Curbside Consult with Dr. Jayne 2/4/19

Our EHR friend John Halamka, MD co-authored a piece in the Harvard Business Review earlier this month regarding strategies for making EHRs less time-consuming for physicians. Their ideas are sound, although I’d like to expand on them a bit from the trenches.

The first point made is the need to “standardize and reduce payer-imposed requirements.” On the surface, they’re talking about the documentation requirements for an office visit, which in the US is approximately 700 words. This is significantly longer than the average note in other industrialized nations, including Canada, Australia, and the UK.

CMS is attempting to provide leadership here in blending the codes for certain Evaluation and Management (E&M) codes, therefore “reducing” documentation in some areas, but it doesn’t go far enough. Instead of trying to describe complex rashes, why can’t we upload pictures and have that count for payer documentation? Instead of trying to describe a trauma or laceration, we could fully document it. In those situations, the adage about a picture being worth a thousand words is true.

Getting relief from onerous workflows in the EHR is one thing, but if you want to impact clinician satisfaction and reduce burnout, I’d go a step beyond to look at other payer-driven workflows such as pre-authorizations, pre-certifications, and peer-to-peer conversations that waste clinician time.

I was called recently to provide documentation to prove why I needed to order a CT scan of a patient’s abdomen since an insurance reviewer felt I hadn’t given the right information. I asked the reviewer if she bothered to look at the patient’s CT scan result. Perhaps the large pancreatic tumor that was discovered — based on my clinical suspicion and corroborating exam findings — should be enough to prove why the CT scan was necessary. She stated she didn’t have access to the reports. Instead of using their own resources to review the outcome, they wasted my time trying to prove something that turned out to be obvious.

The second point made by Halamka et al is that EHR workflows need to be improved. I whole heartedly agree with the need to remove non-value-added steps from the workflow and to minimize disruptive or unnecessary alerts. Information needs to be available to the people who need it, at the time they need it, and at the appropriate level of detail. Our EHR went haywire for a while and every user was seeing a popup declaring that “Eligibility Checking has returned on John Doe,” which was ridiculous and took several days to correct.

No matter how much improvement vendors make in their workflows, however, there is still the tendency for practices to misapply those workflows, either through lack of understanding or lack of skill. Our EHR continues to throw errors whenever we try to prescribe certain medications because the NCPDP codes aren’t mapped. I know our vendor uses the premier database for medications, so I have to assume that it’s poorly implemented in the practice. If there are risks that a client might not keep their formularies up to date or might have implementation issues, then vendors should consider process that provide automatic updates so that physician workflows are preserved. A nice side effect is that confidence in the vendor will increase, since physicians rarely understand that their own practice has misapplied the technology and tend to blame it on the vendor.

The team’s third point is that the EHR user experience needs to be improved. I don’t know of a physician out there who wouldn’t agree with this point. I continue to see EHR “upgrades” and “enhancements” that are downright silly. One EHR that was shown to me by a client had a title bar that was blue and displayed the patient’s name and information. Since the EHR would allow you to have multiple patient charts open at the same time in separate windows, the title bar was essential so you could not only see quickly which patient was loaded, but also so that you could tell which window was active. In the interest of making the screens more “vanilla,” the vendor removed the blue title bar, making it much more difficult to see which window was active, forcing users to go to the Windows taskbar and click on the different taskbar buttons to cycle them and reactivate them. The upgrade was definitely a downgrade, and since it’s been that way for a year, I doubt the vendor thinks it’s an issue.

Another EHR claims to be “mobile friendly” but the screens don’t fit on a standard mobile device, requiring right-to-left scrolling of popups, which isn’t very mobile friendly. When trying to use it on my Microsoft Surface, it won’t accept the native handwriting recognition input and instead makes me use a tap-tap-tap keyboard to enter data. What a waste of time. The same EHR doesn’t have restricted fields for blood pressures, allowing nonsense values such as 80/1000 to be entered. For years, vendors used the ongoing proliferation of regulatory requirements as an excuse for why they couldn’t develop “nice to have” features that end users had requested. Now that those requirements have slowed a bit, I don’t see vendors sinking vast amounts of R&D funding into usability.

I continue to see healthcare IT products that don’t include basic elements of usability, such as using indicators beyond color to indicate whether lab values are high or low. Someone who is red/green colorblind isn’t going to see your red/green schematic – they need other indicators, such as graphics or text, to provide meaning. I see vendors that include password requirements that don’t meet current NIST recommendations, such as requiring overly long passwords with high degrees of complexity or mandating changes every 30 days. Clients can’t opt out in many cases and are stuck with a vendor’s interpretation of security needs that is out of date or untenable. I see EHR searches that can’t handle partial strings or aren’t intelligent enough to recognize typos.

I can’t wait to get to HIMSS next week and see what vendors have been up to and whether they should move up in my Hall of Fame or should be relegated to the Hall of Shame. I’d like to see some bold new user interfaces with lots of bells and whistles intended to keep physicians happy. I hope I’m not sadly disappointed.

If you’re a vendor and have bells and whistles you want to show off, leave a comment or email me. I’ll be sure to drop by anonymously and check it out.

Email Dr. Jayne.