The Future of EHRs: Less Meaningful Use and More Physician Satisfaction
By John Squire
Healthcare providers have been turning against the Meaningful Use program in growing numbers since the switch to MU Stage 2. The original concept of MU was supported by well-meaning public health advocates, but the ultimate manifestation of the program had the unintended consequence of intruding on the physician’s time with patients, and breeding more costly and difficult to use software.
Is MU Already Over?
For years, critics have knocked MU for focusing too much on providers checking off boxes rather than actually improving care. It makes physicians less efficient in the exam room and forces them to spend more time typing and clicking than healing. MU2 added new metrics over which physicians have little or no control, such as getting patients to sign up for a practice portal, or reporting immunizations to non-operational state registries.
Recently, CMS finally acknowledged that the program was not benefitting physicians or patients. Acting CMS Administrator Andy Slavitt said publicly that the agency "has the opportunity" to sunset MU in 2016 and that "the Meaningful Use program as it has existed, will now be effectively over and replaced with something better.”
The Blueprint for Future EHRS
That still leaves EHR systems bloated with MU Core and Menu measures embedded in all workflows, and many physicians no longer want them. Providers want to strip away all the check-boxes, reports, and other clutter. They want clean, streamlined screens that look the way they did before the mandates, and they want to complete routine tasks with minimal clicks. Let’s explore what the EHR of the future might look like.
The Reality of Cognitive Overload in the Exam Room
One criticism of MU is that it interferes with how providers think about patient problems in the exam room. By removing MU, we have an opportunity to make EHRs “think” more like a provider – or at least support the logical thought process of a provider, rather than hinder or intrude upon it.
Providers think in problems, yet nearly all EHR systems organize data by source. A patient’s lab results, for example, are presented as a single list, regardless of the problems for which the labs were ordered. The same source-based organizing principle is used for exam notes, medications, orders, referrals, etc. As a result of this mismatch, providers feel as if they are drowning in an ocean of disorganized data and the addition of MU measures only exacerbates the issue. The capacity of providers to multitask effectively is often stretched beyond its limits, leading to cognitive overload, which impairs the medical decision-making process and can lead to errors such as misdiagnosis and other potentially life-threatening mistakes.
Use a Problem-Oriented Medical Record
The future EHR system will be a problem-oriented medical record (POMR). In this approach, all notes, medications, labs, orders, referrals, etc. are associated with specific patient problems. A problem list not only delivers a “table of contents” to clinically relevant issues, but also gives a provider a longitudinal view of a patient’s healthcare over time. Another benefit of this approach is it allows user interface designers to make screens look cleaner and less cluttered.
This more intuitive, problem-based method of organizing information makes it easier for both provider and patient to set the agenda at the start of the exam. Once the exam is underway, the POMR accommodates the nonlinear nature of an encounter. The provider can easily shift from problem to problem, or document new problems, as they interact with the patient, allowing for more eye contact and less clicking and typing.
Support Sound Medical Decisions
In medical school, providers are trained to “think” in patient problems. Because the POMR organizes and presents patient health information the same way, it is naturally more intuitive to use. An EHR with the patient problem list as its organizing principle can even help reduce cognitive overload in the exam room. Providers can now see “bits” of datum – like lab results – associated with a specific problem, thus easing the number of mental connections required to make a sound, well-informed medical decisions.
Learn How a Provider Practices
The future EHR system will learn a provider’s behavior as they practice to minimize typing and time spent looking at the screen, which has always been one of the biggest complaints about MU. For example, the EHR system can learn which medication a provider typically orders for a particular problem, including details such as dosage and formulary, and then suggest the same medication whenever the problem is diagnosed again. In theory, a medicine could be ordered in as few as three mouse-clicks. The same principle is applied to labs, orders, referrals, etc. These efficiencies will return time for face-to-face interactions with patients.
Allow for Quality Reporting and Data Exchange
The early signs are that the CMS program will shift to emphasize quality of care and outcomes, allowing physicians to focus on patients and care. It will encourage quality tracking and reporting, but limit intrusions into the physician’s workflow. CMS will also continue to promote the idea of standard interfaces between disparate EHR systems to enable information exchange among physicians, hospitals, health information exchanges (HIEs), and other elements of the broader healthcare ecosystem.
As these changes occur, the EHR of the future should be able to manage them in the background, in a way that maximizes productivity and does not interfere with patient visits. It should support the ability of providers to operate independently, but still interact with their ecosystem.
The Future is Bright for Providers
As we gaze into our crystal ball at the future of the EHR, the picture is clear. Providers will flock to a full-featured EHR system that combines the efficiency of pre-MU software with a POMR. This new approach to the EHR system promises to deliver both increased professional satisfaction for providers, as well as improved health outcomes for patients.
John Squire is president and COO of Amazing Charts in North Kingstown, RI.