Solving information overload in the EHR

I have been using electronic health records now for over 10 years.  Like most physicians who have used EHRs, I would not ever go back to a paper-based medical record.

Having said that, it is important to recognize some of the potential problems created by some EHR products.  One potential pitfall of some EHRs is the number of steps it takes to find information that is in the system.  Yes, it may be easier to find than in an old paper-based system but it is still far from ideal.  Also there is a lot more information that is accessible.

To illustrate my point, let take a hypothetical scenario that most physicians will recognize from real life.

You are working in a hospital and you note that one of your patients has anemia on the complete blood count test.  Reported along with the hemoglobin are some other important numbers like the average size of the red blood cells.  This helps to narrow down the list of causes of his anemia.  One would of course want to make sure from the patient if there is history of this condition or of bleeding.  In addition usually you would need more data from the EHR:

  • Previous levels of hemoglobin
  • A trend of hemoglobin values over several years
  • Previous work-ups for anemia like reticulocyte counts, iron studies, vitamin B12 levels
  • Previous investigations for bleeding sources (endoscopy or colonoscopy)
  • Notes from previous consultations with a hematologist

This information tends to be quite fragmented in the EHRs which are often organized under categories like lab results, radiology, cardiology, notes, etc.  Reports of a colonoscopy procedure may be found under the notes section and the results of the biopsy done during the colonoscopy may be under the lab results section with no hyperlink between the two.  Recommendations from the gastroenterologist who did the colonoscopy may be found under the letter to patient section.  Collecting this information from the EHR can take a lot of mouse clicks and several minutes depending on the user interface and various hardware, software, database and networking variables.  This is time well-spent as this information can give one a diagnosis or at least guide our approach to care.

Unfortunately, this is usually only one of several issues that this patient might have.  He could have an abnormal kidney function test, a low level of sodium, an abnormality on the chest x-ray (with radiologist recommending a CT scan), a question of a prior heart attack on the EKG etc.  Tracking down each of these thoroughly could take a significant amount of time.

To complicate matters the EHRs may be fragmented between inpatient and outpatient areas requiring additional work to access the ambulatory records.

As all this time starts adding up, it may be quite tempting for providers to simply reorder a set of tests for working up the anemia rather than look up the prior information.  This process is made simpler due to “order sets” that are available in EHRs to make test ordering easier and standardized.  Thus with a couple of clicks you can reorder all the tests and await the results.

One of the potential benefits of EHRs is to prevent duplicate test ordering.  Unfortunately unless we develop ways for providers to more easily review data in a meaningful manner, this dream may not be realized.  The worst part of this scenario is that as providers order more tests, we have more data to review thus perpetuating the information overload.

So what are the possible solutions?

  • Contextually appropriate menus, like a right click on an abnormal test result to get prior test results.
  • Data visualization tools that can generate graphs of trends and associated factors with one click.  While most EHRs have graphing tools, it takes several steps (selecting data range, tests etc) to generate these.
  • Built-in review sets. If we can have order sets for ordering related sets of tests, we can easily develop review sets for looking up test results and make these built-in.  Some EHRs allow providers to create these filters or review sets but a lot of physicians are unaware of this functionality.
  • Have a view that is based on issues rather than dates.  Thus just like your e-mail client’s conversation view, would it not be easier to see a patients problem list and then click on a problem to see all tests, notes, letters etc related to that problem?  Yes it would take some time to tag each item with the problem but the returns would be well worth it.
  • Have a mechanism for capturing the time spent reviewing data and automatically documenting a summary of the data reviewed with hyperlinks to the data in the visit note.  Presently physicians have to document what they reviewed by typing/dictating/copy-pasting into their notes. This is an inefficient process which could be improved. This will help the physician by saving time and also allow for billing using the time code.
  • Dr. Watson and Siri?  Allow the Watson system to analyze the patient’s EHR and then allow querying of the database using a Siri-like voice recognition and natural language processing.

EHRs may be going through a peak of inflated expectations or the trough of disillusionment depending on your point of view (see the hype cycle).  As we start applying innovative technology to EHRs we should soon be on the slope of enlightenment that will help realize their full potential.

