In 2015, the adage "three is a crowd" applies to the patient-physician encounter. A doctor's appointment has become a three-party experience, as it now includes the electronic health record.
While most physicians remain supportive of the intent behind EHRs and their value, in many ways, the EHR impedes care, affecting physicians' work satisfaction and their proclivity to adhere to the goals of their facility. Granted, EHR technology is still young and most hospitals have deployed first-generation systems, but from a clinical point of view, a wide gap exists between the intent vs. the reality of EHRs.
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This is a brief summary of key issues with which doctors often struggle:
Unclear benefit to quality: Many doctors have yet to see a net positive in the trade-off between their investment in time and the quality of patient care. Perhaps EHRs will prove beneficial to care quality in the long term, but the near-term benefits are not clear. From the physicians' perspective, the reason the hospital installed an EHR system was to improve operational performance.
Monolithic approach: Physicians view the EHR as a one-size-fits-all system not designed to address the particular needs of each medical specialty. Practice management software selected by the medical group is expected to plug in or bolt onto the system, resulting in a patchwork quilt of physician management practices among the various practice groups, even within the same medical specialty.
Data distraction: The real-time data input and retrieval necessary to interact with the EHR forces physicians to choose who gets their attention at a given moment — the patient or the system. They feel pressured to choose the latter, or to engage in an effort to toggle between the two. To the patient, the doctor appears not as a juggler, but as someone with an impersonal bedside manner.
Context confusion: The constant demand on physicians to switch among the EHR, phone, text and fax raises the risk of imprecise communications or outright error. This clearly can affect patient safety as well as raise the likelihood of physician burnout.
Making a Difference in Patient Care
With each encounter, physicians are reminded that the EHR brings little to the bedside or exam room. It's now clear that the EHR's impact on patient-physician interaction was not a primary consideration in the first-generation EHR architecture. The result is an EHR system that undercuts progress toward more transparent and collaborative engagement.
Hospital administrators must do more to make the EHR a welcome guest and useful tool in every physician-patient encounter. Some practical recommendations are as follows:
Acknowledge and accept physicians' concerns with EHRs as legitimate and important to address. Make it known that the hospital will not consider an EHR implementation plan successful unless there is a broad consensus among the medical staff that concerns have been addressed.
View the patient as a stakeholder in the EHR development. Selectively open up the EHR interaction directly to patients and enhance their engagement through tools such as real-time surveys, payment and insurance reviews, demographic accuracy checks and medical diaries.
Allow nonphysicians to interact and input data to the EHR under immediate physician supervision, allowing the physician to focus on the patient. This trend is already underway with the growth in the use of medical scribes. Relegated to the emergency department until recently, scribes are moving into other arenas. It has been estimated that within 10 years as many as 100,000 may operate in both inpatient and outpatient settings.
Actively pursue EHR interoperability with other systems at facilities in your community. Interoperability has become a high priority for many facilities, largely as a result of the strong regulatory momentum behind it. Consider the competitive benefits to your hospital's reputation in the physician community of gaining first-mover advantage.
Re-engineering the Physician's Workflow
Better workflow software designed to keep pace with advances in EHR systems may improve EHR engagement. EHRs in deployment generally fall short of physician expectations of optimizing their time while improving patient outcomes. EHR and workflow software developers have heard the feedback and are taking steps to remedy this situation. While this gets sorted out, physician groups are left to undertake their own searches for bolt-on software solutions they can live with. Compatibility with the EHR remains the priority.
Focus on workflow becomes more urgent — and complex — because each medical specialty requires a workflow management solution customized to its own specific needs. Moreover, the prevalence of different workflow software within the same specialty among competing practice groups in a given facility is counterproductive, and the hospital should assertively take steps to end the workflow cacophony. All users on the medical staff within each specialty should be on the same workflow software.
Each medical specialty should coalesce around one practice management software tool. Doing so should have the additional benefit of promoting greater cooperation and teamwork among the members within each specialty practicing in your hospital, regardless of whether the physicians are employed by the hospital or by an outsourced group.
The hospital should stand ready to facilitate any transition issues and offer both administrative and financial support to the process. This is a choice opportunity for hospitals to promote more consistency and reliability in physicians' practice management.
More Physician- and Patient-centric EHR
There is little point in asking physicians to show patience for a more clinically effective EHR while their patients are put off by the intrusion of the EHR in the examination room. Leading physicians to believe that progress was around the corner, while committing to a timeline that has proven less than realistic, has only exacerbated their impatience, keeping them wondering whether relief will arrive before their retirement.
Physicians want to believe that EHR and workflow management software can live in service to the triple goals of improving quality, promoting efficiency and lowering costs. Until the EHR can do all these things, it will continue to appear to physicians that the cost-benefit trade-off they face with every patient remains beyond the horizon.
Todd J. Kislak is the chief development officer for Hospitalists Now Inc., a physician services company based in Austin, Texas.