- Costly, labor-intensive EHR implementation projects require a full-court press from all hospital staff and health IT experts involved. However, the process of refining and streamlining an EHR system to maintain a level of provider satisfaction and accommodate the constant influx of developments in health IT lasts long after the initial launch.
EHR optimization requires that healthcare organizations continually modify and improve their technology to meet the needs of physicians, nurses, and various other staff members.
While EHR optimization can improve patient health outcomes, provider communication, and the pace of daily clinical tasks, persistent problems can slow the process and cause additional frustrations.
The following is a list of three of the most challenging barriers to EHR optimization:
Achieving EHR standardization
Lack of EHR standardization can cause problems with interoperability, clinical efficiency, and transitions of care. Ensuring a hospital or health system maintains a level of consistency across care settings and facilities can obstruct efforts to streamline healthcare delivery.
According to a study archived in the National Library of Medicine at the National Institute of Health, problems with EHR standardization can hinder the success of primary care teams in the process of optimizing their EHR systems.
Conducted by Pandhi, MD et al., the study was part of a formal evaluation of primary care team building and quality improvement initiative at a health system utilizing an Epic EHR system. Analysts focused on optimization efforts supporting improvements with existing EHR functionalities rather than developing new functionalities.
Researchers experienced difficulties trying to help care teams use the EHR system in a consistent way.
In particular, researchers observed what appeared to be “tension between EHR decisions being made by top HIT leadership and changes in grassroots team empowerment to improve clinical care processes,” according to the report.
This inability to enforce standard use of health IT is emblematic of a larger problem with enforcing standardization across care settings.
Cerner Vice President of Interoperability Kashif Rathore also cited issues with health IT standardization across a variety of care settings as a challenge to EHR optimization and health data exchange.
Certain venues have stricter regulations governing EHR use and health IT standardization, presenting challenges to interoperability.
“What we need to remind ourselves is that care is happening in multiple venues,” Rathore told EHRintelligence.com. “You’re seeing patients in homes, in long term care facilities, and in hospices. That’s the ecosystem we live in today. So it’s not necessarily just the clinic in the hospital, but multiple venues of care.”
“In some of these areas, we lack interoperability standards,” he continued. “In many venues where the standards aren’t enforced or followed, it makes data exchange hard. It still happens to be a limiting factor.”
In response to this inhibitor to interoperability, Cerner participates in the CommonWell Health Alliance.
“The CommonWell Health Alliance is a network we are using to further interoperability at the national level,” he said. “For national standards and national connectivity, that is the network we are relying on.”
Like Cerner and the CommonWell Health Alliance, researchers at the Regenstrief Foundation have made strides in improving and streamlining health data standardization for more efficient EHR use, provider communication, and health data exchange.
The foundation is responsible for developing the Logical Observation Identifiers Names and Codes (LOINC) system. LOINC has provided standardization in medical test result identification, observations, and a variety of other clinical measures used in hospitals, health systems, and physician practices on a daily basis.
"The impact of LOINC and data standards generally is enormous and far reaching," said Regenstrief Foundation President and Dean Emeritus of Indiana University School of Medicine D. Craig Brater, MD. "Such programs often struggle for traditional external sources of funding. If they must charge fees to survive, those fees are often of sufficient magnitude to preclude use by many. The Regenstrief Foundation’s goal is to provide a source of stable support for LOINC that will allow it to continue its great work indefinitely while also enabling access to its expertise by all."
LOINC is the most widely-used code system in the world and promotes interoperability with more than 2,000 new terms for tests and clinical observations available per release through requests from end users.
The data standard includes over 80,000 clinical and laboratory test codes used in 172 countries, and it has been translated into 12 languages.
"Health data standards like LOINC are essential to enabling the kinds of data sharing and analyses that are increasingly essential to the practice of medicine and the conduct of biomedical research," said Regenstrief Institute President and CEO Peter, MD.
Establishing health data standards using code systems such as LOINC assists in reducing problems with consistency in communication and health data exchange likely to limit improvements in EHR use.
Addressing EHR data reporting requirements
Sufficiently minimizing inefficiencies can be the deciding factor between physician burnout and physician satisfaction. However, federal reporting requirements and accompanying administrative burden present a challenge to healthcare organization’s attempting to reduce a physician’s overall hours per day in front of a monitor.
A study published by the American Medical Association (AMA) this year found administrative burden to be one of the top challenges facing respondents.
