As the last federal electronic health-record funding washes ashore, the healthcare industry braces for another big wave: the transformation from volume to value. The shift from volume-based reimbursement means changing how healthcare organizations get paid for care—and therefore, how they think about it. Value is the improvement in outcomes for the money spent.
In a value paradigm, financial success requires that providers reduce the need for care and find new ways to keep people healthy.
So far, so good: Aligning the economics of healthcare is something everyone agrees on. Unfortunately, healthcare organizations have installed a vast array of EHRs that are hampering that transformation.
Despite claims about improving safety and efficiency, EHRs are mostly designed for volume-based reimbursement, ensuring that information needed to bill for appointments and procedures is collected. But they don't facilitate care integration or the communication necessary to make care integration a reality. A whopping 90% of surveyed nurses reported their EHR impeded communication between nurses and patients. Even RAND Corp., an early EHR booster, in 2013 backed away from its 2005 prediction that EHRs will save healthcare more than $80 billion a year.
Adding to the misalignment of promise and reality, EHRs are rarely sensitive to who shoulders the data-collection burden. A recent study by Drs. David Himmelstein and Stephanie Woolhandler showed that doctors with EHRs spend more time on administrative tasks than those with only paper records.
EHRs also don't provide sufficiently customized information to help clinicians meet the needs of individual patients. Needs differ significantly among patients: compare those of a child with cancer, an elderly person with congestive heart failure and a healthy middle-aged person seeking to preserve good health. Because EHRs don't support care at this level, and instead place greater focus on high-level records and billing information, they make care delivery harder and inhibit the transition to value-based care delivery.
The gusher of federal funds achieved its stated goal of spurring adoption, but few healthcare organizations thought about the impact of an EHR on the workflow of clinicians. The cost of the systems had to be paid upfront, with incentive dollars flowing in later years, and many providers lacked the resources to thoughtfully design or effectively manage the system's launches. Cash-strapped, overwhelmed organizations couldn't restructure care delivery to streamline processes and make use of some of the EHRs' capabilities, and clinician discontent grew.
Moving forward, services must be structured around patients with similar needs. Then EHRs can provide decision support along care paths and records of patient preferences while improving team communication and enabling outcome measure collection.
EHRs should be easy to use efficiently. Online retailer Amazon monitors the number of keystrokes its customers take in the course of placing an order. Likewise, EHRs of the future have to recognize that every click and keystroke matters to busy clinicians. EHRs must provide the information clinicians need—and only the information that is needed. Reminders and alerts must be more customized to each patient's circumstances, rather than triggering a cascade of useless menus that require rote reactions.
The Cleveland Clinic has adapted its EHR to support clinicians within their existing work patterns. One innovation allows clinicians to access information about multiple patients without having to log in and out of multiple records. Described by CIO Dr. Martin Harris as “electronic rounding,” the information from the EHR flows the way clinic doctors attend to hospitalized patients.
The EHR that Boston-based Iora Health developed for its clinical teams is so intuitive that new users learn to use it on their own in less than an hour. Automated registry functions help Iora monitor patients' health, and search functions allow clinicians to easily find relevant information.
KLAS, a healthcare technology research firm, this past summer reported that more than a quarter of clinicians want to replace their EHR. To support the volume-to-value transformation, the primary focus of the next-generation EHRs has to be making it easier for individual caregivers to improve patients' health. In a value world, EHRs have to be tools that help, rather than impede, clinicians.
