STANFORD MEDICINE 2019 EHR NATIONAL SYMPOSIUM

In a relatively short time, health care providers across the U.S. have digitized their medical records. Incentivized by the HITECH Act of 2009, thousands of hospitals and doctors’ offices jettisoned their old color-coded manila folder filing systems and adopted electronic health record (EHR) systems. Today, nearly all hospitals and health systems use them as a primary tool for documenting patient care.

The transition has produced many benefits. Medical errors have decreased. Digitized records have helped improve care coordination and knowledge sharing. And to an extent, they are enabling patients to gain more access to their records.

And yet, this digital transformation has also produced unforeseen side effects. Well-intentioned regulations, billing requirements, and other pressures have led to physicians spending more and more of their time entering notes into their EHRs — often at the expense of time with patients. And as physician burnout has grown to epidemic proportions over the past decade, many feel that the design of EHRs, and their drain on physician attention, are at least partly to blame.

On June 4, 2018, Stanford Medicine brought together health care, industry, insurance, and regulatory experts from around the nation to identify solutions to start rectifying this problem. The mission was two-fold. First, to uncover the systemic issues that have made EHRs a significant burden for physicians. And second, to support the development of a national health care IT infrastructure that is powered by modern, interoperable EHR systems — recognizing that, although digital records have obvious advantages over paper, their full potential has yet to be realized.

This symposium culminated in the creation of a white paper that described the scope of the challenge and outlined actionable steps that hospitals, industry, and regulators could take over the next decade to accelerate change. As part of the 2019 EHR National Symposium, Stanford Medicine convened an expert roundtable discussion representing all stakeholders to assess progress, fine-tune goals, and identify new problems and solutions. The discussion was moderated by Lloyd Minor, MD, the Carl and Elizabeth Naumann Dean of Stanford University School of Medicine. To facilitate a frank and open conversation, the ideas and quotes are unattributed.

Signs of progress

The EHR of the future will be the tool that clinicians couldn't imagine practicing without.

The consensus of the group was that, although there is significant work to be done, EHRs are improving, and that the current environment—with all stakeholders actively seeking solutions—is likely to spur progress. Notably, important regulatory and technical developments are helping to pave the way for accelerated changes.

Regulatory Developments:

·       Information blocking and access: New EHR rules from the Office of the National Coordinator of Health IT (ONC) and the Centers for Medicare & Medicaid Services (CMS) are now under final review with the Office of Management and Budget. As legislated by the 21st Century Cures Act signed into law in December 2016, the new rules define and limit information blocking practices, greatly expand patients’ access to their own medical records, and promote standardized language and platforms to foster application programming interfaces (APIs) that encourage technical interoperability across systems.

·       Evaluation and Management (E/M) Coding: The CMS also recently streamlined its E/M coding regulations to reduce clinicians’ EHR documentation burdens. Aligned with the American Medical Association’s suggestions, the new rules, which go into effect in 2021, may save about two minutes per patient, translating to approximately 40 minutes over the course of a day where a physician sees 20 patients, according to a study commissioned by the AMA.

Technical Developments:

·       The growing use of APIs, including SMART on FHIR, have helped more patients access their records digitally and from different provider organizations. Apple’s Health Records app is a notable example of this trend and is now used by more than 400 hospital systems, clinics, and physician practices. Providers using the Health Records app include Stanford Medicine, Duke Health, Penn Medicine, Johns Hopkins, UCSF Health, University of Chicago Medicine, Kaiser Permanente, and the Department of Veterans Affairs, which cover a combined 9 million patients.

·       Improvements in artificial intelligence and natural language processing (NLP) show the potential to ease the burden of clinical note taking, but considerable challenges remain. Decoding the complexity of medical terminology and nuance of clinical workflows represents a high barrier that must be addressed before EHR tasks can be significantly offloaded to AI. As one roundtable participant put it: “If you look at conversational expectations [of an AI], current technologies can handle ‘pepperoni or sausage’ for a pizza order, not 12,000 drugs.”

Freeing doctors to do their jobs

“Technology needs to move toward enabling teams to work better together. One of our goals in the next 10 years is for the doctor to not have to touch the keyboard or the mouse.

A major unforeseen consequence of EHR adoption is that physicians now spend roughly half of their workday entering notes into an EHR. Additionally, insurance, regulatory, and legal requirements have greatly expanded the scope of the original medical record, creating bloated and unwieldy notes.

The participants brought varied ideas to the table to address this:

·       Conduct evidence-based reviews of current EHR practices to scale nationally those of high value while retiring others. These reviews would more effectively quantify the real-world impact of EHR regulation on medical practice, helping to inform future federal policies governing EHR adoption and use.

·       Seek further regulatory relief that would allow nurses and other care team staff to have a greater role in building and maintaining patients’ health records. EHR regulations should recognize that care delivery is a team-based effort.

·       Take back the note. A number of participants suggested variations on the idea of reserving the traditional EHR note for clinical use, moving information related to billing, legal, and other regulatory requirements elsewhere. “What I would like to see is separating out the information physicians need,” said one participant. “The part that we’ve really fallen down on is the EHR as a communication system. It is a lousy communication system.”