AMA surveyed 1,200 physicians, residents, and medical students about their careers, professional challenges, and level of job satisfaction.
Administrative burden also surfaced as one of the most significant contributors to physician burnout in a post by healthcare CEOs on Health Affairs Blog.
“The high level of burnout among physicians should be considered an early warning sign of dysfunction in our health care system,” wrote healthcare CEOS. “Professional satisfaction for physicians is primarily driven by the ability to provide high-quality care to patients in an efficient manner. Dissatisfaction is driven by factors that impede this effort, including administrative and regulatory burdens, limitations of current technology, an inefficient practice environment, excessive clerical work, and conflicting payer requirements. High levels of physician burnout can thus be seen as an indicator of poor performance by the underlying system and environment.”
While EHR optimization can be useful in minimizing inefficiencies and streamlining clinical workflows, little can be done to reduce the amount of time physicians must spend working with their EHR systems to fulfill reporting requirements.
However, associations and provider organizations throughout the industry have periodically issued proposals and submitted letters to CMS Administrator Seema Verma requesting simplified reporting requirements to ease issues in this area.
In June, CMS responded to these requests with a proposed rule simplifying to Quality Payment Program (QPP) as required by MACRA.
Modifications to QPP primarily benefited smaller, rural practices and took provider feedback regarding the stress of complex reporting requirements into account.
“We’ve heard the concerns that too many quality programs, technology requirements, and measures get between the doctor and the patient,” said CMS Administrator Seema Verma. “That’s why we’re taking a hard look at reducing burdens.”
The American Medical Association (AMA) and others that had issued letters requesting relaxed requirements in the past praised these changes as useful in reducing the likelihood of physician burnout as a result of administrative burden.
“CMS is proposing a number of policies to help physicians avoid penalties under the Quality Payment Program,” said AMA President David O. Barbe. “In particular, it is suggesting several actions to assist small practices. The Administration showed it heard the concerns raised by the AMA on behalf of practicing physicians.”
While federal reporting requirements are outside the realm of what healthcare organizations can modify or improve during an EHR optimization project, associations have been successful in petitioning and proposing changes to further streamline the provider workday and minimize inefficiencies surrounding EHR clinical documentation and quality reporting.
One aspect of EHR optimization healthcare organizations can significantly impact is EHR usability.
However, reducing the number of clicks per day for physicians remains a challenge, and federal organizations are stepping in to voice concerns regarding the lack of progress on this front.
Improving EHR usability
EHR usability improvements have been cited as one of ONC’s top priorities moving forward in 2017 alongside EHR interoperability. While usability is an overarching industry goal, individual healthcare organizations seek ways to improve provider satisfaction surrounding EHR technology.
Many problems with EHR usability targeted during EHR optimization surround technical design and data presentation. Collaborating with vendors to improve design can be an arduous undertaking requiring a complete overhaul of a current system.
To mitigate hassle associated with these usability problems, Chief Nursing Officer at ONC Rebecca Freeman, PhD, RN suggests enlisting the help of nurse informaticists familiar with the inner-workings of EHR technology to approach design and data analytics issues.
Nurse informaticists, according to Freeman, possess the necessary skills to optimize health IT for data quality improvements and reporting purposes in ways that focus on reducing a physician’s time in front of an EHR.
“Nursing informaticists transform the usability of health IT systems in their facilities and practices,” she wrote in a blog post on HealthITBuzz. “Trained with a diverse set of tools to expertly triage and correct any system, workflow, training, and accountability issues, they lead the partnerships between their frontline clinicians, super users (i.e., bedside clinicians who receive additional health IT training), and IT clinical analysts and builders.”
Like on-site health IT experts, nurse informaticists possess technical skills other staff members may lack and are capable of triaging EHR optimization problems to streamline clinician workflows.
“Nurse informaticists possess the ability to mediate and moderate governance and interdisciplinary committees to align practice, health IT, analytics, and outcomes, and they are capable of significantly impacting the usability of health IT across the health care system,” wrote Freeman.
These hospital staff members can assist in surmounting flaws in EHRs to improve user productivity and reduce frustration.
EHR optimization requires significant adjustments across the continuum of care. Overcoming challenges with EHR standardization, burdensome reporting requirements, and EHR usability necessitates a several-pronged approach from health IT companies, policymakers, and members of the care team.