It turns out that inconsistencies around patient death status in the EHR is a pretty common occurrence. A recent report in JAMA Internal Medicine investigated the prevalence of outdated EHR information using records from seriously ill patients at UCLA Health. From the 12,000 patients identified in this category, 676 were marked alive in their health records but were actually dead in state public records.

It gets worse.

As these patients were still assumed to be alive, 541 of them still had appointments scheduled after their death. These patients continued to be contacted by health care staff and received approximately 221 calls and 338 portal messages unrelated to their deceased status. Additional contact attempts urged these patients to get preventative care like flu shots and cancer screenings, and medications were still being authorized for at least 88 dead patients. 

This mistaken follow-up is not only wasteful for the health system, it could be upsetting for family members to receive these messages. Inconsistencies in EHR data could also be perpetuated in AI algorithms trained on this data, which would make these tools less accurate. 

Drivers of EHR inconsistencies

A part of the problem lies in the fragmented nature of EHRs. The average health system uses 18 different EHR vendors across affiliated providers. But these EHR systems aren’t always able to talk to one another, meaning patients may still struggle to access their data, doctors may order duplicate testing, or need to transfer health data with fax or a CD. With so many data sources trying to provide a total view of the patient, it is easy to see why a patient may be marked as deceased in an EHR used for inpatient services but their specialist or primary care doctor may have no idea. And the fact that many EHRs cannot link up easily with federal and state records makes recording patient deaths a much harder task.

Even without interoperability issues, verifying patient death is not easy. Health systems have to access state records to confirm patient death, and ease in state accessibility varies. Even if the patient is found in state records, if they have a common name, there may not be enough information for health systems to verify that it’s the right person. Research services have to be contracted out to do a deeper search, but if the patient can not be linked to a social security number, or the information in their EHR is insufficient, a deceased status can not be officially confirmed. Internal departments often do not have an organized system or incentive to verify a flag in a patient’s chart indicating their death. 

Dr. Eric Cheng, chief medical informatics officer at UCLA, explained challenges with coordinating this information, in an interview with StatNews: 

“If a patient were to call the clinic or a doctor and say a family member died, we don’t necessarily do the best job in documenting that the same way. Physicians don’t know whether that’s stored, the front desk clinic may not be comfortable if they’ve never heard of the patient — they would all document in the note, but not in the official place where it should be.”

Dr. Eric Cheng, chief medical informatics officer at UCLA, in StatNews

How can EHRs be improved?

Creating requirements and standards for interoperability has been a goal for CMS for many years—and now it appears real change is finally on its way. CMS launched the Trusted Exchange Framework and Common Agreement (TEFCA) in December 2023, providing much-needed standards and allowing public-private collaboration to address gaps in health information exchange across EHR systems. Five organizations known as Qualified Health Information Networks (QHINs) are officially signed on to use this framework and can start exchanging data immediately. Hopefully, many others will follow. 

Patient misidentification not only contributes to poor tracking of death records but can also cause trauma and delayed care. To prevent this, another potential solution is creating unique patient identification numbers, a policy supported by some specialty groups, health systems, and industry organizations. 

A large part of making hospitals more accountable starts with having an efficient EHR system that keeps patient values as the focus. As solutions are being pushed, we hope to see advantages also impact entire health systems by preventing physician burnout, reducing administration costs, and providing high quality care.

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In reality, EHRs have made clinicians’ jobs harder without improving quality of care. From the start, EHR development was privatized, leading to a fragmented system of records that don’t connect automatically across institutions. EHRs were built primarily as a tool for billing rather than for clinical care, so performing seemingly simple tasks like bringing up a patient’s medication list can take dozens of clicks.

The structure of EHRs creates another serious problem, which Dr. Saira Shervani at the University of Chicago Medicine and colleagues discuss in a recent “Teachable Moment” article in JAMA Internal Medicine. Shervani et al share a story of a woman with a history of epilepsy who was admitted to the hospital due to recurrent falls and instability. They eventually discovered that she was experiencing adverse events from a duplicate epilepsy drug that was deprescribed by her neurologist, but had continued to be dispensed by the pharmacy.

