EHRs has led to a ballooning of medical records, with large volumes of data to represent complex patients in the clinical decision and impression phases of the documentation guidelines, along with complex treatment plans. This situation illustrates how the E/M documentation guidelines no longer serve the same purpose in a modern digital health care information environment.
The ACS has urged CMS to reconsider what is required to document E/M services. For surgeons in particular, medical decision making is paramount to account for the medical complexity of surgery. The ACS has stressed that the data required for documentation should first align with relevant information for optimal patient care, and the information that CMS needs for reimbursement and audits should be a secondary consideration.
Lack of interoperability
Now that a large number of physicians and facilities are using EHRs, lack of interoperability is another complication. Communication between providers today is difficult because although many practices and health care institutions are using EHRs, some are not. Even within departments of the same institution, different data silos within the EHR system use different formats, fonts, and so on, which create obstacles to communication and data sharing.
Furthermore, surgeons report that when notes are printed or sent from one EHR to another, information can get distorted. For example, not all EHRs identify the history and physical components of documentation in the same manner. Consequently, when a physician sees a note written in one EHR—for example, Epic—shown in a different EHR—for example, Cerner—the order can get rearranged because information stored in Epic’s terminologies and logic does not translate to Cerner’s terminologies and logic. For the information to interoperate between the two systems, the information must be translated into a standard terminology and, at the same time, preserve all the exchanged information’s content and context. The lack of access to interoperable and usable digital information is attributable to the fact that providers spend hours documenting and searching for needed information in an inefficient digital health care environment.
The ACS also notes that interoperability needs to extend beyond EHRs. Today, data liquidity applies to not only a patient’s consolidated medical record, but also to the patient cloud, registries, evidence-based guidelines, clinical-decision support, artificial intelligence, and more. A digital health information system requires creation of digital standards for patient information to smoothly interoperate and be represented in a clinical workflow within and between EHRs and all the locations where patient data reside.
Improving interoperability between prescription drug monitoring programs (PDMPs) also is important to address the opioid epidemic. PDMP access should be as simple as a one-click entry for all EHRs with auto-populated information for each patient. The College also recommends that all hospitals use electronic prescribing for controlled substances. Furthermore, appropriate data encryption should be developed to make it feasible for providers and pharmacists to simultaneously review patient information through an app so that a phone-in prescription would be possible and so that hospitals could avert the expense of fingerprint scanners.
Inability to use EHRs for PA
Although some aspects of the clinical workflow have become automated, prior authorization (PA) remains a manual, paper-based process for many physicians. The exorbitant amount of time and resources practices must devote to PA is due in part to the lack of automated PA processes that integrate with EHR systems. The physician burden that inefficient PA requirements impose represents unnecessarily lost hours of clinical productivity, increased practice costs, and often delayed or interrupted treatment to avoid severe, life-threatening health outcomes. Many patients remain in the hospital while awaiting PA for necessary services or supplies that would allow them to be discharged earlier, putting them at risk for more complications.
To better integrate PA into the clinical workflow and prevent associated patient harm, the ACS recommends that all processes needed to obtain PA for medical services and supplies be incorporated into EHRs. The ACS has encouraged the U.S. Department of Health and Human Services ONC to support leveraged patient and health plan data in EHRs to notify physicians of PA requirements in real time, automate PA decisions for routine services or items, and prepopulate PA documents for cases requiring further review. The use of information already stored in EHRs to complete PA processes could streamline payor-provider communication, improve the accuracy and efficiency of administrative tasks, and ensure the timely provision of care.
Shortcomings of MU program
The CMS EHR Incentive Payment Program, also known as “meaningful use” (MU), is largely credited with rapid adoption of EHRs; however, the program, including its evolution under the Merit-based Incentive Payment System (MIPS), is misguided given its sole focus on EHR functionality rather than more innovative and meaningful applications of technology to harness health care data and use it to improve patient care. The rapid pace of implementing EHR systems discouraged many clinicians and organizations from taking time to consider workflow redesign or even changes to EHRs that would improve usability. Because MU was focused mainly on payment for achieving MU measures rather than leveraging EHRs for better patient care, MU had the effect of moving physicians’ focus away from patients and toward the hospital’s bottom line.
Another problem with MU is the lack of specialty-specific measures and the requirement that some specialties report measures that are outside of their area of expertise. Surgeons are likely to encounter this setback when their nurses are required to laboriously document the following:
- Smoking status, including how long ago the patient quit
- Whether the surgeon has counseled the patient to quit smoking and offered them smoking cessation aids
- If the patient has had an influenza shot this year
- If the patient has had a pneumonia shot
- If the patient lives in an environment that would be considered “safe”
- Whether the patient has recently traveled outside of the continental U.S. and has possibly been exposed to the Lassa virus
These types of questions have little to nothing to do with surgery. Few surgeons offer influenza or pneumonia vaccines, can respond to an unsafe living environment, or can properly treat a patient with the Lassa virus. Most surgical patients already have provided this information to their primary care physician, so for the surgeon to ask again takes time and money, slows the process of patients being seen for a specific surgical problem, and adds volumes of data to the EHR. A solution that the ACS has put forward would be for nonprimary care physicians to document that the patient has a primary care physician who is addressing these important concerns, and MU should only focus on questions that are relevant to the specialty.