Neil Mehta is Associate Professor of Medicine at Cleveland Clinic Lerner College of Medicine and blogs at Technology in (Medical) Education.

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  • Jonathan Marcus

    I’m a physician from Canada.  I am way more technically literate than most of my colleagues.  I am not currently using an EHR for the reasons stated above and because of inflated costs, lack of communication of the various EHR systems, etc.

    There’s no reason, given current capability of technology, that we can’t have such simple and powerful systems.  It’s quite a travesty that we don’t.  We’re literally wasting billions of dollars in lost productivity.  Our patients are also suffering due to this lost productivity and poor communication.

    The EHR companies don’t care.  They are getting government money for their substandard schlock.  They are more concerned about meeting some government standard than they are about pleasing customers like you.

    The key is to create one single national database and have all EHRs read and write to such a database.  The EHRs other purpose would be to be the ‘operating system’ that presents the data to doctors and patients.  If one didn’t like a particular EHR, one should simply be able to turn it off and turn on the system of a competitor.  This would increase competition and allow for quick development of great systems, so that physicians like you wouldn’t have to fantasize for EHRs what can already be done by Google and even our email programs.  We shouldn’t have to tag anything in our EHR.  It should tag itself!

    We need a revolution and we need it now.  So sad that the state of EHR is at least 15 years behind the rest of the digital revolution.

  • Anonymous

    Some people will never embrace technology. Never! Once a neanderthal, always a neanderthal. I know people who have retired from their jobs because they were told that they would be required to begin using a computer. These people were offered computer training but they still retired. Scared to death! You will never change people like this. They still get checks mailed to them and they still go to the local bank branch to cash them. The most advanced of these neanderthals use snail mail. They simply refuse new ideas. They refuse change. We have docs like that too. EHR will catch on in many health centers as we continue to slowly move away from small one-doc and two-doc practices and toward the “big-box” ACO model. The docs that don’t join the migration will simply dry up and blow away. We can’t continue to support a thousand or so small one-doc and two-doc offices in a specific geographical area when we can put it all into a few large hospital owned ACOs. The efficiency of an ACO will force the small operations out of business over time and they will either apply for a salaried job with an ACO or they will retire. Once ACOs become the new way to deliver health care, I see stores like WalMart and other retail department stores offering limited primary health care on a much greater scale. The neanderthals need to either get up to speed or get out of the way because change has already started. It’s time to Occupy Health Care!

    • Jonathan Marcus

      You are right about some people not embracing technology… but these are few and will be replaced by the young.

      But I don’t see that technology will be a force of centralization… quite the opposite.  Technology will allow for decentralization.  It will give the mom and pop shops doctors the same tools and economy of scale that the large groups have.

      We’ve seen this in many industries…self-publishing, ebay (anyone can be a merchant), etc.

      Rather than centralization, homogenization, and depersonalization, technology will help save and enhance the doctor-patient relationship.

      • Anonymous

        It won’t be EHR that drives the migration away from small one and two doctor practices and toward big-box centralization. It will be the gradual desire for patients to migrate away from the failed fee-for-service model that incentivizes sick care and incentivizes keeping the waiting room full. The Affordable Care Act ACO model has rules. ACOs must accept (by law) all patients regardless of health. ACOs must “employ” their professionals (doctors, nurses, technicians, etc.) and all professionals are salaried. The incentive is wellness and good outcomes. The incentive is to see patients less frequently because they are, in fact, well. The ACO still gets paid the same dollars whether the patient is sick or whether the patient is well. So, the idea is to keep them well and spend less on them. The failed HMO model of the past was a hybrid that still included fee-for-service care working against it. The ACO is nothing like the HMO in that all employees on the team work in collaboration and share in money that they don’t spend on a waiting room filled with sick people. I realize this is a very difficult concept for today’s docs to understand. Simply put, the days of volume fee-for-service care (tests, xrays, MRIs, CT scans, blood tests, procedures, etc.) that made docs very wealthy in the past is gradually coming to a close. 