Why would the pharmacy keep giving the patient a drug that her clinician had discontinued? Because when the neurologist discontinued the drug in the EHR, neither the patient nor the pharmacy were notified of this change.

While EHRs have the ability to send deprescribing requests to pharmacies, health networks don’t always turn on this functionality, because that “would entail additional costs for health care professionals and networks, including costs for software licensing and integration, as well as ongoing network fees and maintenance costs,” Shervani and colleagues write. The result is that deprescribing orders in the EHR are not transmitted to pharmacies in the same way as orders to prescribe.

In an accompanying editorial in JAMA Internal Medicine, Vanderbilt University Medical Center pharmacist Scott D. Nelson and professor Dr. Yaa Kumah-Crystal explain more about how clinicians have to work around the lack of deprescribing functionality:

Because most EHRs are not configured to notify pharmacies of prescription cancellations electronically, clinicians and staff are required to call the pharmacy to communicate that a prescription has been discontinued or actively submit a fax communication to the pharmacy about the prescription discontinuation…At times, prescribers attempt to prevent subsequent pharmacy dispenses by modifying the medication order in the EHR and sending a new prescription with “stop” or “cancel” in a free-text field, again hoping that the pharmacists will see and understand the message.

Think about that for a second. Doctors can notify pharmacies when they want to prescribe a new drug, with just a few clicks. But to get them to stop a drug, they might have to submit a fax to the pharmacy or write a note in the EHR and hope the pharmacist gets it. It’s hard to believe that this is the state of affairs in health technology in 2021.

We know that EHRs need a complete overhaul — they should be interoperable across systems, there should be secure and fast information exchange, and they should be much more usable for clinicians. However, part of the problem with deprescribing electronically is not technical but political. As Nelson and Kumah-Crystal write, there already exists a program that can cancel prescriptions through the EHR called CancelRx, which was developed in 2006. However, there are no minimum use requirements for this program, like there are for other EHR programs, so it often goes unused. Clinicians at Johns Hopkins Medical Center and the University of Wisconsin have had success using CancelRx, but adoption nationwide remains slow. Nelson and Kumah-Crystal recommend that institutions engage prescribers, pharmacists, IT specialists, and training teams to make sure that questions about workflow and troubleshooting can be worked out for a successful implementation.

The post How a better health record system could reduce medication overload appeared first on Lown Institute.

However, as Fred Shulte recently reported in Kaiser Health News, gathering EHR data from hospitals across the country “has proved a technical nightmare thus far” because health records built by rival EHR companies are not “interoperable”–they cannot retrieve and share information across EHR systems.

Rather than create a national network of health information exchange on a publicly-maintained electronic medical record system, in 2009 the government endorsed a “regional” approach for building EMRs. As a result, in many regions of the country it is no easier to share medical information than it was a decade ago. 

For example, just a few weeks ago, patient advocate Stacey Hurt shared an anecdote on Twitter: After she had a PET scan, her oncologist asked for it to be burned to disk and overnighted to her surgeons–in the same city–so they would be able to look at it. This seems crazy in 2020, but in many hospitals, it’s where we are at.

I had a PET scan today and my oncologist needs it burned to disk and overnighted to my surgeons right here in Pittsburgh to look at it How are we doing here? #Interoperability #ptexp #digitalhealth #HealthTech #telemedicine #TelemedNow #healthcare #HealthIT #cancer pic.twitter.com/fqJDSZjcq1

— Stacy Hurt (@stacy_hurt) May 12, 2020

Like so many other aspects of our health care system, the pandemic has laid bare the flaws in EHRs: their inability to deliver information to other providers, the lack of a national database of records, even the difficulty in filling out necessary forms electronically.

Although government agencies have moved to introduce new interoperability standards, mandating that all EHR systems use the same interface and make health records available to patients on mobile apps, these rules have been pushed back since the pandemic began. Even when they are implemented, these new regulations will likely not go far enough in connecting the disparate segments of health information.

