ARTICLE IN BRIEF
Neurologists involved in clinical informatics discuss the limitations of current electronic health records and their role in making them more clinically relevant.
Whether or not you are a fan of the electronic health record (EHR) — what it has done to our neurology practice and our personal connections with our patients — one thing is clear: The EHR (or some version of it) is here to stay.
The Health Information Technology for Economic and Clinical Health Act of 2009, which directed the Office of the National Coordinator for Health Information Technology to promote the adoption and meaningful use of EHRs, appears to have succeeded in its mission. Hospital adoption of EHR systems increased more than five-fold between 2008 and 2013, with 93 percent of acute care hospitals possessing EHR technology certified as meeting federal requirements for meaningful use objectives. And as of 2013, 78 percent of office-based physicians used some type of EHR system, up from 18 percent in 2001; the adoption of a basic EHR system by those physicians increased 21 percent between 2012 and 2013.
With this meteoric rise in usage, it has become clear that physicians who understand the clinical workflow are needed to serve as liaisons to the IT staff as well as to help train, motivate, and assist health care providers using the technology and ensure clinical relevancy. Part mediators, part techies, part enforcers, these intermediaries have grown in numbers, contributing to a nascent but growing clinical informatics (CI) subspecialty. [For more about the requirements for the CI subspecialty certification, see the sidebar, “So You Want to Be a Neuro-Informaticist? What You Need to Know.”]
In October 2013, the American Board of Preventive Medicine, in collaboration with cosponsoring boards that include the American Board of Pathology, administered its first CI board exam. Among its diplomates are quite a few neurologists, several of whom spoke with Neurology Today about their interesting career choices and what is needed to improve current EHRs.
THE EHR SCORECARD
Daniel B. Hier, MD, MBA, a professor of neurology emeritus at the University of Illinois, expressed an early interest in CI. He worked for Cerner Corporation as a physician executive from 2010 to 2013, helping large hospital systems implement Cerner EHR for both inpatient and outpatient use. In that role, he helped physicians customize their EHRs to their workflows and trained them on best practices. The work, along with his firsthand experience going live with EHR in 1999, has given him a unique perspective on the EHR scorecard.
“Given the fact that EHRs are no longer new, it is astonishing how immature the technology is,” he said. “It is still hard to enter data, get data out of it, and share data,” he explained. “Much of what is captured is noise, and physicians have a hard time finding the signal through the noise.”
Indeed, many neurologists find the EHR so cluttered with cloned, outdated material that it renders the notes unreadable. EHRs do not anticipate or factor in accurately the physician workflow, Dr. Hier told Neurology Today. If this requires too much cognitive effort to work around, he said, doctors will become vulnerable to burnout.
Allan D. Wu, MD, a movement disorders specialist at the University of California, Los Angeles (UCLA), spends about half his time as a clinical informaticist, working with the academic medical center's EHR to integrate clinician and patient-oriented workflows to improve clinical care. Board certified in CI in 2014, he is concerned that our EHR systems have been designed without enough input from physicians.
“The saying that encapsulates our current EHRs is that they are data rich but information poor,” he said. “We have enormous amounts of data collected, some of it clinically helpful, most of it not, and very little of it designed to directly serve the patient or provider.”
Dr. Wu said information systems should be designed to provide physicians with the information they want, when they need it, and in the form they can digest, so that the EHR partners efficiently and seamlessly with the provider seeing the patient. “We are clearly not there yet, but I believe we will get there eventually,” he added.
These limitations notwithstanding, Dr. Wu said there have been incredible advances that help deliver specific information when needed. For example, he cited as promising features the integration of Up-To-Date (context-based information with continuing medical education credit in some cases), PubMed (literature search), and the Krames databases of patient education materials (encouraging patient engagement).
“There is a lot of work being done on improving decision-making advice tools within the EHR to help providers decide when to transfuse, when to order CT scans, which protocol to select, such as tPA [tissue plasminogen activator], and so on,” he pointed out. “We're also able to integrate data from many different hospitals to improve the ability to look at rare diseases, which is particularly important in neurologic disorders such as focal dystonia.”
Neurologist Sarah Maulden, MD, MS, has been working for the past ten years at the department of Veterans Affairs in Salt Lake City as a medical informaticist. Specifically, she helps to develop standard, computable terminologies for use in EHRs, research, and clinical decision support. She paved her way as a resident at the University of Utah by proposing an informatics elective and then doing an informatics fellowship, funded by the National Library of Medicine. She believes more work is needed to optimize existing technologies, but she is encouraged by improvements in voice recognition and natural language processing (the use of computers to understand written and spoken language). She is also pleased to see InfoButtons — embedded links to reference data — becoming more commonly used.
