What Will EHRs Look Like in 2020?

Ken Terry

June 08, 2015

Electronic health record (EHR) systems need to be reimagined and reengineered to meet the challenges of the next several years, according to a new report from the American Medical Informatics Association (AMIA) on the status and future direction of EHRs. The report was published online May 29 in the Journal of the American Medical Informatics Association.

Among other things, these systems must break free of their current role as the generator of billing codes and must be redesigned to enable care team members and patients to enter data and coordinate care, the authors write. In addition, new methods must be devised to make it easier for physicians to record their notes in EHRs, and EHR developers must begin to take into account new sources of information, including data generated by mobile apps and genomic data.

The AMIA task force also focused on the need to improve EHR features that have the potential to compromise patient safety, an issue both the Institute of Medicine and the Joint Commission have highlighted in recent years. The ability to copy and paste text from past visits can result in "bloated visit notes" that obscure important information. "While cost, usability and other considerations are important, patient safety and quality of care need to guide how we optimize these systems," the authors explain.

Patients, Entire Care Team Should Contribute to Documentation

Noting that some physicians spend up to half of their workday documenting in EHRs, the task force suggests that other clinicians and patients could help populate the record. "Information offered by other care team members and patients should be as valued as that information entered by the physician."

This would represent a major departure from how medical documentation is done today. "An increasing number of physicians are exploring how to engage patients directly in documentation within the EHR," Douglas Fridsma, MD, PhD, the new president and chief executive officer of AMIA, told Medscape Medical News. Dr Fridsma was not one of the report authors. He cited the OpenNotes movement, which encourages physicians to share their notes with patients and, in some cases, to allow them to edit or add to the notes. Not all physicians are comfortable with this approach, but there is evidence it can strengthen the physician–patient relationship, he said.

"Also, as there is more shared care and more care that takes place outside of office visits, it will be even more important to have other caregivers contribute their observations," Dr Fridsma explained.

Billing Requirements Now Drive Much of Documentation

The report strongly urges the industry to move away from using EHRs to collect information that is mainly of concern to payers. "The current [evaluation and management] coding requirement of capturing bullet points has led to constrained notes that target billing requirements," the task force points out. "Continued requirements to support [evaluation and management] codes will slow progress toward new ways of defining the medical record," such as having patients enter information on portals ahead of their office visits.

Physician reimbursement still depends on justifying evaluation and management codes in their documentation, but that may change, Dr Fridsma explained. The recent announcement of the Department of Health and Human Services that an increasing portion of Medicare payments will go to alternative payment models such as affordable care organizations and patient-centered medical homes may hold the key to the solution, he said. By emphasizing shared risk and capitation models, the government could lead the way toward disconnecting documentation from evaluation and management codes.

EHRs of the Future Need to Integrate Data From a Variety of Sources

The AMIA report supports the use of public application programming interfaces to extract data from EHRs and to enable EHRs to interact with external applications. Dr Fridsma, who was formerly the chief science officer of the Office of the Coordinator for Health IT, said, "[Application programming interfaces] are a necessary part of expanding the flexibility and the innovation that's possible with an electronic health record."

However, although APIs can connect systems, they will probably not provide the full interoperability needed to exchange patient records between disparate EHRs, he said.

EHRs of the future should be able to integrate data from a variety of sources, including patient-generated and community data, the authors write. Eventually, genomic data must also be integrated into the EHR for precision medicine. Meanwhile, we should figure out how to include monitoring data from biometric sensors in EHRs.

Dr Fridsma admitted that many physicians are worried about being overwhelmed by home and mobile monitoring data. Innovative analytics will be needed to address this concern and find the "signal in the noise" that is relevant to patient care, he said.

The report also endorses the use of natural language processing, still a work in progress, to ease the burden of documentation. Nobody is ready to rely on clinical data extracted from free text by natural language processing software, but the technology is improving and might be able to provide some benefit, Dr Fridsma noted.

"Good Job of Balancing Longer View…With the Urgency of Moving Ahead"

Farzad Mostashari, MD, a former National Coordinator of Health IT, agreed with that assessment. In an interview with Medscape Medical News, he also praised other aspects of the AMIA report: "I thought they did a good job of balancing the longer view of where we need to go with the urgency of moving ahead in the next 3 to 6 months with some things we can do now," he said.

Dr Mostashari is the founder and chief executive officer of Aledade, a company that helps primary care physicians manage outcomes. He likes the idea of having patients and care team members enter some of the EHR documentation. For example, he said, there is nothing in the meaningful use regulations that requires physicians to enter patients' smoking status on every visit. "Why shouldn't the patient or medical assistant do it?"

Much more needs to be done to design analytics that will be able to screen monitoring data effectively, Dr Mostashari said. Neither that kind of data nor genomic data will be part of routine clinical practice 3 years from now, he predicted. But in 10 years, they probably will be, he added.

Finally, he noted that much of physician resistance to structured data collection is that they are being asked to check off boxes just for compliance purposes. But when value-based reimbursement arrives, physicians will likely have a different attitude about recording structured data, he concluded.

Dr Mostashari, the former coordinator of health IT, is the CEO of Aledade, a new company that helps primary care doctors form accountable care organizations.

J Am Med Inform Assoc. Published online May 29, 2015. Full text

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