In a Health Affairs blog last year, Dr. Michael Hochman, associate professor of clinical medicine and director of the USC Gehr Family Center for Health Systems Science, Dr. Edmondo J. Robinson, chief transformation officer and senior vice president at the Christiana Care Health System, and Lown staff member Judith Garber, proposed a radical departure from our current fragmented system. They advocated for the creation of a national health information exchange public option, to which any health care system can opt in.

Whether a national health information exchange or new interoperability standards, big changes are needed in the health information space–not just to propel new research in times of crisis, but to make it easier for clinicians to practice on a daily basis.

The post Clunky EHRs hinder Covid-19 response appeared first on Lown Institute.

The GetMyHealthData campaign, a consumer-led campaign to help patients request access to their medical records and record their experiences, found that patients who want to access their data face many obstacles. Providers rarely offered digital options for medical records, insisting instead on faxing patients their records or sending them a CD. Other patients were slapped with fees that were unaffordable, unreasonable, and illegal.

Why are there so many roadblocks to patients getting their own data? One reason is that the Centers for Medicare and Medicaid Services did not require hospitals to do much to help patients access their records. Only one patient had to access their records online for an organization to get financial credit under the CMS “Meaningful Use” incentive program. This has allowed many providers to create the capability for patients to access their records, but never promote it, write Bechtel et al.

The limited incentives offered to health providers and EHR vendors to make health data accessible is not near enough to overcome a system that by design discourages data sharing. According to a former national coordinator for health information technology, asking health care leaders to exchange data is like “asking Amazon to share their data with Walmart.”

CMS is finalizing new rules (against strong industry pressure) to make EHRs more accessible and interoperable by requiring Open APIs. Until that happens, Bechtel et al. offer several potential solutions to the problem of difficult patient access to EHRs:

• Health providers should switch to EHR with all Open APIs as soon as possible (don’t wait for CMS to require it!).
• Institutions that hold health data should make sure email is a delivery option on their HIPAA records request form.
• CMS should create comprehensive privacy rules, so that consumers can trust apps and developers to not share their data.
• CMS should promote value-based care models, that provide business incentives for data-sharing and interoperability. “If health care incentives depended upon better health outcomes, care providers and the infrastructure that supports them would have to figure out ways to share data, not only among providers, but with consumers, who play a critical role in shaping and maintaining their own health,” the authors write.   

Finally, a national health information network, which institutions could opt into, would make EHRs interoperable across systems and regions. This “public option” would take significant efforts from the government, but would relieve local communities of the burden of building their own health information networks.

The post Few patients access their EHRs, but it’s not for lack of interest appeared first on Lown Institute.

Bed alarms, alarms built into hospital beds, are intended to prevent falls in the hospital. These alarms will beep when the patient attempts to get out of bed, so that a nurse can help them walk without them falling. However, as Melissa Bailey wrote recently in Kaiser Health News, the alarms do not actually reduce fall rates. Part of the problem is that nurses may not get to the bed in time to prevent a fall when they hear the alarm. But another issue is that the alarms are triggered unnecessarily so often (an estimated 85-99% of alarms do not require clinical intervention) that over time, clinicians simply tune them out.

This “alert fatigue” goes beyond bed alarms; it is also prevalent in EHR alerts. As use of EHRs have grown, pop-up alerts in EHRs have become ubiquitous. Doctors receive warnings and prompts for everything from potential drug interactions to billing queries. Clinicians must either go down a rabbit hole of clicking while other priorities take a back seat, or they disregard the alerts. Often clinicians choose the latter– in one large hospital system, a study found that 95% of drug-drug alerts were overridden. This can lead to patient safety issues such as adverse drug events; despite frequent EHR alerts, patients who experience an adverse drug event are often put back on the drug that caused the event after they are discharged from the hospital.

Too many alarms not only threatens patient safety because of alert fatigue, they inherently harm clinician and patient well being. The prevalence of EHR alerts distracts clinicians, breaks their rhythm, and increases the number of clicks it takes to perform basic tasks in the EHR. As Dr. Vikas Saini and colleagues wrote in WBUR, over time this becomes “death by 1000 clicks:

“Want to order a simple test? That requires getting through multiple prompts. Need to write a prescription — an exercise that used to take less than 15 seconds? Another set of clicks.”