OPPORTUNITIES FOR IMPROVEMENT
Dr. Wu believes that EHRs have been unfairly maligned in some respects, but he concedes that, like any new technology, EHRs are undergoing growing pains, particularly when many different business owners have designed them. Third-party vendors who supply large databases of information on drugs, drug components, and their interactions may set up many alerts about potential safety issues to reduce their liability risk. Consequently, “alert fatigue” may occur, contributing to a much bigger risk, he explained. “As informaticists, we need to balance warning alerts of important items without over-alerting,” he said. “Without physician input when the EHR is customized, there may be 10 times as many alerts.”
Dr. Maulden is surprised by how many EHR systems have been designed and implemented without enough user input. “I think that some EHRs have been hijacked for business, financial, and administrative purposes, over and above clinical care,” she said, “and they can actually get in the way of good care by requiring changes in the workflow.” And she understands why physicians who are inundated with billing rules, the Physician Quality Reporting System, meaningful use, and other requirements are complaining.
“When you combine increased financial and time pressures with new requirements to document a lot of information in specific ways, prescribe electronically, etc., it can be viewed as just one more burden,” Dr. Maulden said. But she is optimistic about the future. “Compare it to the evolution of an automobile,” she suggested. “The first ones were expensive, unreliable, tricky to operate, and potentially dangerous. When I get frustrated with the limitations of our EHRs, I try to remember that we're still in the infancy of their development.”
“We are in desperate need of ‘disruptive innovation’ that will enhance physician job satisfaction by easing the cognitive work of patient care,” Dr. Hier said. “There is absolutely no reason that information technology should not ease the process of writing a note, communicating with another physician, arriving at a diagnosis, and ordering tests and medications. We need strenuous efforts to make information technology work for physicians; physicians are tired of working for information technology.”
Neurologist Steven L. Meyers, MD, who recently became board-certified as a clinical informaticist, finds that he is asking himself regularly, “How can I improve the electronic medical record?” Working in the North Shore University Health System in Illinois as vice chair of quality and informatics for the department of neurology, he likes knowing that he can have an impact on tens of thousands of patients through the tools that his team has developed. Those tools capture data through questionnaires, screening instruments, quality of life measures, and outcomes measures to run analyses for specific diseases. Although he likes clinical practice and has an interest in headache and stroke, he believes that he can ultimately contribute more to the health of a larger number of people through CI.
Neurologists are ideally suited for a CI career, the informaticists interviewed here told Neurology Today. “I hope neurologists consider the field, both for what they can contribute to making the neurology workflow better and for what they can contribute to CI in general,” Dr. Hier said. “Neurologists tend to be very logical, detail-oriented, and workflow-savvy,” attributes that also lend to excellence in informatics.
“If you are very analytical, have an interest or background in the interface of computer science and health care, and are willing to go off the beaten path a little, you are likely to find this niche enjoyable,” Dr. Maulden agreed.
Dr. Wu added that, he, too, would like to see more neurologists trained in CI. There may come a point when neurologists are no longer considered great because they remember unique diagnostic information, he noted, but rather because they are able to find, filter, and interpret an ever greater amount of potential information available from histories, questionnaires, monitoring devices, and knowledge bases, and interpret all that for their patients, Towards that end, he hopes that exposure to CI starts early. UCLA has started those conversations with its medical school, and has had a resident informatics program in place for the last two years. And this July, it will offer a new informatics fellowship.
SO YOU WANT TO BE A NEURO-INFORMATICIST? WHAT YOU NEED TO KNOW
* All member boards of the American Board of Medical Specialties have agreed to allow their diplomates to take the clinical informatics subspecialty examination if they are otherwise eligible.
* Until the end of 2017, an eligible candidate may sit for the board exam in clinical informatics through the “Practice Pathway.”
* Beginning in 2018, the board exam will be available only for those physicians who have completed a fellowship in clinical informatics accredited by the Accreditation Council for Graduate Medical Education (ACGME). For eligibility requirements, visit http://bit.ly/ABPM-CI
* In February 2014, the ACGME released its program requirements for Graduate Medical Education in CI. Although a resident from any specialty may apply for these fellowships, the clinical informatics fellowship must be overseen by an ACGME-accredited residency program from one of the following specialties: anesthesiology, diagnostic radiology, emergency medicine, family medicine, internal medicine, medical genetics, pathology, pediatrics, or preventive medicine.
* Find training programs in medical informatics here: http://bit.ly/medicalinformatics