How Providers are Achieving EHR Usability

While governments and groups gnash their teeth and craft future policy concerning electronic health record usability, providers are turning to overlay software to recast EHR workflow.

This article first appeared in the June 2015 issue of HealthLeaders magazine.

Electronic health records are doing more than ever, but providers are challenged like never before to find ways to make them easier to work with and more productive; in short, more usable.

In January, the American Medical Association, joined by 34 other medical professional organizations including the College of Healthcare Information Management Executives, told government regulators there is an urgent need to change the current federal EHR certification program to better align end-to-end testing to focus on EHR usability, interoperability, and safety. CMS has even recommended enhanced user-centered design principles in the 2015 EHR certification criteria proposed in conjunction with meaningful use stage 3.

"A lot of the traditional design in a lot of these legacy systems was never really built to encompass the full range of physician documentation and order entry."

While governments and groups gnash teeth and craft future policy concerning EHR usability, providers are turning to overlay software—some of it powered by speech input, some of it running on simplified tablet-based desktop or mobile user interfaces—to recast EHR workflow.

"A lot of the traditional design in a lot of these legacy systems was never really built to encompass the full range of physician documentation and order entry," says Brian Yeaman, MD, chief medical information officer of the Norman Physician Hospital Organization at Norman (Oklahoma) Regional Health System, a multicampus system with more than 3,000 employees.

Many EHR vendors resorted to numerous overlays or additional pop-up screens, but these often just compounded usability issues in the interest of fulfilling some requirement of meaningful use, Yeaman says. "They are very destructive in terms of workflow, thought process, and how we're moving through the EHR to evaluate data and to evaluate a patient."

Repetitive typing and mouse-clicking are also causing eyestrain and prompting carpal-tunnel surgeries for clinical staff, Yeaman says.

Two years ago, Norman installed Nuance's Dragon NaturallySpeaking in its 4,000-square-foot, 39-bed emergency room. To prevail in this noisy environment, Norman uses noise-canceling microphones with the software, along with Nuance's macros to input significant amounts of information via simple commands.

A limitation of many speech-input technologies is the need for a clinician's voice profile to be present at the point of speech. While deploying dedicated dictation computers can help, Norman has yet to make the investment in infrastructure that would allow such voice profiles to move with the clinician, Yeaman says.

A common tension runs through any EHR usability improvement in healthcare. On one end are those pushing for totally standardized user interfaces and workflows, for reasons ranging from simplicity of training and help-desk support, to larger issues such as implementing quality measures. At the other end are those who want flexibility, either because it conforms to previous workflows or physician preferences, or because a particular specialty's EHR workflow is much different than the workflows of other specialists.

A neurologist and a nephrologist are going to evaluate a patient in a significantly different way, Yeaman says. "One is heavily numbers-driven. The other is heavily exam-driven and imaging-driven. How those templates set up and how those macros would work are significantly different, and as a health system, we can't slow down our providers by forcing them to do a one-size-fits-all in significantly different specialties."

Saving work for later
Many clinicians fume about EHRs that force them to complete lengthy structured notes during or immediately after a patient encounter. New technologies sitting on top of EHRs not only allow such notes to be saved in draft form and completed later, but they even permit clinicians to complete the notes on a mobile device or start on a mobile device taken into the exam room and then finish later on a desktop device.

In April, 165-bed Conway (South Carolina) Medical Center, in order to finish migrating its last physicians from paper, standardized on one such technology with physician workflow software published by PatientKeeper, a company acquired by HCA in 2014.

All Conway physicians are now required to enter their orders through the PatientKeeper portal and to enter notes using PatientKeeper NoteWriter, says Paul Richardson, MD, vice president of clinical informatics and utilization, and chief medical information officer at Conway.

Prior to April 1, some of those physicians still used paper charts, even though Conway had a separate Meditech Magic EHR since 1998, and continues to use Meditech as its EHR. In 2009, Richardson, who is also a practicing internist, and a few other Conway physicians, started using PatientKeeper to perform computer-assisted order entry with Meditech Magic.

"I particularly like that they're able to integrate multiple systems, to pull the x-ray reports and the films themselves right into what I need and incorporate it all into one platform," Richardson says.

PatientKeeper allows Richardson and other clinicians to be more efficient than they were on paper, despite conventional wisdom he had heard from colleagues at other organizations who found EHR order entry and note-taking slower than on paper.

Recently, PatientKeeper began reconciling medications at discharge time at Conway. "CMS is mandating through meaningful use that this facility needs to have a 60% usage of CPOE," Richardson says.

So, as of this spring, rather than Meditech, Conway physicians "live in" PatientKeeper NoteWriter all day long, he says. "I personally don't know why a practicing physician would need to go back into Meditech. I can't see a workflow where that would be necessary."

On the standardization versus flexibility issue, "customization cannot circumvent some core quality items. These are evidence-based guidelines, and no physician should really disagree with these guidelines. In my opinion, those are non-negotiables," Richardson says. "Beyond that, there's something to be said for some workflow tweaking and customization."

