The widespread implementation of electronic health records (EHRs) was predicated on hopes that they would rapidly improve care, but initial experiences have been disappointing and thought to be a key part of physician dissatisfaction and burnout. The crisis created by EHR implementation is only in part due to EHRs themselves, and might also be viewed as a crisis that has served to surface longstanding problems in healthcare-ones that if grappled with, will lead to more rapidly effective digital transformation

Adler-Milstein, Julia

Auerbach, Andrew D

Khanna, Raman

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UCSFUC San Francisco Previously Published WorksTitleLetting a Good Crisis Go to WastePermalinkhttps://escholarship.org/uc/item/1br0j1h8JournalJournal of General Internal Medicine, 35(4)ISSN0884-8734AuthorsAuerbach, Andrew DKhanna, RamanAdler-Milstein, JuliaPublication Date2020-04-01DOI10.1007/s11606-019-05552-z Peer reviewedeScholarship.org Powered by the California Digital LibraryUniversity of CaliforniaLetting a Good Crisis Go to WasteAndrew D. Auerbach, MD, MPH1,2, Raman Khanna, MD1,2, and Julia Adler-Milstein,PhD1,31San Francisco Division of Hospital Medicine, University of California, San Francisco, CA, USA; 2San Francisco Center for Digital Health Innovation,University of California, San Francisco, USA; 3San Francisco Center for Clinical Informatics & Improvement Research, University of California, SanFrancisco, USA.The widespread implementation of electronic healthrecords (EHRs) was predicated on hopes that theywould rapidly improve care, but initial experienceshave been disappointing and thought to be a keypart of physician dissatisfaction and burnout. Thecrisis created by EHR implementation is only in partdue to EHRs themselves, and might also be viewedas a crisis that has served to surface longstandingproblems in healthcare—ones that if grappled with,will lead to more rapidly effective digital transforma-tion.J Gen Intern MedDOI: 10.1007/s11606-019-05552-z© Society of General Internal Medicine 2019I n the past 7 years, the majority of health systems inthe USA have transitioned to electronic health record(EHR) systems. The profound effects of EHR implemen-tation on the work of healthcare professionals have beena core part of a crisis described repeatedly in recentyears.1Troubles ascribed to EHRs are valid. However, cur-rent discussions often forget or gloss over the distinctionbetween problems EHRs create and preexisting ones thatEHRs have simply made more visible. If we routinelylump these two forms of problems together rather thanreframing them both as core challenges to healthcare,we are letting an important crisis—a crisis of physicianand provider burnout, of loss of connection to patientsand peers due to electronic tools, and of widespreaddissatisfaction with EHRs—go to waste. We provideexamples of complaints that represent latter aspects ofthe crisis, and point out how they provide opportunitiesfor reframing and addressing fundamental features ofhealthcare that have been surfaced by the arrival ofEHRs (Table 1).OUR EHR DOESN’T IMPROVE CARE AS RAPIDLY ASWEWOULD LIKECare improvement efforts have always been constrained both bythe tools available to carry out the change. In the digital era,EHRs have expanded access to key improvement resources (suchas data), while also raising hopes that—by centralizing improve-ment opportunities in a ubiquitous system—quality improvementand safety enhancement would be greatly facilitated.Sadly, the pace of improvement remains slow and EHRs’ability to improve care has proven more limited than hoped.However, limitations in quality improvement tools have al-ways limited the scope of our goals for the interventionsthemselves. What may be different in the EHR era is theexpectations from many users that simple changes in EHRswill lead to instant changes in care quality. Providers andimprovement teams need to recommit to core methods ofquality improvement and harm reduction and consider howEHR solutions are best developed as components of largerinitiatives, rather than treating EHR programs as a simple flipof the switch (or by pushing all “improvement” work to thefront line providers in the form of extensive documentationrequests or hard-stops). Stated alternately, while EHRs are akey part of quality improvement, EHRs are usually not the firstor sole part of an effective improvement strategy.OUR EHR IS TOO COMPLEX TO BE USEFULEHRs suffer by comparison to websites and apps we relishusing in our everyday lives. A disconnect between consumer-facing digital apps and websites drives dissatisfaction withEHRs, and prompts requests for customization and add-onsthat meet individual’s needs, but which only add further com-plexity to the EHR.However, EHR complexity is a problem of healthcare’sown making. Vendors of EHRs have built software inresponse to requests to accommodate an incredibly diverseset of wishes from customers at a large number ofhealthcare settings. As a result, the complexity of thesoftware provided by vendors represents healthcare’s larg-er demands for flexibility.Even within hospitals and health systems, EHRs are config-ured in ways that meet the needs of many possible personnelReceived June 4, 2019Revised September 22, 2019Accepted October 31, 20191289Published online November19, 201935(4):1289–91and processes.2 In this way, seemingly unnecessary complexityin the EHR is the response to how many ways we do our work;it also places huge strains on informatics teams to create moreand