Bed alarms too harm patients, because they make it difficult to sleep and restrict their mobility. Being bedridden for too long can lead to blood clots and muscle atrophy. In a JAMA Teachable Moment article, a patient described feeling like she was “in jail” because she couldn’t sit up or go to the bathroom without her bed alarm going off. And that patient was far from the only one who felt the same, said one of the authors Dr. Stephanie Cull, now Fellow Physician at Rush University Medical Center, in an interview with the Lown Institute:

“I can think of three other patients off the top of my head who felt the same about the alarms,” said Cull. “I saw one patient doing pushups on top of his bed because he wanted to exercise but couldn’t leave his bed.”

The more Cull looked into bed alarms, the more she was convinced that the problem was systemic. “The checklist [for determining the need for a bed alarm] is arbitrary. Whether or not you get an alarm is based on how many medical conditions on the Morse Fall Scale you have, but most of the conditions aren’t even related to falling,” said Cull. However, since in-hospital falls are labeled a “Never Event,” hospitals do not get reimbursed for additional costs associated with in-hospital falls. This puts a lot of pressure on hospitals to adhere to the guidelines and affix many beds with alarms, even though they have not been proven to prevent falls. 

There is no easy answer to the problem of alarm-happy hospitals. It will take broad changes to make EHRs more user-friendly and create new evidence-based guidelines to prevent in-hospital falls. In the meantime, some hospitals have reduced their use of bed alarms at night or converted sounds to visual alerts. Other health care institutions are removing “stupid stuff” from EHRs to lessen the administrative burden on clinicians. Hopefully, these changes will help reduce the harm from excessive alarms on patients and clinicians.

The post Sound the alarm: Excessive alarms lead to alert fatigue and patient harm appeared first on Lown Institute.

Unfortunately, it seems clinicians are correct when it comes to EHR usability. A recent study in Mayo Clinic Proceedings asked 870 to rate their EHR usability using the “System Usability Scale” (SUS) a metric used across industries to measure usability of products and programs. The SUS evaluates the usability of technology based user satisfaction (do doctors like using their EHR?), learning curve (did it take a long time to learn how to use the EHR?), and how complex or cumbersome the tool is. 

What they found will come as no surprise to clinicians—overall, EHRs received a 45 out of 100, which is a failing grade. To put that in context, Microsoft Word has an usability score of 76 and a microwave oven has a score of 87. The low grade puts EHR’s in the bottom 9% of scores; among technology we use every day, EHRs were rated worse than 91% of them. 

There was some variation in usability based on physician specialty and type of hospital. For example, doctors at academic medical centers rated their EHRs lower than average, whereas doctors working at VA hospitals rated their EHRs higher than average. Anesthesiologists, pediatricians and general internists rated their EHRs highest, while dermatologists, orthopedists, and general surgeons rated their EHRs the lowest.

Why are EHRs so terrible for clinicians to use? A large reason is because they were developed primarily for billing and coding purposes, rather than clinical purposes. Thus, doing seemingly simple tasks like pulling up a patient’s medication list can be arduous. “Looking for communication from another doctor or a specific test result in a patient’s chart can be like trying to find a needle in a haystack,” said Dr. Ted Melnick, Emergency Medicine doctor at Yale University and lead study author, in The Hartford Courant.

Given how difficult EHRs are to use, it’s no wonder that they contribute to physician burnout. Researchers found a strong association between EHR usability and burnout in almost all specialties. For every point that EHR usability increased, there was a 3% decreased odds of professional burnout. While this does not prove that EHR clunkiness causes burnout (it’s possible that physicians who are burned-out rated are more likely to rate their EHR poorly), it adds evidence to a body of research finding EHRs as a driver of burnout.

Clearly EHR programs must be drastically changed to improve their usability. EHRs should be streamlined to reduce unnecessary clicking and reformatted to prioritize tools that doctors use in their clinical encounters, rather than prioritizing billing. Government agencies should continue to push EHR vendors to make their systems interoperable and consider creating a national health information highway. 

