AUA 2020: State-of-the-Art Lecture: Has Electronic Medical Records (EMR) Improved Patient Care?

( In a plenary session at the American Urologic Association 2020 Virtual Annual Meeting this after, Peter Basch, MD, presented a state of the art lecture addressing the question of whether electronic medical records (EMR) have improved patient care. 

Dr. Basch began with an introduction highlighting his roles as a general internist and senior director of health information technology. He is a self-described early adopter of EMRs, also referred to as electronic health records (EHRs).

In initially addressing the question of whether EMR makes care better, he highlighted the importance of context stating that EHR can both lead to better and potentially worse care. Prevailing circumstances can affect the likelihood of a beneficial outcome. He, therefore, highlighted a variety of circumstances which make it more likely that EMRs will lead to better care including both technology-related and other circumstances. In the technology-related sphere, he discussed an interface and workflow design which is a specialty, sub-specialty, and visit specifically to maximize productivity as well as the integration of an elegant, robust, and focused decision support to aid clinical decision making. Among other relevant factors, he considered regulatory and administrative burdens, how clinicians are trained in EHR use, the role of team-based care, and the business case for EHR integration in practices.

One of the foremost issues in EHR value is the appropriate design of the EHR for individual clinicians. One-size-fits all (or better, one-size-fits-none) is common. Such an approach can be distracting, inefficient, and dangerous. The design of the EHR to match current practice, rather than expecting practice to accommodate a rigid structure of EHR design is likely to increase the utility of EHRs.

Further, the integration of decision support can make care both better and more efficient. While many initially think of intrusive pop-ups and interruptions when considering decision supports, when appropriately deployed, decision supports can be role-based and target advisories to specific individuals to perform (or not perform) the appropriate action at the appropriate time. These approaches can introduce guideline-based recommendations at the appropriate time in a patient care pathway.

Moving beyond technologically specific issues, Dr. Basch then assessed regulatory and administrative burdens. While these are not specific to EMRs, they are intimately related. Issues of documentation burden and burnout pre-dated introduction of EMRs. However, administrative burdens, in Dr. Basch’s estimation are a failure of omission in that EMRs did not cause these issues but the introduction of EMRs failed to reduce or remove these burdens as had been expected. This failure however was not a technology-driven issue but rather related to the resistance of stakeholders involved in their implementation. In contrast, he considered regulatory burdens to be issues of commission in which better EMR design may be able to partially alleviate existing issues. To that end, ongoing updates to E&M coding should reduce the administrative burden associated with billing as of January 1, 2021.

The next issue relates to how physicians learn to interact with EMRs. Most physicians undergo a process he deems functionality based training in which doctors are taught all functions of an EMR without focusing on the necessary skills. In contrast, use case-based training provides an on-the-go approach in which physicians are taught the skills necessary, within the EMR, to do the work they need to in the course of their typical clinical practice.

Transition to EMR has resulted in a downloading of work to physicians. Whereas previously, patients would complete intake paperwork that the medical assistant would assist in entering the medical record, the use of the EMR has transferred this workload to the physician. Optimization of team-based care with members of the care team other than the physician, including the patient, contributing relevant data to the medical record can increase the utility of EMRs.

One of the critiques of EMRs, which also predated their introduction, is the lack of sharing of information between systems. In a view he deems somewhat heretical, Dr. Basch suggests that having all information for a given patient from all EMRs which capture data on that patient may not be beneficial, akin to drinking from a fire hose. Instead, he suggests data should following the five rights of information including the right information, to the right person, at the right time, through the right channel, in an actionable format.

Integrating this, he suggested that the utility of EMRs depended on the underlying business case in which EHR may be viewed as an “information MRI” with value for those practices dependent on robust information management. For those practices with such a business model, maximal value from EHRs can be derived from improved decision support and information display. In contrast, for those where the model is not supported, the goal should be to minimize the burden of interaction with simplified display and reducing decision support. In both cases, efforts should reduce regulatory and administrative burdens.

He closed by highlighting the importance of EHRs in facilitating medical practice during the COVID-19 pandemic without in-person interactions.

Presented by: Peter Basch, MD, Medical Director of Ambulatory Electronic Health Records (EHR) and Health Information Technology (IT) Policy at MedStar Health, certified internal medicine provider at MedStar Medical Group and MedStar Washington Hospital Center, 

Written by: Christopher J.D. Wallis, MD, PhD, Urologic Oncology Fellow, Vanderbilt University Medical Center, Twitter @WallisCJD on Twitter at the 2020 American Urological Association (AUA) Annual Meeting, Virtual Experience #AUA20, June 27- 28, 2020

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