How Will This Toolkit Help Me?
Learning Objectives
Identify leadership, system, and individual strategies to optimize EHR use
Explain the importance of teamwork in implementing and using the EHR in your practice
Describe how your practice can leverage EHR data to improve overall workflows
Electronic health records (EHRs) have profoundly changed the practice of medicine and are often perceived as both a blessing and a burden by the clinicians who use them. Decisions made in the design, regulation, implementation, and individual use of the EHR contribute to its benefits and challenges. In this toolkit, we present strategies that health care delivery organizations can deploy to maximize the benefits and minimize the burdens of EHR use, along with Success Stories from organizations that have made progress in optimizing their EHR.
Nine STEPS to Optimize EHR Use in Your Practice
Align Leadership and Clinician EHR Users
Stop Doing Unnecessary EHR Work
Optimize Hardware and Built-Environment Solutions
Optimize Software Solutions
Reduce the Burden of Order Entry and Documentation
Optimize Teamwork
Optimize Clinician User Skills with the EHR
Optimize Information Flow Throughout the Health System
Leverage EHR-Use Data
STEP 1 Align Leadership and Clinician EHR Users
Quiz Ref IDEHR implementation is most successful when leadership and end users are working together toward the same goal. For example, if leadership directs the IT department to prioritize security without considering the added physician burden, time is wasted and taken away from patient care.
Helpful Organizational Strategies to Reach Alignment |
Institute shared accountability, wherein institutional leaders share accountability for multiple organizational goals rather than having accountability siloed to only their particular domain. Read more about Creating the Organizational Foundation for Joy in Medicine and the Joy in Medicine CEO Consortium blog post in Health Affairs. |
Regularly measure overall clinician satisfaction/burnout, as well as satisfaction specific to EHR use. |
Include EHR-use metrics on the organization's data dashboard (see STEP 8). |
Consider time trade-offs: if new work will be required of clinicians, then consider what existing work can be made more efficient, delegated, or eliminated. |
Include practicing physicians and other health professionals in all decisions regarding implementation, training, and metrics. |
Train and support a core team of clinician informaticists. |
Value the users' training time and be sure it continues after go-live. |
STEP 2 Stop Doing Unnecessary EHR Work
Uncovering and getting rid of any unnecessary work is essential. Eliminating tasks and processes that detract from patient care is crucial for successful EHR optimization.
Consider your unique practice environment. Are you getting too many alerts? Are you still at the workstation when screens time out? Remedying unnecessary EHR work can run the gamut from simplifying login to minimizing alerts to streamlining order entry. Work with your colleagues, IT, leadership, and any other stakeholders to rectify these issues.
Some unnecessary work may be the result of your compliance or IT department overinterpreting rules “just to be safe.” Leadership should consider de-implementing processes or requirements that add little or no value to patients and their care teams.
Table 1 covers considerations for EHR work to eliminate or change and is part of the AMA STEPS Forward™ “Getting Rid of Stupid Stuff” toolkit.
De-Implementation Checklist (126 KB)This document will help you identify then get rid of burdensome EHR tasks or processes.
STEP 3 Optimize Hardware and Built-Environment Solutions
Many institutions struggle after implementing an EHR because of an inadequate investment in hardware or physical workspace optimization. Examples of changes that can improve patient care and workflow—and could even save 15-30 minutes per team member per day—include:
Implementing flow stations where clinical support team members and physicians are seated side-by-side
Installing widescreen monitors (eg, 24 inches)
Having networked printers in every exam room
Optimizing the user sign-in process with technology such as radiofrequency identification (eg, badge readers)
Optimizing exam rooms for team documentation and information-sharing
STEP 4 Optimize Software Solutions
Having certain functions integrated within the EHR can improve workflow and efficiency, for example*:
e-Prescribe controlled substances. Support physicians e-prescribe controlled substances instead of printing prescriptions, if allowed by state law.
Patient photos. Capture patient photos to facilitate recognition of the patient and their story upon opening the record. The clerical team can capture the photo at arrival or check-in. In some applications, patients can upload their own photos using kiosks or a mobile patient portal.
After-visit summary. Use the after-visit summary that is given to patients to record patient education.
Patient access. Encourage patients to access their medical record and visit notes because when a patient has access to the entire note, this precludes the need to repeat instructions in an after-visit summary
EHR fit for purpose and person. Optimize EHR use and configuration to filter large amounts of information for the particular task and user
Patient portal. Encourage patients to sign up for and use the patient portal. When used effectively, patient portals can reduce workload and increase efficiency for physicians and the care team by transferring routine administrative tasks from the care team to the patient.
