Informaticians Propose ‘Essential EHR Reforms for This Decade’

In a proposal published in the Journal of the American Medical Association, two distinguished informaticians have outlined what they are calling “essential electronic health reforms for this decade.”

Don E. Detmer, M.D., M.A., is professor emeritus and professor of medical education at the University of Virginia. While at Virginia he led implementation of a physician order entry system. Among his many other accomplishments, Detmer served as president and CEO of the American Medical Informatics Association. Andrew Gettinger, M.D., served as chief medical information officer and the chief clinical officer for the Office of the National Coordinator for Health IT. He is a professor of anesthesiology emeritus at Geisel School of Medicine and adjunct professor of computer science at Dartmouth, and was formerly the CMIO for Dartmouth-Hitchcock and associate dean for clinical informatics at Geisel.

Detmer and Gettinger noted that despite distinct advantages that EHRs bring, the structure of healthcare services in the United States “has made it difficult to exploit their most desirable features. Instead of supporting clinicians seeking to deliver care more effectively and efficiently, current EHR design and configurations attempt to manage clinicians and how they do their work. The deterioration in the patient-clinician relationship and increased clinician burden are often blamed on the EHR.”

In their JAMA piece, Detmer and Gettinger call for three key changes they say could be implemented fairly easily:

• Removing all administrative and regulatory documentation obligations for care providers during their “clinical time” with patients, except for matters pertaining directly to the reason for the patient’s visit. This would effectively separate care provision from payment and billing, cutting through red tape. For example, Detmer and Gettinger suggest streamlining all insurance approval and authorization practices to eliminate, as much as possible, the need to get “pre-approval” from insurers for treatments. 
• Adding the ability for patients to enter information in their electronic health record, making them more active participants in their care.
• Reinventing the “clinical note,” one of the most common records providers create, to better support patient care. These notes, Detmer and Gettinger say, should directly address expected or desired results from each visit and could include timelines, when possible.

  “A major move in these directions will allow far greater creativity and innovation between clinicians and patients to transcend the traditional boundaries of what constitutes care,” the authors say. “The focus of care can broaden to consider all the social determinants of health [the external factors that affect outcomes] that may be relevant to a particular patient.”

In addition to those proposals, Detmer and Gettinger argue that the most urgently needed change is the least likely to be implemented. They say there is a desperate need for “unique personal safety identifiers” that would let hospitals, employers, health plans, insurance companies and other healthcare organizations streamline operations by jointly identifying individual patients. That idea was originally mandated in 1996’s Health Insurance Portability and Accountability Act (HIPAA) but has not been implemented at the national level because of concerns about patient privacy and other issues. The lack of such consistent identifiers, Detmer and Gettinger maintain, “presents a continuing threat to privacy, safety, cost reduction and administrative errors.”

The authors say that that enacting some of the changes they suggest could make a big difference for both clinicians and patients.

“Although addressing shortcomings in EHRs will not cure all that ails our current healthcare system, implementing these recommendations should positively affect patients and clinicians and move us toward the original vision of a patient-centered, technology-enhanced healthcare ecosystem that is designed to significantly improve outcomes at a lower cost, with more satisfied patients and clinicians,” the authors conclude.