Electronic Health Records: A Radical Shift Beginning to Realize a Much Broader Promise
The conversion of paper medical charts to digital has been a massive effort over the past 10 to 15 years. The energy has led to the creation of an integrated patient record with every bit of information needed to provide diagnosis treatment and prevention while allowing full access of information to the patient. In this process EHR companies have been criticized for not being on the fore front of innovation. But this is far from the truth. Many radical shifts in technology have led to unforeseen downstream effects. Examples include the internet which enabled ecommerce, electric cars enabling self-automation, and the iPhone allowing complex computations with apps. The electronic health record (EHR) is a radical shift that is beginning to realize it’s promise, particularly in four key areas: data supporting care improvement, data supporting diagnostics, treatment, and discovery, usability, and interoperability.
Data that Supports Care
EHR companies, which had been focused on making sure EHR systems were populated with all the clinical data needed for patient care, now can build systems that allow the data to be extracted in ways to improve care at the point it is delivered. But for the companies to assist managers of provider organizations in building real-time information flow systems, managers must first define their organization's data needs.
The EHR contains a lot of point-of-care-data, but this must be organized in a fashion that allows caregivers to make fast, accurate decisions in real time to improve care processes quickly. For instance, Morningside Mount Sinai (MMS) in New York City built a data command center in spring 2020 that transformed how staff saw Covid-19 patients. MMS managers worked with EHR programmers to create a digital display in a large meeting room so that managers could see, minute by minute, information on the status and location of Covid-19-positive patients as well as those under investigation for possible infection. (Reference NEJM Catalyst article)
This information provided immediate insight into the need for additional beds, locations of possible infectious outbreaks, and areas where staff might be overly stressed. Other information included deaths, discharges, and movement of patients with Covid-19. The immediate availability of this information was vital for planning the many patient movements that were required for safety and was core to the decision to add 60 critical-care beds at MMS within a very tight time frame.
Data Supporting Diagnostics, Treatment and Discovery
EHR innovations are changing the face of medical diagnostics, treatment, and discovery. Large databases of information have been created by merging millions of de-identified patient records with the goal to improve care for all. With the eventual full participation of all EHR customers, these databases will include more than 200 million patient charts. But even now, with about 100 million records, doctors can compare a group of similar patients and determine the best treatment for their individual patient based on similar comorbidities, age, sex, and so on. Rare diseases can be diagnosed, and treatment begun more swiftly as providers who treat these patients can connect with each other.
This vast observational database is creating immense opportunities to conduct research that takes days, not years, to complete. A common data source is also leading to ways to share information quickly such as the Epic Health Research Network (EHRN), an open-access journal designed for rapidly sharing knowledge to help solve medical problems. Any organization can submit articles, which are peer reviewed by EHRN staff and then immediately shared. Studies that have emerged on EHRN include the first evidence that COVID-19 had resulted in delayed cancer screenings and that anticoagulation is an important early treatment for severely ill patients with COVID-19.
Another emerging area of discovery has been the EHR impact on Covid-19 vaccinations. EHRs have been used to identify priority populations based on age, risk factors, and occupation. Health systems can then use patient portals to send targeted notifications and communications to patients. This same data can be used in mobile apps by patients or by caregivers working with underserved communities to match patients with vaccine availability and make appointments. And finally, healthcare organizations can share the vaccine data in real time with state and local immunization information systems, public health agencies, and tribal departments. Some states such as Wisconsin have already enlisted the help of an EHR vendor to manage all vaccine information for the state.
The real breakthrough here is the emerging use of artificial intelligence (AI) and interfaces such as voice recognition to relieve the EHR burden on clinicians. Systems now exist that allow caregivers to call up specific records – lab reports, medication lists, x-ray results – by voice command to review with patient’s mid-exam. Likewise, providers can call out examination data during the patient visit and software allows for the entire visit to be recorded, transcribed, and documented. Very soon, physicians will be able to compare patient symptoms easily and quickly against the observational data base to fine-tune therapies based on the patient’s age, comorbidities, weight, and so on.
While most health care systems have yet to adopt these technologies, many have taken steps to make their EHRs more user-friendly or to reduce the amount of time that clinicians must devote to them. For instance, some have had their physician “super users” of EHRs (those who are experts in using them) design simplified EHR templates of the best ways to document the care that is delivered in the exam room. And some vendors have also developed efficient processes for providers to follow.
Separately, many health care systems have moved to having less-skilled staff enter much of the data. Medical assistants, for example, do medication reconciliation and take and input information such as the initial vitals and chief complaint. Then the provider can simply focus on the patient and then document key parts of his or her history on templates that are easy to use.
For years, the inability of the EHR system of one vendor to easily exchange information with those of other vendors has posed a problem. But much work has been done to break down these walls. Surveys conducted by the independent research firm KLAS in 2020 found that 66% of Epic customers were able to achieve “deep interoperability” – a stage where providers have consistent access to outside data, can easily locate patient records, can view outside data inside their EHR workflow, and experience EHRs having a frequent, positive impact on patient care. The vendor who scored the next highest in this area was Cerner, with 28% of provider organizations reporting that they had achieved deep interoperability — four times the number in 2017.
What this means is that if you show up in an emergency room 500 miles from your home tonight, chances are much greater than eight years ago that caregivers working to save your life will know exactly what medications you are taking even if you cannot say. The interoperability of some vendors’ EHRs is better than those of others, but research organizations such as KLAS are shining a light on such disparities, and customers (i.e., health care systems) are pushing the laggards to move faster to improve.
The transition to digital records has been bumpy but now we are beginning to see how the practice of medicine can be enormously improved with the use of digital records.
Imagine a practitioner being able to determine the most appropriate treatment within seconds and put a full explanation of condition and treatment on a big screen to review with the patient. Vitals such as EKG and oxygen levels will be downloaded from wearable biotechnology – either the patient’s own or a bracelet slipped onto the patient’s wrist when he or she enters the clinic – and entered into the electronic record automatically. Clinicians will not have to search for reports or wait for information. The doctor-patient relationship will be front and center and all the technology and care processes will be behind the scenes, running smoothly. Thanks to what we have learned from EHR, we are on the cusp of revolutionary change.
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