However, Richardson shudders at tales of hospitals with up to 6,000 order sets. "But you do have to have a little bit of flexibility, because not everybody's workflow is the same."

"Customization cannot circumvent some core quality items. These are evidence-based guidelines, and no physician should really disagree with these guidelines."

Richardson also points out the weakness of allowing physicians to save draft notes, returning later to complete them. "If you come back two hours later, how fresh is your memory of that interaction?" he asks. "Are you going to miss something? That worries me. Now, there may be physicians able to do that, but that makes me a little bit uncomfortable."

And yet "obviously, emergencies are going to happen," Richardson adds. "I'm doing a note, then a patient's crashing. Again, patient safety and patient care come first, always. So I need that ability to be able to walk away and not have my computer time out and losing everything I was doing."

One shortcoming of PatientKeeper: Right now it is targeted at physicians, but not at nurses, who must instead struggle with the older EHR's user interface.

"I've told the folks at PatientKeeper I wish it were there for nurses," Richardson says. "It would be very helpful for nurses to tee up orders for the physician."

Rethinking usability via iPads
The advent of tablets such as the iPad have sparked a once-in-a-generation opportunity to rethink how clinicians interact with EHRs, with implications far beyond the core usability debate,such as unexpectedly advancing preparedness for ICD-10.

The Electronic Medical Assistant from Modernizing Medicine is one EHR that several providers have used to tap the intuitive interface of the iPad, although the technology is limited to the practice of several lines of specialist medicine, rather than being aimed at general practitioners.

At Coastline Orthopaedic Associates, a six-physician Fountain Valley, California–based group with 35 employees, the patient encounter begins with the clinician carrying an iPad to the exam room—no PC in room, no laptop, no paper chart. By using the iPad screen to touch, pinch, and zoom in on different displayed anatomical features on the iPad screen, clinicians can access the EMA database, where more than 75,000 anatomical locations are revealed graphically in layers. If a patient reports pain or popping, the clinician can paint the location of the report in this database, which under the covers can generate appropriate diagnostic codes, even in ICD-10, which is due to become a U.S. standard later this year.

"It combined my vision of what an electronic health record should be, and has made it much easier for us in the office, actually spending less time in the office, getting better reports out, and complying with governmental regulations," says Daniel Stein, MD, founding orthopedic surgeon at Coastline. Yet clinicians can still add traditional notes in EMA by touching to open a text box—and even dictate those notes using the iPad's Siri voice transcription feature.

Coastline implemented EMA in August 2014, and within a few weeks, all its physicians had made the transition from paper, Stein says. "We did it slowly purposefully, because there's always going to be something to be dealt with," he says. But, "we lost no time, and we lost no charges to the patients."

Another EMA user is Donald Abrams, MD, chief of ophthalmology and director of the Krieger Eye Institute. He is also the chair of the Graduate Medical Education Committee for Sinai Hospital in Baltimore. The department of ophthalmology employs 11 ophthalmologists and more than 60 employees overall.

Six years ago, the hospital's IT department implemented the ophthalmologic version of its EHR. "It was a system that was heavily customized to meet our practice, but after a year of customization, the actual use and output was so terrible that we had to abandon it after about six weeks," he says. "Our productivity dropped to 25% or 30% [of usual patient visits], and we could never recover from that. We had very upset clinicians, technicians, and patients. It was very laborious to sit there in front of a massive computer or even carry around a big laptop to get the data in, and ophthalmology has a lot of data points. There's vision, pressure, all sorts of eye measurement, and it's very difficult to do that with some of the traditional electronic medical record software programs."

After the department returned to paper and witnessed another disappointing demo of the same EHR in 2014, the department received approval not only to implement EMA in June of that year, but also to avoid interfacing with the hospital's EHR for the 2014 meaningful use reporting period. (The interface is being implemented for this reporting year.)

The transition from paper to iPads running EMA was speedy, Abrams says. "I started on a Monday, where I did maybe more than half of my patients, and by Wednesday I was at 100% of my patients," he says. "From a practice standpoint, we had ratcheted back to between 25% and 50% of the normal number of patients, and we were back at over 100% by August; so within five to six weeks, we were as productive or even more productive using the electronic system, and I don't know any electronic system where you can say something like that."

The capper came when the hospital IT team met with ophthalmology department leadership to discuss conversion to ICD-10. "I said, 'I don't really know what you're talking about, what you want me to do, because I kind of think we're ready,' " Abrams says.

When the IT team asked for an explanation, Abrams demonstrated using EMA to chart a patient, and then changed the date of exam to October 15, 2015. "Immediately it gave me the CMS 1500 form and all the summary fields with all the ICD-10 codes in it, and I showed it to them, and they said, 'I guess you'd like us to cancel all the rest of our time with you for the rest of the year, right?' And I said, 'It's up to you.' So that kind of blew them all away."

Reprint HLR0615-8