*Some circumstances may require the use of third-party tools for these functions.
STEP 5 Reduce the Burden of Order Entry and Documentation
The clerical burden associated with EHR use is one of the most significant drivers of professional dissatisfaction and burnout among physicians. Physicians spend nearly 2 hours on EHR and desk work for every 1 hour of direct face time with patients.3 On top of this, physicians typically take 1 to 2 hours of inbox and documentation work home every night.3,4
Quiz Ref IDIt is seldom the safest, most efficient, or best business model that assigns new work created by EHR implementation to the physician. Sharing EHR tasks across a well-trained team allows multiple individuals to contribute to the effort and preserves physician resources for work for which they are uniquely trained—medical decision-making and relationship-building.
Components of optimal teamwork could consist of:
Effective inbox management. An unmanageable inbox is a safety hazard for patient care, as well as a driver of physician burnout, reduction of clinic hours, or exit from the practice.9
Medication reconciliation by other care team members. Others besides the physician, such as a pharmacy technician, pharmacist, medical assistant, or nurse, can perform medication reconciliation before the physician sees patients.
Leveraging the patient portal. Patient portals can improve the efficiency of results reporting and other communication with the patient. When empowerd to communicate with patients and research patient questions before involving the physician, the clinical support team can manage the patient portal.
Updated rooming protocols. Empower clinical support team members by expanding their roles in medication reconciliation, agenda-setting, care gap closure, and quality metric documentation (see the AMA STEPS Forward™ Expanded Rooming and Discharge toolkit).
Modify the rooming protocol so that the patient is not automatically put on the exam table but in a chair adjacent to the desk to facilitate face-to-face conversation.
Printing selected information for each visit. There are still uses for paper in an electronic environment. The goal is to provide efficient and excellent patient care, not to be completely paperless. Some physicians find it useful for the clerical or clinical support team to print out a few key sources of information, such as the medication list and/or the last problem list for each visit. A team workflow like this supports practice efficiency and reduces the cognitive workload of medical decision-making.
STEP 7 Optimize User Skills With the EHR
EHRs are powerful tools that take some time and training to master. Users learn best hands-on, so at-the-elbow support at the time of a major software change is beneficial. Users also learn best from their peers and within the context of their own team.
STEP 8 Optimize Information Flow Throughout the Health System
Some organizations have begun to rethink how information flows throughout the entire health system. Rather than assuming it is preferable or safer to send all information to all potentially relevant parties, these organizations recognize the value of parsimonious information sharing.
Information overload contributes to cognitive workloads, work-after-work, and a hazardous environment for medical decision-making. Not every element of care needs to flow through the EHR, and not every element of care in the EHR needs to be performed by the physician.
STEP 9 Leverage EHR-Use Data
Measure EHR-use data and track these metrics on the institution's data dashboard.11 Many EHRs provide access to EHR-use data, such as Lights On Network® in Cerner or Provider Efficiency Profile or Signal in Epic. Other EHR vendors may offer EHR-use data as well. EHR-use metrics include:
Work-after-work. Also known as “pajama time,” this measurement counts the hours the physician is logged into the EHR on nights, weekends, and while on vacation. See Figure 1, Figure 2, and Figure 3 for examples of how work-after-work may impact different physicians.
Click counts. Whether you count clicks per task or clicks per day, tracking and following click data can be useful for identifying opportunities for improvement in EHR set-up, workflows, user training, or accessibility. For example, Atrius Health has found that using a widescreen view saves over 300 000 clicks per day within their organization.
Teamwork. This metric shows the percentage of total keystrokes for a patient visit that the physician performs. A lower score here is generally optimal.
Below are examples of work-after-work data for 3 physicians in the same specialty.
The department chair or clinic manager who reviews this data may choose to “go and see” each of these physicians in action to identify best practices that can be more widely shared and gauge the potential for utilizing peer mentors in optimal EHR use.
EHRs can be powerful tools for improving patient care, practice efficiency, and professional satisfaction. Achieving these goals requires effort, beginning at the leadership level. Intentional organizational and individual efforts to leverage the power of the EHR while preserving time and cognitive focus for relationship-building and complex medical decision-making can create a safer, more effective, and more rewarding care environment.
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