Electronic Health Record Innovations for Healthier Patients and Happier Doctors

The Future of Electronic Documentation

Early EHRs functioned mainly as a digital version of the Article chart and a tool to support charge capture. Even today, clinical encounter notes are designed to document content needed for reimbursement in a fee-for-service market. Many have criticized the quality of encounter notes generated by EHRs, stating notes are cluttered, redundant, irrelevant, duplicative, and at times spurious.⁵ Koopman et al⁶ used cognitive task analysis to simulate how clinicians prepare for an office visit to understand what information is needed from encounter notes. Clinicians identified narrative sections as having particular value, whereas check box sections and automatically cited content already available on summary dashboards had no value. The findings highlight a need to reengineer antiquated progress notes. Unlike prior paper-based notes that needed to summarize everything about a patient, electronic progress notes should be viewed as one data element in the patient's broader electronic record. This may reduce cognitive load, errors, and fatigue, as well as allow clinicians to focus more on the patient.

Prompts at the Point of Care

Four studies in this issue report the value and use of prompts at the point of care, a task particularly well suited to EHRs. Alerts and reminders can be triggered by clinical information already within or being entered into an EHR. Such prompts before and during busy encounters can be helpful in reminding about needed care. They can also be used as standing orders to better engage multiple team members to deliver care.⁷ Conversely, prompts can be a distraction during crowded encounters, when more pressing issues are being addressed than those prompted. This can result in alert fatigue, culminating in clinicians ignoring all prompts, even potentially useful ones.⁸ The studies in this issue help to define the scenarios in which prompts are useful, show us how cognitive science can create more useful prompts, and demonstrate how unique information contained within prompts can change practice patterns.

For example, Ruffin et al⁹ compared patient human papillomavirus vaccination rates in practices with and without a prompt and reminder system. Human papillomavirus vaccination was more likely to be initiated in the prompted cohort. More important, the prompts seemed to work better in groups at greater risk for not being vaccinated: African Americans, older patients whom clinicians might not think about vaccinating, and patients seen in the office less frequently. Zazove et al¹⁰ had a different experience. In the same group of practices with the same institution-created EHR and reminder system, they observed no change in documentation or screening interventions after instituting a simple family history prompt that identified patients at high risk for 6 common conditions. Whether the family history prompts lacked the immediacy or clear response action of the vaccination prompts or whether other factors result in differential uptake is unclear and worthy of future research.

Bunt et al,¹¹ through a double-blind simulation, demonstrated that sharing not only guideline recommendations for the workup of pediatric hematuria but also information about radiation exposure influenced clinician decisions to lower pediatric radiation exposure. Interestingly, the order in which information was shared (guideline vs radiation exposure information) influenced outcomes. This study highlights the value of thinking outside of the box about what—and when—information should be shared in prompts to change clinician practice patterns.

Green et al⁸ show that prompts and alerts do not necessarily result in reminder fatigue. Clinicians in 5 practices received nearly a million reminders related to half a million encounters. Amazingly, clinicians took action to respond to >60% of prompts and documented discussions for another 26.8%. Green et al attribute this success to the use of cognitive science and human factors engineering in designing the prompts. Strategies included ensuring reminders occurred only when services were due and were actionable, allowing clinicians to choose when to attend to reminders, making reminders simple, and ensuring practices desired the reminders before they were implemented.

It Takes a Team

Through the study of meaningful use exemplars within a national network, Ornstein et al¹² remind us that it takes a team to effectively use HIT. Higher-quality performance was associated with staff education, use of standing orders, and care team reminders. EHR use was necessary but not sufficient for high performance, and staff reported a greater impact when it was clear how to apply education directly to performance.

Shultz and Holmstrom¹³ expand our idea of who we might consider as part of our care team: scribes. A systematic review identified 3 high-quality studies of the impact of scribes to help clinicians cope with the difficulties, time, cost, and inefficiencies introduced by EHRs. While scribes were studied in only the emergency department and specialty offices, they improved clinician satisfaction, productivity, and the patient–clinician relationship.

The patient will always be the most essential member of any care team. Engaged, activated patients have better outcomes. Kuhn et al¹⁴ show us how HIT can be used to create an electronic asthma action plan (eAAP). While action plans are considered best practice, clinicians are not very good at routinely creating them with patients. Kuhn et al describe how a multidisciplinary team of investigators, clinicians, and health system leaders worked together to create, implement, and broadly disseminate an eAAP using their health system's EHR. The eAAP engaged >5000 patients to better self-manage their asthma, resulting in fewer pediatric asthma exacerbations and fewer prescriptions for oral steroids.

EHRs Can Bring People Together

At its core, primary care is about relationships. EHRs will never replace relationships, but they can facilitate communication. In a mixed methods study Liddy et al¹⁵ report clinician satisfaction for a web-based e-consult service designed to improve primary care clinician and patient access to specialist consultation. Primary care clinicians reported high satisfaction with the use of this virtual platform, citing benefits like quick response time, the helpfulness of responses, and reassurance for the patient and clinician. In previous studies the use of the virtual platform even reduced unnecessary face-to-face referrals by 40%. Findings from O'Malley et al¹⁶ further reinforce the value of communication between primary care and specialists. By linking responses to a national survey with Medicare claims data, they identified that greater primary care and specialist communication is associated with reduced hospitalizations for ambulatory care–sensitive conditions. This was magnified by EHR use, suggesting that EHRs can help to coordinate communication between primary care and specialty clinicians.