Electronic health records have become an integral part of healthcare delivery over the past decade or so, and for the most part, providers have adapted to using them in varying capacities. Still, there is a sense in the industry that EHRs aren't fulfilling their enormous potential as conduits for personal health information, patient diagnostics and monitoring, point-of-care decision support and as an optimal financial tool.

EHRs definitely need to be optimized, industry analysts say, but going about it brings forth some thorny issues regarding healthcare's changing business model, utilization protocols, definition of purpose and enriching the technical capabilities necessary to give them more functionality.

As for why EHRs haven't yet become a pinnacle of success for the modern age, the menu of reasons is vast.

Jon Melling, partner with Scottsdale, Arizona-based Pivot Point Consulting, can cite a multitude of reasons himself. The challenges are all over the map, ranging from regulatory difficulties to the business model transition to cost questions to confusion over the EHR's role in the organization.

"My concern today and for a number of years now, is that the vendors are overloaded with federal and state mandates to keep abreast of, which creates a concern both on whether vendors can cope, and a major concern on whether providers can cope with it as well," Melling said.

[Also: ONC releases EHR optimization guides for Million Hearts campaign]

"There seems to be disconnect between timeframes being placed on them, which forces them into a situation where vendors have to find a way to make it work," he added. "For end users, optimization is a wish that the vendors could do more, but the only way seems to be a workaround. That is suboptimal and creates more work for end users."

Likewise, healthcare's transition from fee-for-service to a value-based business model also presents challenges for EHR optimization, Melling said.

"As we move to value-based reimbursement, we have a variety of venues to select, including value-based care and fee-for-value, which are incompatible in the system," he said. "FFS, which goes back to the diagnostic-related group policy in 1983, can have a code placed into the charge master to support the level of granularity and payers will cover it. But that is only a partial solution and not a lot is settled."

'Concrete is poured'
Complicating the EHR optimization question is the fact that "the concrete has already been poured" and the systems are in place, observed Dave Lareau, CEO of Chantilly, Virginia-based Medicomp Systems.

"So now it doesn't matter how much more functionality there is if it isn't working with the systems," he said. "For those who have the ARRA money for the systems and weren't optimized for clinical users at the point of care, anything that is done now has to work with the existing systems and provide significant value that vendors can't provide on their own."

Because of the current way EHRs are organized and deployed, healthcare providers are behind the curve, Lareau said. With the advent of analytics, precision medicine and big data, the EHR's limitations are exposed, though he added that more data doesn't equal the most relevant data.

"There is lots of wisdom to be gained from that," he said. "The more data you give a clinician at the point of care is not always relevant to that moment – it's a tsunami of information that gets in the way and needs to be filtered better. You want the data points related to that one click."

As a physician, Medicomp Chief Medical Officer Jay Anders, MD, says many in his profession share his frustration with the clinical limitations of EHRs. Accessing the most pertinent information at the point of care can be a labyrinth to navigate and often turns into an exercise in futility, he said.

"EHRs tend to be big piles of data collection," Anders said. "The problem is that no one took into account how physicians actually do their work, so it doesn't fit what they do. It slows them down and makes them mad."

Lareau adds: "The technology is in there, but the use of that technology is seen as an impediment rather than an enabler of what physicians do. Data has to be usable at the point of care and that is the real challenge."

The original EHR design can be blamed for its un-intuitive method of furnishing information, Lareau said, because "their main purpose was for reimbursement – to get it over to billing." The clinician's purpose wasn't really taken into consideration, he said.

Anders explained the source of the frustration by using an encounter with a diabetic patient as an example. Because diabetes has so many co-morbidities and elements, data from different sources needs to be accessed, typically from different silos in different places.

"I have to click on six different places to see if the patient's renal condition is getting better or worse," Anders said. "What I need are the primary data points and I don't want to navigate through different places to get it. Show me what I need to know. Everyone thinks population health and big data will solve everything when I don't need that – I have a population of one in front of me, which is where I need to focus."

Plugging gaps
Chris Hobson, MD, CMO and chief privacy officer for Scottsdale, Arizona-based Orion Health, has a similar view to Anders' about how circuitous the access to relevant data can be for practicing physicians. From Hobson's perspective as a facilitator for health information exchanges and other health networks, EHRs tend to be static in their data function, so that they are reliant on other sources for the most pertinent, up-to-date information.

Thus, Orion serves as a go-between entity that plugs gaps between the HIE and EHR through automated data feed and by utilizing clinical support staff to procure the most significant data for the physician.

"We're well aware physicians are unhappy with the value they get from EMRs," Hobson said. "Clearly they've not been given all they hoped. So what do we do about it? Orion started integration to integrate data and web portals to see the data from multiple systems. We've done that with HIE, which gives clinicians a lot of value. Part of it is to replace and give functionality the client doesn't have."

Orion is working to configure HIEs to collate and sort data by topic and chronology, with the most recent developments at the top. It is also assembling the system so it provides all relevant data in the most logical manner.

"We are working on cracking the nut – we haven't quite cracked it yet, but we know what the nut is," he said.

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