Medical Economics: Can EHRs be fixed?

November 19, 2019

Can EHRs be fixed? The government thinks they can. We talk to Andrew Pecora, MD, about how to improve EHR usability

Medical Economics: The medical economics EHR scorecard found that physicians are very dissatisfied with their EHR systems. How did we get here?

Andrew Pecora, MD: You know, I'm not surprised at all the physicians find EHR is not complimentary to their work and in the care of their patients, and have difficulty in their use and would rate them as not necessarily helpful to them but adverse to what they're trying to accomplish.

Medical Economics: EHRs were supposed to transform healthcare. But many doctors would say they've caused more problems and they fixed. What went wrong?

Pecora: Well, EHRs were built to be billing systems. They were built to look at the content of a note not for the content to care for a patient, but the content to support a level of service. And that really hasn't changed. That's not an absolute statement, because there are now changes being made. But they're not user friendly. They're not intuitive. They don't compliment the way the doctor thinks or approaches, seeing a patient examining a patient and making a clinical decision to how best to treat the patient. They're not supportive. They don't show data that could help. So really, it's just another thing to do, whereas they used to just write a note.

Medical Economics: How would you assess the state of EHR today?

Pecora: I think electronic medical records vendors in general understand there needs to be an EHR 2.0, that the versions that were built to support billing and coding are a necessary platform but nowhere near sufficient. And when you look at the content and information technology now, we're talking about machine learning and artificial intelligence, there needs to be add-ons or bolt-ons that make the note much more intuitive to the doctor, particularly when it's doctors in a specialty with decision support with real time analytics to help you make a decision best for your patients. And also, there's way more we can do to make the note writing itself a lot easier for the doctors, you know, we're doctors are not secretaries. We don't pay physicians to write a great note. We pay physicians to make a good decision for their patient. And that has to be the emphasis. Physicians feel like they've become glorified note-keepers, and the value of the service they provide has been diminished.

Medical Economics: When physicians say they want usable systems, what actually are they looking for? What capabilities do they need to succeed?

Pecora: Well, the biggest enemy to a doctor is time. You know, patients and physicians are both complaining that not enough time is spent face-to-face, hands on the patient, sitting there talking to the patient about not just their illness of the moment, but how their life is going. That empathy is so important to being a doctor. Instead all of that time is sitting by the computer, making sure you get your 10 elements of this note and 15 elements of that note. That should be automated. There is no good purpose for a doctor wasting their time typing or dictating stuff that should just be automated, and a doctor shouldn't be penalized for that. We automate every industry in the United States and if you can lower your cost of goods sold, you make you do better economically in healthcare if you lower your cost of goods sold, you’re attacked. So I think fundamentally, we have to get back to creating tools at the best size for physicians that facilitate their interaction with their patients and not take away from them.

Medical Economics: Physicians regularly point to EHRs as a contributor to physician burnout and career dissatisfaction. How did we get here?

Pecora: Fundamentally, physicians went into the practice of medicine to care for their patients, not to write notes. Right now the emphasis is on writing the note and less on caring for the patient. And people say all that's not true or but in fact, it is because the number of patients per hour a doctor needs to see given what has happened to reimbursement has gone up. And the amount of documentation necessary to have the coding properly for a proper bill has gone up. So when you look at those two things, what is what has been sacrificed? What has been sacrificed is the very Reason doctors went into medicine in the time they get to spend in a caring environment with their patients that's been taken away.

Medical Economics: Major tech companies such as Google, Amazon, and Apple are entering the healthcare space. What impact do you think these companies will have on the EHR marketplace?

Pecora: Well, the hope is, they will allow for the facilitation of doctors to be able to spend more time at the bedside with their patient. If they do that, I think it'll be a home run. In addition, and not just those companies, but there's plenty others that are creating real world evidence that will enable a doctor to look at data in real time to make a decision for a patient and share that information with their patient in real time, to best make their decision when you think about a pilot landing a large airplane at any major airport United States, the amount of decision support they get around landing the plane. And they're not they're taking notes are logging in their logs there. They're focused on doing their job. We've taken that a little bit away from doctors, we have to bring that back to doctors.

Medical Economics: There's been a huge growth in patient generated data from wearable devices. But physicians often complain that this data is very difficult for them to use. How can we allow physicians to harness usable data from these wearable devices?

Pecora: Healthcare is ready for evidence-based medicine. I mean, evidence based medicine should be the basis of care decision-making and actually should be the basis for proper reimbursement. No one can keep up with everything that's being published and available today. You could spend a lifetime trying to just keep abreast of the latest advancements. It should be there at the click of a button in your computer, and the thing is, is that particularly in specialty care-I'm an oncologist-and while I need to know a little bit about cardiology, when I'm taking care of a lung cancer patient, that's not my focus. My focus is what is the latest information at this moment in time to make the best possible decision for this patient in front of me, with all of their unique attributes accounted for, that doesn't exist in today's EHRs, but can soon exist. And I believe, if we bring value through information back to doctors, their perceptions of EHRs will change and improve.

Medical Economics: What role should physicians have in fixing EHRs?

Pecora: Well, first and foremost, and I won't name names, but I visited some of the largest-brand EHRs in the country. And they're proud of the fact they didn't have a single doctor involved in making the EHR. It's kind of interesting that you know, computer scientists are great people are Smart but they're not physicians, they don't think like physicians and go to medical school, and yet they made the hrs. And so if you think about how crazy that is, going back to my example, I guarantee you pilots are involved in simulators and how training is done for pilots. pilots are involved with one information where the buttons are on the airplane. Why aren't physicians you think it's obvious, but it's not. Now in other areas like robotic surgery and radiation on college physicians were involved, and you don't hear these complaints. You hear these as accessories and great tools for the betterment of their patient. EHRs, I think, have to get physicians way more involved. The note, the use of the EHR, the flow of the content should be intuitive to the specialty and the care that needs to be provided at that point in time for that particular patient. Then, and only then, I think this  trend will change.

Medical Economics: If EHRs were easier to use, do you think that more physicians would enter specialties such as primary care?

Pecora: You know, medical school is still a coveted position. There are way more people that want to be doctors and there are seats available in medical school classes. So it's not a question of do people want to be physicians and people want to be physicians for the right reason, you know, they have a love of humanity, and they have a love of science. And that's the magical combination. You may hear different words, but fundamentally, that's it. You want to help someone else and you want to apply science in order to do that. And then you become a doctor. Young, aspirational. People have no idea about this until they start to do it, and then it's too late. I think what we're really looking at is mid-level and senior physicians who have accumulated not just knowledge but wisdom, the kind of people that if you had a serious problem, you want them taking care of you. Those are the people we need to save. Those are the people we need to focus on.