The [EHR] Doctor is in

Rebecca G. Mishuris, MD, MPH, MS, Associate Chief Medical Information Officer, Boston Medical Center & Assistant Professor, Boston University School of Medicine

When patients come to me with “I’d like an antibiotic for my cough” my first instinct is to say “Let’s talk about your cough and figure out the best course of treatment.” The same is true when a user of the EHR comes to me with a request for a specific feature in the EHR – “Let’s talk about your issue and figure out the best course of action.” Quite often it is not either the requested antibiotic or the requested EHR feature that is actually needed.

I am part of a large group of physicians and other clinicians, including nurses who have an interest in making the EHR work better for delivering care to patients. We are called informaticists, informaticians, and sometimes even “the EHR lady”. One of the many roles we play is to help diagnose your problem and solve it – when it comes to how you interact with the EHR. Most often the diagnoses involve both operations issues and information technology issues (also training, experience, folk lore, regulatory, security, privacy, safety, and every other type of issue), and we are trained to recognize and help resolve them. We are also physicians with intimate knowledge of the work of caring for a patient, giving us a unique perspective on how an EHR should be designed to support that endeavor. We know that every click is a burden, because we make the clicks, too; we know that there are regulatory requirements that healthcare delivery systems must adhere to; we know that there are data and reporting needs and requirements at many levels; we also know that the EHR can be harnessed to improve care and outcomes while simultaneously putting the joy back in medicine.

The EHR is often cited as one of the main contributors to the trend of increasing physician burnout. How do we turn this around?

Atul Gawande recently wrote in The New Yorker about the frustrations physicians have working with computerized records, and the divide it can cause when caring for a patient. While I don’t disagree that this is one possible effect of an EHR implementation, another is that the EHR can actually work for you and make you more effective and efficient – there has to be a mechanism to raise and address these concerns, however. Gawande cites some common complaints with having to put discrete information into the EHR – some of this arguably could be fixed in his system by being taken automatically from other areas of the chart, using a default value, and otherwise improving the workflow. The need for this discrete information should also be examined – who is using it and is it really necessary? Does the physician have to be the one who enters it? Does it need to be discrete, or could natural language processing help identify the necessary elements? We should be examining clinical workflows and then designing the technology to support it, rather than forcing the clinician to conform to the technology.

The EHR is often cited as one of the main contributors to the trend of increasing physician burnout. How do we turn this around? How do we design an EHR that helps physicians do their work more effectively and efficiently? Here are five things you can do as you implement or optimize your EHR:

1. Involve end-users in the design of the system

2. Start with the clinical and operational workflows and design the system to meet those needs, rather than the other way around.

3. Emphasize the need for not just initial training, but ongoing training and personalization of the EHR with end users. Personalization is one key way to improve efficiency.

4. Measure the impact of the system. Design changes will be better informed if you have data to know how the system is being used and the impact it is having.

5. Encourage a culture of problem solving rather than learned helplessness. Areas for improvement are much more likely to be addressed if an end user raises them as issues rather than internalizing them in a negative way.

Much the same way we encourage patients to tell their physician if something is wrong, encouraging end users to speak up whensomething is bugging them about the EHR is the primary way to help identify a problem. The EHR has to be designed to support the work of health care professionals to effectively and efficiently care for a patient. While I, and many other medical informaticists, are spending our careers trying to make sure it does, it helps when the entire health care community remembers that we are all in this together.

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