Optimal Use of the EHR for All

Lawrence Garber, MD

This edition of Worcester Medicine looks at the Electronic Health Record’s (EHR) impact on the healthcare system from many perspectives: Physicians, nurses, pharmacists, first responders, patients, students, and researchers. We hear from those that are receiving incredible benefits from their EHR, and those who are benefiting a lot less from their EHR. We learn about how EHRs can pull us away from our patients as well as make us more connected to our patients. We can see that the EHR principles and vision laid out by Dr. Weed 60 years ago in Dr. Magee’s article have been enjoyed by some EHR users, but certainly not all. If some healthcare providers are efficiently reviewing patient records, identifying and acting on patient needs, documenting encounters, effectively managing the health of their population, and giving patients the convenient-care that is only possible with EHRs, why aren’t we all?

This is a complicated question. Most EHRs today are capable of facilitating efficient and effective healthcare. But not all implementations of the same EHR are of equal quality. Features need to be turned on and properly configured. Users need to be trained, supported and optimized. The optimal hardware needs to be identified, procured, deployed, and maintained. Patients need to be engaged to use the new technologies. This is a lot of work, and EHR vendors aren’t typically incentivized or capable of doing all of this and doing it well. Large organizations have the best shot at doing all of these things well. They can have 1 full-time physician informaticist and 1 full-time nurse/pharmacy informaticist dedicated to look out for the clinical needs of 100 physicians and their staff. And they can have 1 trainer/optimizer, 1 billing expert, 1 clinical build expert, 1 scheduling expert, 1 reporting/analytics expert, 1 network/interface expert, 1 hardware expert, and 1 database expert to support a practice of 100 physicians. That’s 10 humans to properly support a 100 physician practice. If you have a 200 physician practice, then you actually have backup so that some of those people can provide after-hours support or perhaps even take a vacation without hurting the practice.

But what does a 10-physician practice do? It’s hard to hire a tenth of a trainer/optimizer and a tenth of a scheduling expert and a tenth of those other roles. And 1 person can’t be an expert in those 10 areas. The situation is even worse if you are a 1-physician practice! Drs. Fisher and Doret’s article gives great advice on what large practices and hospitals can do to excel, but what does the solo practitioner do to thrive with their EHR?

A decade ago, when Washington rolled out the “Meaningful Use” program to incentivize the deployment of EHRs, they also created “Regional Extension Centers” designed to “hold the hands” of smaller practices and lead them through their EHR implementations. But like most EHR vendors, their success metric was an EHR go-live, not necessarily a highly-optimized system.

It’s now time for an “Optimal Use” program. We need State, Federal, or payer funding to support a new clinician-led EHR optimization industry whose mission is to make a practice’s EHR as efficient as possible. The 10 people that are needed to support 100 providers would instead support ten 10-provider practices, or more smaller practices. They would be dedicated to a single EHR vendor that they have deep experience with. They would be active in that EHR vendor’s user community to learn best practices, as well as to provide feedback to the vendor on needed improvements. They would make sure that all of the bells and whistles are turned on, including efficient documentation tools, appropriate clinical decision support, and electronic interfaces with other parts of the healthcare system. They would ensure that workflows are optimized and users are properly trained. They would be responsible for timely and smooth upgrades of the software and maintenance of the hardware. Their pay would be partially based on provider, staff, and patient satisfaction.

An “Optimal Use” program isn’t needed because doctors are whining. It’s needed because doctors are needlessly burning out, patients are receiving suboptimal care, and an optimized EHR can help. We have reached the point where EHRs are excellent, technology is powerful and affordable, and patients expect the same convenient experience that they get in other parts of their lives. It’s imperative that we take action now. If you are unhappy in a large practice or hospital system, follow Drs. Fisher and Doret’s advice and get involved. If you are unhappy in a small practice, also follow their advice but talk to your friends in the payer sector or in government to help fund an “Optimal Use” program. And if you are like me, loving my EHR and the experience I give to my patients, then spread the word about how good EHRs can be.