more customized tools. While customization is likely agood approach in some cases, if we want the elegance ofcommercial websites (none of which deals with processes near-ly as complex as healthcare), we must first standardize andsimplify our electronic and non-electronic work. Only then wecan simplify our digital workspaces accordingly.THE EHR SHOULD BE ABLE TO ACCOMMODATE THEWIDE RANGE OF CLINICAL DECISIONS I NEED TOMAKEDeciding on the best treatment or diagnostic test for a patientrequires consideration of many options. EHRs can efficientlywarehouse an infinite number of diagnostic and therapeuticchoices, but without curation, the EHR warehouse quicklybecomes cluttered. For example, order sets can be tailored toprimarily meet the goal of “which medication do I frequentlyorder?” or the goal of “how can I select medications that aresafe and high-value?” The balance between these two view-points represents another key tension in the EHR era: present-ing many or all potential clinical choices, and guiding care-givers towards the best care possible.These tensions are not new: Challenges in defining best clin-ical practices, gaining consensus, and then moving these realiza-tions into practice have been longstanding.What has happened inthe EHR era is that adaptations to dealingwith a perceived lack offlexibility keep us from the standardized solution forwhichEHRsare extraordinarily well suited, while also adding to the complex-ity and lack of usefulness we described earlier.THE EHR EXISTS PRIMARILY TO SUPPORT CHECKBOXTASKS AND BILLINGImplementation of EHRs has brought to light checkbox activ-ities that were carried out using implicit standards (e.g., rubberstamps to substitute for physician signatures), workarounds(e.g., verbal orders), or the need for supervising physicians tocosign or attest to trainees’ documentation. However, makingtasks explicit and auditable was a desired outcome from thetransition to EHRs and in some cases has made care safer byreinforcing best practices and providing a platformwhere rolesand tasks are clear to all involved.Issues around billing requirements and associated docu-mentation and compliance tasks are real, but are not solelyof EHRs’making. Much as EHR vendors have had to adapt tomultiple different workflows in order to produce a productviable in the marketplace (our first point), they have also hadto simultaneously deal with rapidly evolving and idiosyncraticrules for billing and their customers’ adaptations to and inter-pretations of those rules. As a result, improved adherence tobilling requirements is the worst-case scenario of EHR clericaltasks. However, billing is a major part of EHR work burdennot because EHR vendors are unsophisticated—but becausetheir product needs to ensure that hospitals and physicianswould continue to be paid.DOCUMENTATION IS ALL I DOSeparate from the need to document for billing purposes is ourneed to document in order to create a durable record of apatient’s treatments and relay this information to ourselves orto the next provider. When referral letters, progress or consul-tation notes, and discharge summaries were only available onpaper, they were the sole means for this form of communica-tion, easier to create (via dictation and transcription), certainlymore tailored to providers’ needs, and in some ways moreeasily searched through in physical form because the volumeof information gathered in paper form was lower and becausehealth systems had developed workarounds such as “shadowcharts” representing subsets of patient information relevant togroups of providers but unfindable to others.EHRs have had multiple negative effects on the work ofcreating notes—many of which relate to billing and checkboxclerical tasks. The ability to automatically pre-populate noteswith complex clinical data, as well as cut-and-paste, is anadaptation to documentation burden, but makes notes bothless useful and more complicated.Table 1 Reactions and Reframed Responses to Electronic Health Record SystemsReaction to EHR use Reframed current stateOur EHR doesn’t improve care as rapidly as we wouldlike.• Resources and staff dedicated to EHR improvements are limited and may need to beprioritized.Our EHR is too complex to be useful. • EHRs are attempting to represent complex processes that vary both within and acrossproviders and institutions.The EHR should be able to accommodate the wide rangeof clinical decisions I need to make.• Reducing variation in clinical care also represents an opportunity to improve the EHR.The EHR exists primarily to support checkbox tasks andbilling.• Billing and other clerical tasks are not likely to go away, so approaches to reducingburden on providers may require reexamination of how and why such tasks are carriedout or consider supporting them outside the EHR.Documentation is all I do. • In order to reduce documentation burden, it may be most important to first considerwhat information needs to be documented in each note or should be discoverable in theEHR.Auerbach et al: Letting a Good Crisis Go to Waste JGIM1290Our EHR notes digitally reproduce our old ideas of “good”clinical communication between providers, rather than an actof curating patient-centered care. Solutions such as scribes orartificial intelligence–enabled transcription and searches willsave time by finding clinical data more quickly, creatingdistilled notes, or helping ensure that key aspects of clinicaldata collection or decision-making are documented. But weneed to grapple with simple things—like divergence in pro-viders’ views of which information needs to be included in adischarge summary3–5—so that new tools can be deployedmost effectively. More fundamentally, we should reconsiderhow information should be gathered, transcribed, or enteredinto the EHR. Which should be relayed in documents at all?Which are best found in standard places in electronic systems?And who should receive which information via a “note,”whenthe information is readily available in the EHR?CONCLUSIONSWe are not writing this piece as an apology for EHR vendors, orto suggest that effects on morale and burnout are not valid—farfrom it. Both sets of issues are real, well-documented, andcritical to address. However, we need to recognize how ap-proaches to healthcare improvement and the culture of medicineboth add to and are amplified by EHRs’ limitations, leading tothe overarching theme to our reframing: Healthcare needs topay attention to this relationship, or the crisis we are currentlyexperiencing will be prolonged. We see several ways forward.The key first step is recognizing our role inmaking the EHRwhat it has become. At a fundamental level, EHRs are arepresentation of local standards and practices even if deliv-ered by a software vendor. In this reframing, many aspects ofthe “EHR-as-enemy” narrative can be reframed as signalingunfinished business for our hospitals and clinics. Healthcaremust pay greater attention to the leadership, management, andpolicy work needed to update practices and standards so thatthey can be represented more effectively in the digital era,rather than using digital tools to represent paper-based stan-dards, recreate past controversies, or simply act as a clutteredwarehouse of various potential tools and suggestions.Health systems must grapple with how the EHR can be aplatform upon which improvement and standardization takesplace, rather than the sole method for achieving change. Weremain optimistic that improvement will accelerate rapidlyonce this holistic view is embraced. However, whether thegoal is reducing documentation burden or improving a clinicaloutcome, process redesign and measuring change both insideand outside the EHR remain critical components of successfulprograms. For example, work tasks surfaced in the EHR eramight be better represented as part of a scope of practice, ratherthan requiring an order or “approval”; the EHR can then beused for decision support to facilitate the process and helpeveryone practice at the “top of their license.”While EHR technical limitations can be a core issue, theyare potentially a handy set of excuses for what may be betterdescribed as an EHR governance failure. In our view, futurestate EHR governance needs to first standardize practices andworkflows and focus on the EHR as a “platform” for spread ofbest practices. Becoming an improvement platform foragreed-upon work and clinical practices leads to a holisticimprovement strategy that emphasizes spread, usability, ongo-ing training, and clinical impact rather than customization andcomplexity acting as band-aids over longstanding problems.Governing will mean understanding needs of patients andproviders, intense focus on training and support, and closecollaboration with the EHR team not as technicians but ascollaborators and consultants. Importantly, these discussionswill—by their very nature—better integrate the “IT” worldwith the clinical care delivery world, and we would encouragethis thinking as a core tenet going forward. EHR vendors needto be responsive to requests for modifications that result fromgovernance, and likely have a key role to play in supportinggovernance approaches as a larger part of their ongoing rela-tionships with their customers; this role will need to changetowards being focused on helping sites pick platforms andsolutions that work across problems, rather than supportingcustomizations as a primary customer service goal.The future is bright and opportunities of the digital era nearlyunbounded. However, our current crisis will be wasted and thebright future delayed, if healthcare misses the opportunity tolink digital reinvention to clinical process reinvention.Corresponding Author: Andrew D. Auerbach, MD, MPH; SanFrancisco Division of Hospital Medicine, University of California, SanFrancisco, CA, USA (e-mail: ada@medicine.ucsf.edu).Compliance with Ethical Standards:Conflict of Interest: Raman Khanna helped develop CareWeb, anelectronic communication product which has been licensed by Voalte,Inc. The authors declare no other conflicts of interest in relationship tothis article.REFERENCES1. Downing N, Bates DW, Longhurst CA. Physician burnout in the electronichealth record era: Are we ignoring the real cause? Ann Intern Med 2018.2. Vaughn VM, Linder JA. Thoughtless design of the electronic health recorddrives overuse, but purposeful design can nudge improved patient care.BMJ Qual Saf 2018.3. Sheu L, Fung K, Mourad M, Ranji S, Wu E. We need to talk: Primary careprovider communication at discharge in the era of a shared electronicmedical record. J Hosp Med 2015;10:307–10.4. Sorita A, Robelia PM, Kattel SB, et al. The Ideal Hospital DischargeSummary: A Survey of U.S. Physicians. J Patient Saf 2017.5. van Walraven C, Rokosh E. What is necessary for high-quality dischargesummaries? Am J Med Qual 1999;14:160–9.Publisher’s Note Springer Nature remains neutral with regard tojurisdictional claims in published maps and institutional affiliations.Auerbach et al: Letting a Good Crisis Go to WasteJGIM 1291

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