Electronic health records fail because they are merely digital remakes of paper charts
Once hailed as essential to advance healthcare into the 21st Century, electronic health record (EHR) systems have increased rather than decreased physician work load, contributed to physician burn out, and returned little back to patients in improved healthcare quality. Writing in a new Perspective published in the New England Journal of Medicine, researchers from Penn Medicine’s Center for Health Care Innovation argue that the same record systems can be reconfigured to achieve their original promise.
The authors suggest restructuring EHRs from mere digital remakes of their old pen and paper ancestors into platforms that allow doctors to “subscribe” to their patients’ clinical information to receive real-time updates when an action is required, similar to social media feeds and notifications.
The researchers point to several examples implemented within the University of Pennsylvania Health System that reveal how record systems can be reconfigured into subscription services.
For one, receiving important patient information could depend less on physicians remembering to search the chart. For safety reasons, Penn established automatic medication expiration dates for antibiotics and antiepileptics for inpatients, for instance, but the system initially required physicians to remember when to renew the expiring prescriptions. As a result, medications were not ordered 10% of the time because physicians didn’t check the chart in time or notice the need for renewal. To address this, Penn developed a web application that, among other features, allowed residents to receive push notifications on their mobile devices. The result? The number of missed renewals was cut by one-third.
Push notifications—which are sent using a HIPAA compliant messaging platform—can also shorten the lag time between when information becomes available and when it’s used. An older approach at Penn waited until morning rounds were over to evaluate whether patients on ventilators in the intensive care units could breathe without assistance. Now, digital information has both enabled patients to be automatically evaluated and clinicians to receive prompts to act when patients meet the readiness criteria. The new process has reduced delays so patients spend, on average, half a day less on ventilators.
Not all information needs to be known as soon as it becomes available: It’s about sending the right message at the right time. Push notification services can filter what’s important and relevant, just as news feeds and alerts are managed on smart phones. That requires that systems be carefully designed to reduce the risk of alert fatigue, the authors wrote.
Beyond one-off intervention alerts, these notifications can also manage panels of both inpatients and outpatients, according to the authors. One program at Penn monitored the 30 patients with the highest use of care in one of its hospitals, using a dashboard to follow their needs, such as the best way to communicate with them, engage with their family, and next steps for setting up social services. The multidisciplinary team covering the patients was automatically alerted to a patient’s arrival in the emergency room and pointed to the action plan in real time. One year after implementation, 30-day readmissions and total days in the hospital for this group of patients decreased by 67% and 56%, respectively.
