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Meeting the Unfulfilled Promises of EHRs

Transforming data into action in healthcare

"We are not trying to control the doctors; we are trying to get the doctors to control the system."1

Though electronic patient records have been around for more  50 years,2 for the past decade, U.S. physicians have been navigating one of the largest health information technology roll-outs in history. Promising increased efficiency, improved access to relevant clinical information, and funded by federal dollars, the recent rise in electronic health records (EHRs) has been met with both fanfare and fear.

Over the past decade and a half, the percentage of office-based physicians using any EHR has risen from less than 20 percent to nearly 80 percent.3 Today, the federal government, private industry and the consumer/patient market demand that EHRs replace written records in healthcare entirely, while adding functionality, often termed "analytics."

The functionality promised by many EHRs can also result in a deluge of data that threatens to bury busy physicians. As the EHR transition passes, the need exists for healthcare teams to be able to access not only data, but truly actionable knowledge from this data that can help transform clinical decisions and ultimately improve patient outcomes.

Though many physicians now have access to EHRs with basic functionality,4 industry reports show low satisfaction with EHRs among the healthcare provider community. Recent reports suggest 70 percent of physicians deem their EHR initiative "not worth it";5 and more than 20 percent of physician practices will replace their existing EHR platform over the next five years.6 In part, this dissatisfaction stems from the unfulfilled promises of EHR interoperability and analytic value. Interoperability is that quality of an EHR that allows it to work with other EHRs as well as other electronic information systems. Analytic value is the ability of an EHR (or other system) to arrange and present data in an informative way that enhances practitioners' knowledge and allows for action to be taken within existing workflows.

As the quote at the top of this article from Dr. Terry Clemmer, notable health system informaticist of Intermountain Healthcare (Salt Lake City, Utah) suggests, the aim of health information technology, including analytics in particular, is to give clinicians control over the data and disparate systems in which they work. As an industry, we must deliver healthcare analytics that better meet some of the unfulfilled promises of EHRs and provide real value to practicing physicians.

Analytics: Meeting the 3 "I's" of Health Information Technology
Analytics has been defined as "the discovery and communication of meaningful patterns in data".7 Humana CIO Brian LeClaire identified the "three I's of health information technology" needed for the successful use of analytics in healthcare: integration, insight, and incentives.8 By addressing these key factors, as an industry, we can better ensure not only adoption of EHRs and analytics, but real benefit to care teams and patients.

Integration
Integration is the normalization, de-duplication, and combination of data and its storage in a common location. Some refer to this location as a "data lake," and refer to such data as "liquid." Data must be refined and presented appropriately in order to be informative.

Insight
Insight is the conversion of information into knowledge, and analytics are a key tool in this conversion. Analytics derives insights not just from clinical (e.g., EHR) information, but also from administrative (e.g., medical claims) information and consumer information. Useful analytics delivers these insights where they are needed - in the clinical record, in population health reports, and in a variety of applications, including mobile applications - easily accessible during patient appointments to inform care decisions.

Incentives
The final "I", incentives, needs to be seen in a broad context. Dr. Don Berwick, former Center for Medicare and Medicaid Services (CMS) administrator and founder of the Institute for Healthcare Improvement (IHI), has said, "If clinical front-line staff decide they do not want to make changes then no one outside the health care system can be powerful or clever enough to make them do so."9 Incentives must not merely be financial or punitive. Rather, incentives should involve sufficient benefit to care teams to motivate real change. As physicians are called upon to leverage health information technology, success of adoption relies on ensuring analytics provide "news they can use" - actionable information that both eases their workflow and can help them improve the health of their patients.

Incentives should also increase adoption and repeat usage of analytics output. Tools supporting physician practice, for example, need to enhance rather than distract from patient care, adding value to each click, swipe, or view. The emerging field of cognitive ergonomics describes the importance of understanding physician workflow, and how physicians and other clinicians access and use information and take action based on that information. Factors such as mental workload, decision-making, skilled performance, human-computer interaction, human reliability, work stress and training10 directly impact physician adoption of health information technology tools. Analytics tools must meet these needs if they are to be adopted in our hospitals and physicians' offices.

Finally, an often overlooked aspect of "incentivized analytics" is patient involvement. The most powerful opportunity for action is often at the point of care. For analytics to have the greatest impact, analytical output needs to be available at the bedside or in the exam room in order to engage patients and make meaningful, informed care decisions to ultimately improve health.