Patient-first proposals

“I want the EHR to provide timely, pertinent, nonredundant, personalized, integrated, confidential, portable information. As a patient, that’s what I want.”

For EHRs to reach their full potential, they must be useful tools for patients as well. Opening access to health records might meet the letter of the law, but falls short of fulfilling the spirit of it. Patients shouldn’t be required to wade through complex medical and billing terminology that provides no context when making health decisions. Additionally, other ideas raised during the discussion included:

·       Empowering patients and caregivers to contribute information to the medical record, recognizing that they have valuable context to add to clinical discussions. As one person put it, “Storytelling is at the heart of the doctor-patient interaction and clinician-clinician interaction. We humans know how to do that. Whatever we can do to foster that notion is good.”

·       Leveraging EHRs as a tool to make costs of care more transparent, for both patients and physicians. As more care transitions to value-based payment arrangements, and as patients increasingly shoulder higher out-of-pocket costs, this information would be beneficial to inform decision making.

·       Making digital records more accessible and shareable cannot come at the expense of patient privacy. The group acknowledged that herein lies a complex web of decisions, protections, and trade-offs that must be considered and balanced. In the 21^st Century Cures Act, for example, APIs are prioritized to give patients the flexibility to share their records as they see fit, including with third-party health app developers. However, these developers are currently not covered by federal privacy laws such as HIPAA. Patients authorizing third-party apps to access their records creates an even greater need for easy-to-understand privacy controls to enable patients to share and protect their information according to their wishes. A few roundtable participants felt a need to update HIPAA regulations to define third-party developers as “covered entities” to hold them accountable to the same stringent privacy standards as health care providers.

·       Finally, some participants felt that EHR systems needed more robust safety features to protect patients, including a real-time error reporting function. Having a national error reporting center for EHRs, for instance, would help track medical errors linked to problematic software design or user interface issues that could be prevented in the future.

Great expectations

“I want the electronic health record system to make me a better doctor.

 “I’ve spent the last four years trying to explain to my 7-year-old daughter what I do and [how] it is ongoing. But just last week, she said, shouldn’t the EHR contain all the information needed so I can be treated well?

“The EHR is a limiting concept. It’s oriented around a visit-based model of care, and I think looking ahead, a lot of care isn’t going to fall into that model.

“ Expectations are changing. How do we develop a true learning health system? We have to raise the bar on how quickly we’re moving because incremental changes aren’t going to be enough.

The above comments speak vividly to the high expectations for EHRs, which have continued to evolve since the technology was first deployed at scale in 2009. They also hint at two visions of the future that emerged during the roundtable discussion.

In the first, EHRs will remain the primary focus of technology development and will be optimized for the clinical setting, while serving the needs of other key stakeholders (e.g., patients, insurers, caregivers).

The second envisions a more democratized future, where the EHR is just one input among many others (wearables, genetic testing reports, patient notes, etc.) within a broader platform. One participant referred to this idea as an “individual health record.” Such a record could be system agnostic and owned by individual patients.

Ultimately, these visions are not mutually exclusive. The original goal of digitizing health records was to create systems that would lead to more personalized care for patients and help them achieve superior and equitable outcomes. While many paths to these goals exist, significant progress will demand the continued engagement of all stakeholder groups.

As the discussion wound down, one participant asked another big question: “In the next two or three years, do we need a big national effort, such as another stimulus, to make progress in one area or do we continue to let a thousand flowers boom?” Going forward, those with a stake in the future of EHRs must have this conversation.

MODERATOR:

Lloyd Minor, MD, Dean, Stanford School of Medicine

PARTICIPANTS:

Sam Butler, MD, CMO, Epic

Andy Gettinger, MD, Chief Clinical Officer, ONC

Michael Halaas, CIO, Stanford School of Medicine

Ed Lee, MD, EVP of IT and CIO, The Permanente Federation

David Entwistle, President and CEO, Stanford Health Care

Bill Hagan, President, United Healthcare Clinical Services

Ed Kopetsky, CIO, Stanford Children’s Health

Paul King, President and CEO, Stanford Children’s Health

Josh Mandel, Chief Architect, Microsoft Healthcare

Amy Merlino, MD, CMIO, Cleveland Clinic

Julia Milstein, Associate Professor & Director, CCIIR, UCSF

Natalie Pageler, MD, CMIO, Stanford Children’s Health

Marc Overhage, MD, VP, Population Health Intelligence Strategy, Cerner

Raj Ratwani, Director, MedStar Health National Center for Human Factors in Healthcare

Topher Sharp, MD, CMIO, Stanford Health Care

Vanila Singh, MD, Clinical Associate Professor, Anesthesiology, Stanford Medicine

Chris Sinsky, MD, VP, Professional Satisfaction, AMA

Hemant Taneja, Managing Director, General Catalyst

Thomas Van Gilder, MD, Chief Medical and Analytics Officer, Wellness, Walmart

Allison Weathers, MD, Assoc. CMIO, Cleveland Clinic

Ashwini Zenooz, MD, Senior VP and GM for Healthcare & Life Sciences, Salesforce