Letter from the Editor

Making the Electronic Health Record Better: An EP’s Perspective

Bradley P. Knight, MD, FACC, FHRS, Editor-in-Chief

Bradley P. Knight, MD, FACC, FHRS, Editor-in-Chief

Electrophysiologists interact with the electronic health record (EHR), as most physicians do, when providing consultative care to patients, either in the office or hospital, and when performing heart rhythm procedures on patients. They also interface with the EHR when over-reading EKGs, Holter monitors, event recordings, and pacemaker and defibrillator interrogation reports. Many of these items are handled by the EHR as imported PDF files that need to be opened to view. 

Implementation of the EHR has dramatically changed the practice of medicine, and there are certainly some advantages now compared to the old paper record system. For example, the EHR has greatly improved the ability for administrators to have access to operational and billing data, it allows for easy viewing of encounter notes from outside institutions, the automatic dictation and transcription tools work well, and the systems are very stable and rarely crash. But the tradeoffs have been many. The EHR has had a major negative impact on the ability of physicians to efficiently take care of patients. The EHRs could not be less intuitive, and are a major source of frustration for physicians. They have resulted in clinical workflow inefficiencies, bloated documentation, constant prompts, and a bottomless inbox of multiple folders with nonsensical folder names. Much of the old “paperwork” tasks have been shifted to the physician, whether it is the hard stops asking for more information when placing an order for an MRI, the complexity of prescribing a steroid taper, or the need for a clustered multilevel order set to close an open chart when a patient is a no-show. 

Equally frustrating is the lack of progress or apparent interest in improving the EHRs for the physicians who use them. It has been seven years since the American Medical Association (AMA) had RAND Health conduct a physician survey, concluding that the EHR is a major source of physician dissatisfaction: “Aspects of current EHRs that were particularly common sources of dissatisfaction included poor usability, time-consuming data entry, interference with face-to-face patient care, inefficient and less fulfilling work content, inability to exchange health information, and degradation of clinical documentation.”1 But nothing has changed since then. A recent Twitter poll found that 68% of 149 respondents are “Not very” (34%) or “Not at all” (34%) satisfied that their EHR system helps them to best take care of patients with heart rhythm disorders.2 That is over two-thirds of respondents! Just last month, a dermatology journal published the results of a survey finding that most dermatologists feel that the EHR has negatively impacted their workflow efficiency and face-to-face time with patients.3 Also last month, our hospital added seven additional mouse clicks and keyboard strokes to each telemedicine encounter to add a modifier to the billing code and to document the type and duration of each virtual visit, despite the fact that such information is already included in the progress note. 

Physicians are desperate for help in making some basic improvements. Below are some simple changes that could be made to improve the EHR to better help physicians take care of patients, particularly those with heart rhythm disorders:

  1. Allow direct integration of pacemaker and defibrillator electronic management systems into the EHR.
  2. Reduce mouse clicks and keystrokes rather than adding them. At the minimum, require the IT department to balance any new clicks with the removal of others.
  3. Automatically hide from view any button or field that has not been used or clicked on by the user in the past year. The EHR screens are cluttered with hundreds of pieces of unused data fields and click buttons.
  4. Reorganize and triage inbox folders so that results and messages are placed in order of priority rather than as a continuous stream of information requiring constant attention.
  5. Allow a single-button mouse-click to close a patient chart when the patient does not show for an appointment after the physician has already opened the chart and started making notes.
  6. Require the clinic schedule view to show who referred the patient and why. Figuring out why a patient was actually scheduled to see their doctor can be one of the biggest challenges.
  7. Change the Patient Call folder to only include situations when the patient has called and is awaiting a call back. Using that folder to document other information, such as anticoagulation clinic phone correspondence, is confusing.
  8. Allow the user to remotely close a chart from another workstation when it is left open in the exam room or in a different workspace by the same user. It should not be necessary to physically return to that room to close the chart.
  9. Allow the option to limit chart search results to patients with whom the provider has had an encounter with in the past. Current search functions display hundreds of John Does who have never been a patient of the provider in the past.
  10. Allow users to customize and save the default page layout preferences of the program that opens PDF attachments, so that adjustments are not needed every time an attachment is opened to perform functions such as over-reading Holter monitors.

Physicians are rarely given the opportunity to provide simple suggestions that could make the EHR better. The current system of using asynchronized, impersonal, frustrating communication (ie, submitting a “ticket” to the hospital IT department) rarely ever results in solutions or progress. Patient care will not improve until physicians have a greater voice related to the EHR. 

Disclosures: Dr. Knight reports that he is a consultant, speaker, investigator, and offers fellowship support for Abbott, Baylis Medical, Biosense Webster, Inc., BIOTRONIK, Boston Scientific, Medtronic, and SentreHEART. He has received compensation for serving as a consultant to CVRx, Inc. 

References
  1. Friedberg MW, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. RAND Corporation. 2013. Available at https://www.rand.org/pubs/research_reports/RR439.html. Accessed September 18, 2020.
  2. @DrBradleyKnight. How satisfied are you that your electronic health record (EHR) system helps you best take care of patients with heart rhythm disorders? Twitter. September 15, 2020. https://twitter.com/DrBradleyKnight/status/1305999197376843776
  3. Katamanin O, Glazer AM. Dermatologists’ perceptions and use of electronic health record systems. SKIN The Journal of Cutaneous Medicine. 2020;4(5):404-407. https://doi.org/10.25251/skin.4.5.2.
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