Taking Ambulatory EHRs From Obstacles to Enablers of Care

Oct 23, 2018 at 03:50 pm by Staff




By Dana Bensinger and Jeanette Ball


If there has been one consistent mantra among physicians about technology, especially those in ambulatory settings, it's that electronic health records (EHRs) get in the way of the patient/provider relationship. Physicians complain that they spend more time looking at the screen than at their patients, and long for the "good old days" of paper when they could spend more time with patients and understand their needs at a deeper level.

While what they say is largely true, it isn't the EHR itself that's the issue. It has more to do with the way EHRs were originally deployed.

When the Health Information Technology for Economic and Clinical Health (HITECH) Act was passed, the goal was noble. It was to take all of the data physicians were gathering individually on paper and make it available in the aggregate to help drive large improvements in overall health. There's certainly nothing wrong with that.

Unfortunately, in our enthusiasm to make it happen, the focus was placed on putting some sort of EHR in place rather than on building systems that enhanced clinicians' workflows--or actually made it easier to share data between providers. That emphasis on technology over utility brought us to where we are today.

As an industry, healthcare has learned a lot since that time. We actually understand what is wrong and how to fix it. But after the last 10 or so years of misfires, there's an understandable trust issue among physicians and other clinicians when we tell them we have a new approach that will optimize the EHR and give them more time to spend talking with their patients.

We can't speak in generalities; we need to be specific. Here's what needs to be done to make EHRs better--and the benefits clinicians and their patients will realize.

Use data to enhance the clinical visit

One of the big complaints has been that requiring clinicians to gather all of this data has made interactions with patients more difficult, yet little has been done with data. That is one of the first changes that needs to be made.

Instead of being a passive repository for historical data, the EHR needs to present useful information to physicians and other clinicians at the time of care to help improve health outcomes while enabling value-based care. When clinicians open the patient's record, there should be a section on the home screen that uses rules-based logic to highlight what tests or screenings the patient should have based on both population health data and the patient's own medical history.

It can be as simple as a notification that the patient will be 50 years old this year and thus should receive orders for a colonoscopy. It should note whether female patients of a certain age need their yearly mammogram, with logic built in to exclude those who have had double mastectomies and high-risk patients who should have their mammogram before the age of 50. It should also have more patient-specific messages, such as that a transgender male may still need a pap smear.

These notifications can also be used to help manage patients with chronic conditions. For example, the EHR can include a reminder that a diabetic patient is due for eye or foot exams, or needs updated laboratory tests. It can also remind the physician to enter the diagnosis of diabetes, even if the patient has come in for a non-related illness or injury, to ensure the Hierarchical Condition Code (HCC) is captured and submitted to Medicare for accurate risk adjustment.

All of this information has tremendous value to physicians and other clinicians who want to do a better job of treating patients and keeping them healthy. This alone makes the EHR an enabler of, rather than an obstacle to, care.

Take a team approach to data gathering

To make point #1 work, providers must collect the right data in the EHR. But that doesn't mean it must be done by the physician alone.

Much of the background data can be obtained by registered nurses, medical assistants, or others in the practice. In many cases, this may require changing the makeup of the practice itself or tweaking roles to ensure everyone is working at the top of their license. By making this change, physicians are less collectors of data and more consumers of data, freed to use the EHR in a way that allows them to spend their limited time with patients on high-value activities that will improve health and wellness instead of data gathering.

Change workflows

The same team approach can be applied to workflows within the practice. Pre-visit planning can be led by nurses, care managers, or others to identify care gaps that can be addressed by the care team during an upcoming visit. Here's an example:

As nurses and staff conduct the morning huddle, they see in the EHR that a diabetic patient who is coming in to receive her flu shot has not refilled her statin prescription in several months. When the nurse is rooming her, she can mention the prescription and discuss why this medication has not been refilled.

The team can also look at user-collected data, either from formal telehealth programs or the patient's own wearables, to see if there are any concerning trends, such as a chronic heart failure patient gaining two or three pounds overnight, indicating possible exacerbation of their heart failure. If so, an alert can be added to the EHR so the physician knows to address it during the office visit or the care manager knows to make a call to the patient at home.

If the practice is sharing data with a local hospital or specialist providers, the care team can incorporate that data with their EHR, and during a transition-in-care follow-up call, review all medication to ensure the patient understands any new or discontinued medication. This will help prevent issues with a patient unknowingly taking incorrect dosing or potential medication conflicts, which require immediate attention, and the care team can address them with a call or during an office visit.

By working together, they can use the EHR to maximize the value of the visit and take steps while the patient is there that support the goals of a value-based, outcomes-focused approach to healthcare.

Manage social determinants of health

Social determinants have a profound effect on a person's health outcomes. The care team plays an important role in capturing these barriers to health. To ensure an understanding of the environmental influences affecting patients, the clinical team needs to dig deeper to capture social determinants. At first, this may be an uncomfortable conversation for staff used to dealing solely with clinical questions, but it is necessary to uncover and address these fundamental barriers to health with community solutions.

The EHR should be optimized to capture this type of information. After all, it makes little sense to tell a single mother working two jobs to get more exercise by walking when her neighborhood is dangerous at night. It's tough for a low-income diabetic to eat healthy when fast or processed food is cheap and plentiful while raw foods are scarce and expensive in his neighborhood.

By capturing social determinant information and making it available in the EHR, physicians, nurses, care managers, and others can work with the patient (and outside agencies where appropriate) to develop a plan that is not only effective, but practical.


Change of thinking

The reality is any tool is only as good as how it is used. By optimizing the EHR to help drive outcomes and gather information efficiently, as well as re-thinking who uses it for what, providers will view the EHR as a tremendous enabler of effective patient-centered care rather than an obstacle to it.


Dana Bensinger and Jeanette Ball are Client Solution Executives with CTG, a company providing industry-specific IT services and solutions that address the business needs and challenges of clients in high-growth industries in North America and Western Europe. Visit www.ctg.com.