EHR Optimization-making the EHR Work for Physicians

By Luis Saldana, CMIO, Texas Health Resources

Luis Saldana, CMIO, Texas Health Resources


Healthcare remains a hot topic in the media and in daily conversations. Within those conversations are threads about the crisis of physician burnout. This trend emerges within a period of rapid change in healthcare, which has seen the advent and rapid adoption of Electronic Health Records (EHRs). Much of this rapid growth in EHR adoption has been driven by government mandates and programs such as meaningful use, rather than being physician driven, which has fostered a real sense of a loss of control.

This regulatory-driven growth has driven an explosion of documentation and reporting requirements and thrusts burdens onto physicians and nurses via the vehicle of the EHR. It can consume precious time, sometimes at the expense of time best used with their patients and their families.

There is a great quote that says “technology makes a good servant but a poor master,” and I think this is very relevant to physicians’ relationships with EHRs. So how can we shape the EHR to reclaim the right relationship with physicians and reduce their burden? Many of the barriers reside within EHR optimization.

Much of the burden probably falls on EHR vendors who have had the same pressures in development, driven by regulatory requirements. These programs have been a boon to EHR vendors, while also handcuffing them in terms of development prioritization. This has also led to consolidation in the industry, with the disappearance of many niche specialty-focused vendors. This unfortunate consolidation appears to benefit “big” vendors, who work to fill these needs with specialty “modules.” They spend more time supporting existing functionalities to work within these frameworks rather than developing novel functionalities to solve physicians’ real challenges. They also spend much of their development efforts on functionalities rather than on workflows, and most of healthcare is delivered via workflows.

But will these regulatory burdens diminish or disappear? Unlikely, but we have heard some rumbles on this from CMS. According to a recent CMS article on quality payment programs to reduce physician burdens, CMS has “heard the concerns that too many quality programs, technology requirements, and measures get between the doctor and the patient.” CMS administrator Seema Verma, adds, “That’s why we’re taking a hard look at reducing burdens.” So, how can we find a way forward to benefit clinicians in the context of these burdens, and ultimately benefit patients?

There is much dialogue around improving the usability of EHR systems, which largely focuses on data presentation, user interfaces and technical design. Much of the burden here falls once on again to the EHR vendors, who are starting to put more attention on usability, but there is still a long way to go to approach the usability of consumer applications. In addition, there is a need for healthcare organizations to invest in clinical informatics talent, as there is more opportunity to enhance usability via local workflow optimization. The role for physician and nursing informaticists who truly understand how care is delivered and how care workflows are designed is imperative. The need is increasing, not decreasing. Like it or not, the EHR is here to stay, at least for the foreseeable future, and experienced informaticists can help to unlock the value of clinician-facing technologies.

So, I will lay out three areas of focus for healthcare organizations to prioritize if they are truly serious about EHR optimization for clinicians. To set the stage for a successful effort, there is, first and foremost, a need to prioritize the resources necessary to support the initiative. This has to begin at the top with an earnest, long-term organizational commitment to supporting this hard work and prioritizing the resources to execute. The areas of focus are:

1. Vendor Optimization. This requires a long-term collaborative relationship to communicate, timely and effectively, the needs of your clinicians to the vendor so that observations and feedback is turned into action. This requires assistance from local informaticists who can help to translate clinical needs to the non-clinical vendor developers. Know how your vendor is approaching usability development and testing, and be involved in avenues to include your organization’s voice in these efforts. Vendors must put more attention into creating more simplified user interfaces, as current user interfaces tend to overwhelm the average end-user to the point where they operate in “survival mode” to get through their clinical workdays. Vendors need to minimize barriers to allow for different modes of user input, especially voice, which is becoming more and more consumer-friendly and focused. This will also require integration of machine learning and cognitive technologies to leverage prediction to “guide” the end-user. Current data and information displays overwhelm the end-user. Information should be simplified to intelligently filter data for more effective data displays. Vendors should increasingly focus on development to support clinical workflows over development focused on novel functionalities. Also, they can leverage cognitive technologies to support the user as they walk through clinical workflows in the EHR. Also, vendors are starting to develop analytics that provide a glimpse into how end-users interact with the EHR, which can support user optimization.

2. Local Optimization. As mentioned previously, this requires a long-term organizational commitment of resources to support an effective EHR build and optimization. Local informaticists should be connected to and collaborate with the broader informatics community to see emerging trends and learn from others seeking the same goals. Such efforts must be aligned with organizational strategic goals to be sustainable and require active and continuous physician and clinical engagement. Build and optimization decisions should be guided by clinicians, and feedback needs to be earnestly incorporated into a strategy to build an EHR that supports physician efficiency and effectiveness, while delivering improved patient outcomes. According to the former management consultant and educator Peter Drucker, “What gets measured gets improved.” In essence, a deep commitment to measurement and metrics is the only way to achieve these goals, so make a commitment to measure all that you can.

3. User Optimization. This one cannot be ignored. The EHR has become a central tool in the delivery of clinical care. The need for effective training and ongoing user optimization to efficiently use the EHR must be taken seriously and requires investment in resources and talent to execute on. While the tools and work flows are in no way intuitive, competence with the tools and workflows is critical in delivering good patient outcomes. User shortcuts and workarounds compromise patient outcomes and often circumvent safety checks and balances in the system. By implementing vendor-user data analytic tools as described earlier, training can be targeted to provide user-specific coaching or training to improve the user experience. Physicians are creatures of habit, and will continue to interact with the EHR the way they learned it, unless you can efficiently show them a better way and reinforce it. On-demand tools such as short workflow-targeted videos, at-the-elbow coaching, or even intuitive tools built into the system can be beneficial. If educational resources are presented at the right time, they can deliver significant value.

In summary, EHR usability issues are a real concern for physicians, and they must be addressed with a constructive partnership between vendors, healthcare organizations and physician users. Let’s make our dialogue on this topic constructive by transforming it into action and finding a positive way forward.