        • Jonathan Marcus

          Good luck with that!  In Canada we tried this ACO model.  It’s called capitation here where doctors get paid per patient per year and in theory this incentive is to keep them well.  Problem is that doctors tend to cherry pick those that are already well.  As you can imagine there is a huge incentive to do this.  Don’t be surprised if doctors find loopholes around taking all comers as there incomes will fall by taking sick patients.  Additionally here in Canada doctors tended to not be available to see their patients when they are sick as there is no additional incentive to do this.  Bottom line is that these systems pay doctors to not see patients.  Say what you want about fee for service but at least doctors get paid to actually see patients.  Fee for service would work better if the end user (patients) has control over how and when a doctor is actually paid…. just like it works with my accountant, lawyer, dentist and most other professionals.  Just because fee for service has incentives to do treadmill medicine and order too many tests is not a reason to go directly in the opposite direction.  Excellence in medicine will only be achieved when the end user gets involved in re-embursing physicians (as in all other industries and the way medicine was practiced for the last few thousand years).   I find it infuriating that government bureaucrats and economists think they can plan their way around human nature and the doctor-patient relationship.  It’s arrogant and they will fail.

          • Anonymous

            Canada spends roughly half per person on health care as compared to America. Everyone in Canada is covered. Talk to average Canadians and, although they aren’t thrilled, they aren’t dissatisfied either. They usually respond by saying, “It works!” So, I guess Canada must be doing something right. Cherry pick? Huh? By even mentioning “cherry picking” you show your ignorance regarding the new law. Obviously, you have not read the provisions in the new Affordable Care Act (ACA). Your post makes absolutely no sense. Why do I even bother replying to your post? It’s pure fantasy. Take some time, grab a cup-o-tea and sit down and read the rules outlined in the ACA regarding ACOs and then come back and talk sensibly.

          • Margalit Gur-Arie

            That’s very good advice, dave, and you should probably do the same because you seem to have some misconceptions regarding ACOs (physicians need not be employed, payments to doctors are fee-for-service based, ACOs don’t have to take patients – patients are assigned to ACOs, payments are better if less care is delivered – shared savings, the measured quality is for process not outcomes, ACOs don’t get paid the same if patients are sick or healthy – they actually get paid more for sick patients,……)

          • Anonymous

            Until you get familiar with the “facts” as contained in the new law and stop spreading lies like most Republicans do here like their rant about death panels and their constant Mediscare tactics, maybe we can have an intelligent discussion. You and your kind had a chance to rehabilitate your own industry but your greed wouldn’t allow it. Now that the goose is dead and you can get anymore golden eggs, get used to the idea of WalMart style and Home Depot style health care. The tiny mom & pop family practices are doomed. You ruined a good thing over decades and only have yourselves to blame.

  • Anonymous

    Great example of a common problem and some innovative solutions that should already be happening.  I think this myth that doctors are techno-phobes needs to be put to rest.  I love my technology!!  I bank online, book travel online, use e-mail almost exclusively, shop online.  But EHR???  Eh….

  • Neil Mehta

    @MirandaHuffman:disqus @facebook-793435623:disqus Thanks for your comments. 
    One way to think about EHR adoption is “Don’t let perfect be the enemy of the good”.  (i.e. don’t wait for EHRs to become perfect).  The problem with this thought is that EHRs are not even close to perfect and some would argue if they are even “Good” in their present state.
    This means they have to get better with time.  They have to!  Some of the suggestions made in the post are obvious to everyone including the EHR vendors.  So why are they not implemented?When adopting EHRs the initial hassle of change in workflow and conversion from paper to digital can be huge.  The benefits are more visible as you use the system more – over several years.  The concern is that once you adopt a system and invest your time, efforts and money in it, at present, it is difficult to migrate if a better EHR system comes along. Most physicians who have used any web application for finance, travel, shopping etc know that the features and user experience of some EHRs are way behind the times.  In an increasingly digital world, EHRs will not go away.  They have huge (but mostly unproven) potential.  They will get better over time.  The big question for each physician is not IF but WHEN is the right time to adopt them!  This is a decision that a lot of physicians are struggling with and need to decide for themselves.

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