Could Reduced Physician EHR Use Improve Quality Healthcare?

Grubenhoff, Joe Joe.Grubenhoff at CHILDRENSCOLORADO.ORG
Thu Aug 18 18:59:47 UTC 2016

Is there any data that expressly examines the impact that using “point-and-click” documentation (e.g. EPIC’s Notewriter) has on the synthesis of the history? I refuse to use such documentation in the room with the patient as I feel it reduces my history taking to a data entry function and my relationship to my patient to one of scribe.

Certainly there is a higher level reckoning of the patient’s story that occurs when the individual data elements are translated from the lay patient’s description to “medicalese” using semantic qualifiers that may call up particular illness scripts or differentials.

This may extend to the “assessment” as well (though we all know how often ER docs write up their assessment before arriving at a disposition). I have often realized as I write (or type) out my medical decision making that I did not explore a differential as thoroughly as, perhaps, I should have since I didn’t take time to synthesize my thoughts. This has led to “a few” follow-up phone calls the next day.

But as templated MDM sections with their drop-down lists of “I also considered [pick from among a predefined list of DDx], but are unlikely given [history, physical, labs, etc]” I can see in my trainees that they are less and less able to track how they reasoned to a diagnosis because they are so accustomed to just completing the note template.

Joe Grubenhoff, MD, MSCS| Associate Professor of Pediatrics
Section of Emergency Medicine | University of Colorado
Children's Hospital Colorado
13123 East 16th Avenue, Box 251  |  Anschutz Medical Campus  |  Aurora, CO 80045 | Phone: (303) 724-2581 | Fax: (720) 777-7317
joe.grubenhoff at<mailto:joe.grubenhoff at>

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From: HM Epstein [mailto:hmepstein at GMAIL.COM]
Sent: Thursday, August 18, 2016 10:58 AM
Subject: [IMPROVEDX] Could Reduced Physician EHR Use Improve Quality Healthcare?

​​Are EHRs hurting proper Dx evaluations or are they helping? ​

In an op-ed in JAMA entitled, "Evolutionary Pressures on the Electronic Health Record-Caring for Complexity" the authors talk about

dangers of
​diagnostic errors when ​
clinicians' focus on the computer screen instead of the patient in front of them and the inadequac
y of the EHRs
​as learning tools
​I've attached the JAMA piece as a pdf and have included the article
about it
​ ​
in EHR Intelligence below​

Could Reduced Physician EHR Use Improve Quality Healthcare?

Despite some of their benefits, reducing the emphasis on physician EHR use may be key to improving patient care.
[Image removed by sender. physician-ehr-use]

In a recent op-ed<> published in the Journal of the American Medical Association, authors Donna M. Zulman, MD, MS, Nigam H. Shah, MBBS, PhD, and Abraham Verghese, MD, highlight the pitfalls of the EHR, arguing that the healthcare industry should decrease the importance of EHRs in an effort to preserve certain elements of quality care.

“Deimplementing the EHR could actively enhance care in many clinical scenarios,” the authors wrote.

“Simply listening to the history and carefully examining the patient who presents with a focused concern is an important means of avoiding diagnostic error. Many phenotypic observations… change the diagnostic algorithm and are easy to miss when work revolves around the computer and not the patient.”

Physicians need to look away from the EHR screen during care encounters and better assess the patient on an individual and personal level. In doing so, the authors said, physicians can catch certain characteristics of symptoms that may not have been recorded in the EHR.

“What is the story of the individual?” the authors asked, noting that providers should look to uncover this question during each care encounter.

“The most sophisticated computerized algorithms, if limited to medical data, may underestimate a patient’s risk (eg, through ignorance about neighborhood dangers contributing to sedentary behavior and poor nutrition) or recommend suboptimal treatment (eg, escalating asthma medications for symptoms triggered by second-hand smoke).”

The resolution to this issue could also lay in better electronic information capturing. Through patient portals<> and other digital communication tools, physicians should be able to gather individualized patient information about their geographic environment or lifestyle choices. EHRs, however, have not caught up to this point.

Lagging EHR sophistication brings about a whole bevy of problems, the trio said. These technologies have yet to successfully integrate information and synthesize it in a useful manner, making them less functional in the actual care setting. Should EHRs be able to aggregate information and display it in an efficient graphic manner, for example, they may be of more use for providers.

Although many EHRs are starting to incorporate predictive analytics<> functions, many of them still are not useful in improving quality care. The authors suggest functions that allow providers to compare patients in the moment.

Seeing how certain hypertension treatments have worked on similar patients is more useful for providers than understanding the likelihood that the patient will develop another condition along the line, the three explained.

This massive amount of data – which is often disorganized – brings about another issue: alert fatigue. With many patients suffering from a litany of chronic and acute conditions, EHRs are producing a number of alerts and reminders and providers are inundated.

“Better triage of EHR alerts and fewer workflow interruptions are needed so the physician can maintain situational awareness without being distracted,” they authors wrote. “Outside of health care, other sectors have found suitable solutions for this type of challenge: the airline industry limits pilots’ audible alerts to critical and life-threatening events, and financial software enables users to set investment goals without inundating their inbox at every price fluctuation.”

As they stand now, EHRs are standing in the way of improving quality healthcare because they are not seamlessly integrated into physician workflow<>, the authors explained. The technology causes pauses in workflow, and put a strain on providers.

“There is building resentment against the shackles of the present EHR; every additional click inflicts a nick on physicians’ morale,” the authors concluded. “Better medical record systems are needed that are dissociated from billing, intuitive and helpful, and allow physicians to be fully present with their patients.”

Going forward, the authors explained, the EHR industry will need to catch up with technological trends. By adopting better methods to prioritize digital reminders, represent information, and collect qualitative patient data at the point of care, EHRs developers can help make these tools more functional within the physician practice.



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