The use of EHRs is a leading source of physician burnout. A large national study from the Mayo Clinic found that physician satisfaction with EHRs and computerized physician order entry (CPOE) is generally low. The study also found that physicians who use EHRs and CPOE are less satisfied with the amount of time spent on clerical tasks and are at higher risk for professional burnout, and physicians who use CPOE report higher rates of burnout than those who do not.1 Another feature of EHRs that consumes significant amounts of physician time is e-mail notifications. The volume of inbox notifications makes it difficult to discern between important and irrelevant information.
The ACS has repeatedly heard anecdotally from our members that use of EHRs is a significant disincentive that adds hours to their work day and that entering information into the EHR is usually done from home late at night. Surgeons observe marked increases in the time spent in front of a computer instead of with patients, colleagues, and family and believe EHRs have been a driver of early retirement. The ACS supports the National Academy of Medicine’s approach to studying physician burnout, which examines a range of factors, both external and individual. External factors include sociocultural factors; regulatory, business, and payor environment; organizational factors; and learning/practice environment. Individual factors include the role the clinician plays in delivering health care; personal factors; and skills/abilities.2
In spite of their many benefits, EHRs also may lead to medical errors and patient safety issues.3,4 In 2013, the Institute of Medicine (IOM, now the National Academies of Science, Engineering, and Medicine) released a report that concluded that “[p]oorly designed, implemented, or applied, health IT [information technology] can create new hazards in the already complex delivery of health care…. As health IT products have become more intimately involved in the delivery of care, the potential for health IT-induced medical error, harm, or death has increased significantly.”5 The report cited dosing errors, delays in detection of fatal illnesses, and delayed treatment because of poor human-computer interactions or loss of data as health IT-induced harm that can result in serious injury and death. Another report cited juxtaposition errors, in which users select an item next to the intended choice, such as a wrong patient being selected; desensitization to alerts or alert overload; confusing order option presentations; and system design issues related to poor data organization and display.6 Yet another report, from the National Institute of Standards and Technology, which focused on the interactions between health professionals and EHRs, noted that “[i]n safety-critical environments (e.g., hospitals, emergency departments, etc.), the importance of well-designed, usable interfaces is increased precisely because of the potential for catastrophic outcomes.”7
Although some EHR-related errors can be attributed to lack of user experience or training, poor system design and the failure to account for the realities of clinical practice have been serious and ongoing problems. For example, a study of the usability of CPOE in primary care called for the development of a more consistent and intuitive interface to reduce the risk of prescriptions with incorrect dosages.8 Unfortunately, the current federal EHR certification process is not focused on system safety issues, and no standardized mechanism or incentive is in place for EHR users to share feedback about unresolved safety issues or other concerns with EHRs.
In the report Health IT and Patient Safety: Building Safer Systems for Better Care the IOM concluded that “current market forces are not adequately addressing the potential risks associated with use of health IT.”5 The ACS supports the IOM’s recommendation that “[A]ll stakeholders must coordinate efforts to identify and understand patient safety risks associated with health IT by facilitating the free flow of information, creating a reporting and investigating system for health IT-related deaths, serious injuries, or unsafe conditions, and researching and developing standards and criteria for safe design, implementation, and use of health IT.”5
Tell us your story
The ACS will continue the dialogue and partnership with the ONC and CMS as we work toward solutions to the numerous challenges described in this article. The College recognizes that easing the administrative burdens associated with EHRs is critical to ACS members and to surgical patients. The challenges associated with the use of EHRs today and the impediments to EHRs reaching their full potential as part of a fully interoperable health system in the future are complicated by several factors noted previously.
In addition, despite their many benefits, EHRs have serious unintended consequences that must be addressed before the benefits of EHRs are fully realized, for the health care system to continue to move toward interoperability and value-based care, and, most importantly, to avoid patient harm. To share your experience working with EHRs, contact the ACS at firstname.lastname@example.org.
- Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship between the clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016;91(7):836-848.
- Brigham T, Barden C, Dopp AL, et al. A journey to construct an all-encompassing conceptual model of factors affecting clinician well-being and resilience. National Academy of Medicine. January 29, 2018. Available at: https://nam.edu/wp-content/uploads/2018/01/Journey-to-Construct-Conceptual-Model.pdf. Accessed July 16, 2018.
- Sidorov J. It ain’t necessarily so: The electronic health record and the unlikely prospect of reducing health care costs. Health Aff (Millwood). 2006;25(4):1079-1085.
- Yackel TR, Embi PJ. Unintended errors with EHR-based result management: A case series. J Am Med Inform Assoc. 2010;17(1):104-107.
- Institute of Medicine. Health IT and Patient Safety: Building Safer Systems for Better Care. Washington, DC: National Academies Press; 2012. Available at: www.nap.edu/catalog/13269/health-it-and-patient-safety-building-safer-systems-for-better. Accessed January 24, 2018.
- Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2006;13(5):547-556.
- Lowry SZ, Quinn MT, Ramaiah M, et al. A human factors guide to enhance EHR usability of critical user interactions when supporting pediatric patient care. National Institute of Standards and Technology. Available at: nist.gov/healthcare/usability/upload/NIST-IR-7865.pdf. Accessed January 24, 2018.
- Jäderlund Hagstedt L, Rudebeck CE, Petersson G. Usability of computerised physician order entry in primary care: Assessing ePrescribing with a new evaluation model. Inform Prim Care. 2011;19(3):161-168.