Analytics: The Importance of Place
Analytics, properly understood and executed, is critical to population health management and to maximizing return on the considerable time and financial investment in EHRs. Evaluating the appropriate place - both timing and location - for analytics in EHR systems and adoption is critical.

The Healthcare Information and Management Systems Society (HIMSS) created an adoption model that identifies the level of EHR capabilities for an institution,11 presenting a useful framework for considering the timing of analytics. The model suggests that clinical decision support, one of the outputs of analytics, is adopted in later stages by most health systems. However, EHR user frustration suggests that physicians and other care team members may be more engaged and better served by bringing analytics in at earlier stages to enhance functionality, usability and ultimately integration with existing workflows and care protocols.

In the sense of place as location, analytics have a natural home in many EHRs. However, EHR user interfaces (UIs) are not always suitable for all data presentations. Furthermore, not all physicians are comfortable with relying on desktop EHRs in the exam room or at the bedside. As such, the display of analytics outside of, or above, the EHR is an important option of growing interest. Analytics presented on a mobile device could facilitate greater clinician-user satisfaction and engagement and promote patient interaction with analytics.

Advancing Analytics: Physicians in the Driver's Seat
As healthcare delivery and medical practice continues to evolve, as data is transformed into information, into knowledge, and then into action, physician leadership is needed. Leadership is "the art of motivating a group of people to achieve a common goal."12 For many physicians, the goal is IHI's Triple Aim13 of improved population health, controlled health care costs and enhanced patient experience. The diverse data available today, transformed by analytics into actionable knowledge, can be a powerful enabler of physician leadership both at a population level and at an individual patient level.

Analytics must be another tool in a physician's therapeutic toolkit to improve the wellness of patients in their care. The therapeutic application of data should evolve as pharmaceutical therapies have evolved: from non-standard, locally available, do-it-yourself "remedies," to consistent, reliable, credible, and actionable knowledge applied at the point of care - or whenever needed - to improve patient care, experience and outcomes.

Thomas J. Van Gilder, MD, JD, MPH, is Chief of Medical Services, Certify Data Systems. Certify Data Systems is redefining value-driven care with a fully-integrated population health platform offering HIE + Analytics to improve care coordination. The company is a wholly-owned subsidiary of Humana, Inc. 

  1. Terry Clemmer MD, Intermountain Healthcare, 2002, as quoted in Bohmer, R. The instrumental value of medical leadership. The King's Fund. 2012, pg. 4.
  2. IOM (Institute of Medicine). 2014. Capturing social and behavioral domains in electronic health records: Phase 1. Washington, DC: The National Academies Press, pg. 22.
  3. Hsiao C-J, Hing E. Use and characteristics of electronic health record systems among office-based physician practices: United States, 2001-2013. NCHS data brief, no 143. Hyattsville, MD: National Center for Health Statistics. 2014.
  4. Hsiao C-J. Id.
  5. Verdon DR. Physician outcry on EHR functionality, cost will shake the health information technology sector. Medical Economics, Feb. 10, 2014, found at http://medicaleconomics.modernmedicine.com/medical-economics/news/physician-outcry-ehr-functionality-cost-will-shake-health-information-technol. Last accessed April 16, 2014.
  6. Larsen D and Abbott C. Leerink Swann Healthcare IT & distribution: 2014 HIMSS takeaways. March 4, 2014, pg. 2.
  7. Sanders D, Dr. David A. Burton D, and Protti D. Healthcare Analytics Adoption Model: A Framework and Roadmap. Health Catalyst white paper, found at http://www.healthcatalyst.com/white-paper/healthcare-analytics-adoption-model. Last accessed April 16, 2014.
  8. Brian LeClaire, Chief Information Officer (CIO) of Humana, Inc., personal communication.
  9. Don Berwick, 1994, as quoted in Bohmer 2012, pg. 5.
  10. From the International Ergonomics Association website, http://www.iea.cc/whats/index.html, last accessed April 16, 2014.
  11. http://www.himssanalytics.org/docs/HA_EMRAM_Overview_ENG.pdf. Last accessed April 16, 2014.
  12. The King's Fund Commission on Leadership and Management in the NHS 2011, quoted in Bohmer 2012 p. 5.
  13. The Triple Aim-improving the patient experience of care, improving the health of populations, and reducing the per capita cost of care-is IHI's initiative to guide health systems in optimizing system performance. See www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx, last accessed 4/24/14.


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