However, the fault may not be only with EHR vendors. As the differences in usability ratings between specialties and locations shows, usability may have as much to do with the administrative requirements at their institutions as it does the mechanics of the EHR software. An example the study authors give is that some hospitals may require physicians to re-enter their passwords before prescribing a medication while other hospitals do not have the same requirement. 

Improving EHRs must be a collaboration between government agencies, EHR vendors, and hospital & clinic administrators. Vendors must be held accountable for making EHRs more usable and interoperable, but administrators should also work to “get rid of stupid stuff” in the EHR. Now that we have clear proof that EHR usability is at an “unacceptable” level, we need to work to raise the score.

The post EHRs get a failing grade for usability appeared first on Lown Institute.

It sounds like a crazy scenario, but this is how we have built our health information highway. Rather than create a national network of health information exchange on a publicly-maintained electronic medical record system, in 2009 the government endorsed a “regional” approach for building EMRs. As a result, in many regions of the country it is no easier to share medical information than it was a decade ago. 

Health care interoperability is the topic of a new Health Affairs blog by Dr. Michael Hochman, associate professor of clinical medicine and director of the USC Gehr Family Center for Health Systems Science; Dr. Edmondo J. Robinson, chief transformation officer and senior vice president at the Christiana Care Health System, and associate professor of medicine at Thomas Jefferson University; and Judith Garber, Health Policy and Communications Fellow at the Lown Institute.

Hochman et al. discuss what went wrong with health care information exchange, and what keeps preventing the shared goal of seamless, safe information exchange. Among the reasons are the lack of a unified health information exchange initiative, and lack of incentives for EMR vendors to participate in these initiatives. Getting private EMR companies to get on board with sharing information isn’t easy. According to David Blumenthal, the inaugural national coordinator for health information technology, asking health care leaders to exchange data is like “asking Amazon to share their data with Walmart.”

To fix this problem, Hochman et al propose a radical departure from our current fragmented system — the creation of a national health information exchange public option, to which any health care system can opt in. This would require grappling with issues of governance, funding, oversight, and privacy concerns. But these are issues that all health information exchanges must deal with; the true challenge to change will be political, not practical.

For more, read the full blog on Health Affairs!

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This study followed 80 internal medicine interns in six US medical resident programs, for a cumulative 2173 hours, making this analysis the largest time-motion study in the US to date. The authors found that interns spent 3 hours (13%) of their day working directly with patients and 2 hours (7%) on educational activities. This is a stark change compared to the 1990s, in which interns spent 81% of their workdays engaged in direct patient care activities. Additionally, the time-motion study highlights how much interns today are multitasking; even when they are face-to-face with patients or at a lecture, they are also working in the EMR 25% of the time.

In an accompanying commentary in JAMA Internal Medicine, Dr. Christopher Moriates, MD and Dr. F. Parker Hudson from the Dell Medical School at The University of Texas at Austin relate this study to larger concerns about internal medicine. This study confirms that over time, technology seems to have increased interns’ administrative burden, not relieved it. The study also finds that the same pattern of more time spent on indirect than direct patient care is consistent across types of care settings, from major academic programs to community-based programs. No EMR system appears to be providing relief from the mounting burden of patient documentation. 

Moriates and Hudson address the question of whether spending time on electronic medical records (EMR’s) is directly related to the ever-worsening problem of physician burnout. They draw from their own teaching experiences, recalling interns who went into medicine to care for patients, not document their care, being discouraged by the lack of time they had with patients. They fear that the pattern of growing EMR burden for interns could be “leading to a deficit in the humanistic bonds that create exceptional care and replenish our psyche.” How will internal medicine retain doctors when their first taste of medicine is so cold and metallic? 

If we indeed value the human side of medicine, this study should serve as a “clarion call to reinvest in the humanistic aspects of medical training,” write Moriates and Hudson. This could mean hiring scribes to do more patient documentation, restructuring EMRs to make them more intuitive and clinician-friendly, or streamlining EMR messages to reduce alert and message fatigue. If we do nothing to solve this problem, we will likely see an even more detrimental impact on clinician burnout and doctor-patient relationships.

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