Essential Electronic Health Record Reforms for This Decade

“the American Medical Informatics Association, with seed funding from the National Library of Medicine, formed a group under the moniker of 25 × 5 to reduce clinician documentation burden by three-quarters during the next 5 years.

A workshop in 2022 allied with the 25 × 5 initiative identified 6 major EHR issues:

  • Persistent failures to achieve interoperability (owing in part to the absence of a unique personal identifier)
  • An inadequate personal health digital infrastructure
  • An inadequate public health digital infrastructure
  • Inadequate attention to diversity, equity, and inclusion
  • Weak privacy, endangering safety
  • EHR design, configuration, and implementation issues

Based on those discussions and our professional observations, 4 issues emerged as most salient and 3 as most actionable. The continued lack of nationally used unique personal safety identifiers for health as originally mandated in the HIPAA (Health Insurance Portability and Accountability Act) in the mid-1990s presents a continuing threat to privacy, safety, cost reduction, and administrative errors while remaining the least likely to be corrected.

[..] [The other three are:] include removal of all administrative and regulatory content from “clinical time” unless such content is the primary clinical issue, inclusion of patient-entered information in the EHR, and reinvention of the clinical note [..].

Although it is difficult to separate payment models and other administrative requirements from clinical documentation, this is essential because they are currently associated with many of the frustrations that clinicians and patients face. All prior approval or authorization practices should be reviewed to determine whether they can move to an audit approach post hoc or be removed. If they are still required in some circumstances, streamlined methods must be developed.

[..] The tactics should be multiple. The Centers for Medicare & Medicaid Services (CMS) should reform its requirements to remove all such intrusions into the clinical encounter. [..] More broadly, health information technology developers must invest the time and resources to make such data accessible without placing any demands on clinician time.

Because patients are the most vested, patient-entered data must become a natural part of the record and be accessible for analysis. Despite the multiple challenges this change will present, meaningfully incorporating patient-derived data as part of the record deserves aggressive experimentation and ultimate mainstreaming as practical paths develop.

Including patient-entered data and removing administrative tasks from the clinician’s work will only mitigate the currently diseased EHR. The clinical note should be prospective in focus (ie, it should speak to expected or desired results of recent clinical action[s] and may include some sense of expected timelines). All hard stops during the ordering process in hopes of added patient safety should be examined critically, so they may be either minimized or eliminated. Clinicians functioning as billers will need to “unlearn” unnecessary patterns of documentation, with less documentation being the norm rather than more. For a 2-year hiatus, EHR software should ban all cutting and pasting functions or other innovations such as “copy forward.” Results from diagnostic tests should be limited to those requiring clinician interpretation or comment, not simple identification.

[..] ambient voice recognition in combination with artificial intelligence may reestablish clinicians’ assessment and plan to their former priority. Accurate medication and allergy lists could be reimagined by developing a cloud-based definitive list for a patient, curated and validated by pharmacists playing a much more active role in patient care, a role that they are capable of and trained for. [..]

Although addressing shortcomings in EHRs will not cure all that ails our current health care system, implementing these recommendations should positively affect patients and clinicians and move us toward the original vision of a patient-centered, technology-enhanced health care ecosystem that is designed to significantly improve outcomes at a lower cost, with more satisfied patients and clinicians.”

Full article, DE Detmer and A Gettinger, JAMA, 2023.5.4