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EHRs exacerbate the pen and paper problems they were meant to solve: study

by John R. Fischer, Senior Reporter | May 30, 2018
Health IT
Penn Medicine researchers argue for
the addition of 'subscription' features,
such as push notifications, to EHRs
for real-time alerts
The current set-up of EHRs has led to greater physician work load, higher risk for burnout and an increase in other challenges it was meant to fix.

That is what researchers at Penn Medicine argue in a new study, referring to EHRs as mere digital remakes of pen and paper files, and opting for a system that enables physicians to "subscribe" to patients, receiving push notifications on real-time updates for when action is required, as they do on social media and news app feeds.

"I think that firms have created platforms that focus almost entirely on the technical task of making medical records digital and not the design task of making them useful," senior author David Asch, executive director of the Penn Medicine Center for Health Care Innovation, told HCB News. "You end up creating something that looks very much like a paper chart. If you focus on the task of making electronic records more useful and think about what people really want from them, you can create something even better.”

Physicians, according to Asch, often feel that more effort is required in using EHRs, and see very little improvement compared to paper charts.

Researchers based their proposal on several examples of subscription-like services implemented within the University of Pennsylvania Health System, including medication management.

Originally required to remember when to renew expiring prescriptions, physicians at Penn found that orders were not made 10 percent of the time due to charts not being checked or the need for renewals going unnoticed.

Following the installation of a web application for assigning automatic medication expiration dates for antibiotics and antiepileptics, missed renewals decreased by one-third.

The authors also evaluated the approach on ICU ventilator patients, finding that a switch from morning rounds to digital evaluations and alerts for ventilator patients decreased delays and the amount of time an average patient spent on a ventilator by half a day.

A further backing for their argument included an assessment of 30-day readmissions and total days spent in a hospital among 30 patients with the highest use of care. Such rates decreased by 67 and 56 percent, respectively, following the implementation of a dashboard for tracking needs and automatic alerts to the multidisciplinary team of ER arrivals and action plans in real time.

The study proposes the adoption of a HIPAA-compliant messaging platform of push notifications to shorten time between when information becomes available and when it is used. It also should consist of filters to determine important information for alerts, so as not to overwhelm physicians, and the ability to alert only those whom the information is relevant to, such as a renal team in cases of kidney trouble.

Asch advises that adding subscription features to an EHR is only “one slice of the pie,” and that its structure requires additional innovations to fully benefit physicians and patients.

“Many elements of health care are now effectively algorithmic,” he said. “For example, there are clear guidelines on which patients should be on statins to lower their cholesterol. There are guidelines for who shouldn't get advanced imaging for low-back pain or who should stop their proton pump inhibitor. Nudges can also move electronic records beyond paper charts, and they may advance value-based care models far more effectively than traditional approaches of education-based decision support.”

The findings were published in the New England Journal of Medicine.

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