When electronic health records (EHRs) were first rolled out a decade ago, it was hard to see the downsides. Rather than keeping written notes on their patients, doctors would be able to input that information digitally, making it easier to share with other providers. Over the long run, EHRs would spur a data revolution in healthcare, smoothing the patient journey and helping clinicians with their decision-making.
Unfortunately, while EHRs are now a staple part of everyday healthcare, not all their touted benefits have come to pass. Rather than saving time, they have actually added to users’ workload, with many physicians now spending more time on EHRs than they do with patients. This stands in contrast to the pre-EHR era, where paperwork typically consumed less than a third of the doctor’s time.
According to a 2016 study, for every hour of direct clinical face time with patients, physicians spend nearly two additional hours on EHRs and deskwork. A different study, in 2017, found that primary care physicians spend almost six hours on EHR data entry during a typical 11.4 hour workday. And in a poll by Stanford Medicine, half of office-based primary care physicians said using an EHR actually detracts from their clinical effectiveness.
Problems with usability
As Rachel Dunscombe of healthcare IT company KLAS Research explains, interacting with these systems can take a while due to the complexity of the data that needs recording.
“The issue in the US that has been highlighted is clinician burnout, caused at least in part by the systems in some organisations,” she says. “In the US the term ‘pyjama time’ has been used to describe the need for clinicians to key information at home before going to bed in order to manage their workload.”
Dr David Blumenthal, a healthcare policy expert and president of the Commonwealth Fund, adds that there are major issues with usability.
“I think it has to do with the fact that the development of the records occurred without a user-centered approach to their development,” he says. “They were not developed with the same attentiveness to the consumer of the product that is true in many other industries.”
He says that some older physicians and healthcare workers also struggle with problems of familiarity.
“It has to do with whether they have learned to use the record, or whether they’ve had to adapt to it later in their careers,” he says. “For younger physicians and clinicians it’s a much easier process than it is for people whose practices are well established.”
How can they be improved?
In short, EHRs are a time sap. So what can be done to remedy this problem and realise their prospective advantages?
According to a 2018 white paper by Stanford Medicine, there are reasons to believe that EHRs will soon start living up to their promise. This will require some changes in technology and regulation, but it’s possible to imagine a world in which EHRs are ‘populated with little or no effort’.
The paper makes a number of concrete suggestions for alleviating the burden of EHRs. These include investing in adequate EHR training; shifting non-essential data entry to ancillary staff; accepting electronic payments and (for technologists) developing systems in partnership with end users.
Dunscombe remarks that, according to KLAS research, there’s more to the story than simply making the technology more effective. In fact, only 22% of the success factors relate to the tech itself, with the remaining 78% down to hospitals and physicians.
“In a world where almost all EHR vendors have sites that perform really well in terms of satisfaction and quality of care, and also sites that do not perform well, we have looked deeper,” she says. “We have found that the biggest success factor for these systems is good education for clinicians in the right form, of the right length, that embeds the learning.”
She adds that the next most important factor is giving clinicians access to personalisations, and the third is the right organisational governance.
“Hospitals and physicians can do a lot locally to make these systems successful. It requires an investment in time for clinicians to master the systems they work on,” she says. “The systems will, of course, need to continue to mature in usability and other areas – this cannot be ignored – but it is not the major factor in terms of achieving success.”
In essence, this is everyone’s concern and the problems can’t be blamed solely on vendors. MedStar Health, a provider organisation in the Washington area, recently launched a campaign that aims to solve the problems caused by poor EHR usability. The campaign states ‘everybody has responsibilities’, and calls on patients to sign up to patient portals; policymakers to promote safety testing; and technologists to guide user implementation.
Blumenthal feels that, while regulation plays a role in ensuring safety, usability concerns are best left to the market.
“I think the great majority of the responsibility lies with purchasers and providers of EHR services, and the hope is that competitors will arise that will put pressure on EHRs to be more user friendly,” he says. “They need to create user standards that are flexible enough and strong enough to meet the needs of consumers without inhibiting innovation.”
Realising the benefits
None of this is to suggest that EHRs have been a complete disaster story so far. As Blumenthal explains, most of the problems relate solely to efficiency – the records already have many benefits in terms of improving the safety of care.
“Care in American hospitals has never been safer, as judged by national statistics on the occurrence of adverse events in hospitals, and some of the improvement has coincided with the implementation of EHRs,” he says. “This is not to say it’s a proven causal relationship, but there are reasons to believe that EHRs facilitate safety.”
He adds that most physicians already like many aspects of EHRs. To name just three, the records are never lost, they’re remotely available, and they can facilitate coordinated care between different providers, even without making verbal contact.
“The other untapped potential of records has to do with interoperability and the exchange of information across the healthcare system,” he says. “It’s a universal problem in healthcare systems throughout the world that interoperability is hard to accomplish, because it takes time and effort.”
A final untapped benefit, he says, is giving patients access to their own electronic data.
“There’s a very active movement here in the United States to make claims information and EHR information available to patients on their request,” he says. “That may provoke a pretty substantial change in the way healthcare is provided and the balance of autonomy and authority between clinicians and patients.”
Dunscombe feels that patient-provided data – such as data from wearables and other consumer devices – will ultimately be combined with their EHR information to give an accurate snapshot of their wellbeing.
“The future of the EHR is that they will be joined together in future with the citizen lifestyle data to allow them to holistically manage their health,” she says.
It appears, then, that EHRs could have benefits even beyond what was originally envisaged. In the meantime it will fall to hospitals, payers, regulators, technologists and patients to work together, and determine how the challenges can be overridden.