Electronic Health Record Optimization: Strategies for ThrivingStrategies to help health care organizations maximize the benefits and minimize the burdens of the EHR

Why is shared accountability valuable?

When individual leaders and practicing clinicians within an organization have different goals, a harmful “us vs. them” dynamic can develop between those charged with creating organizational policy and implementing the EHR, and those charged with using the EHR. This harmful dynamic can be minimized by intentional organizational actions to align values and goals.

It can be helpful to create opportunities for clinicians and leaders to work toward shared values and goals that are impacted by the EHR implementation, such as optimizing patient experience, patient safety, quality, access and financial viability.

What are some measures for shared accountability?

In a shared accountability framework, the annual performance review of the Chief Executive Officer (CEO), Chief Medical Information Officer (CMIO), Chief Medical Officer (CMO), Chief Compliance Officer and other leaders might be driven, at least in part, by the overall satisfaction/burnout scores of the workforce. It might even be influenced by Work After Work scores. Other overall organizational goals may also be included, such as productivity, patient satisfaction, retention, and recruitment.

How is shared accountability helpful?

Shared accountability protects an organization against suboptimization around a single value at the expense of other organizational values.

When Chief Compliance Officers are responsible, in part, for the ability of clinicians to be productive and to find meaning in their work, decisions will be made differently than when their only responsibility is to protect the organization from an audit failure.

Can you give an example of an organization that implemented shared accountability?

At Atrius Health, the CEO asks his board to hold him accountable for the satisfaction scores of his workforce. He in turn holds his executive leadership accountable for these measures. Because of this, the team saw the need to deploy a “SWAT Team” to reduce clinician dissatisfaction with the implementation and use of their EHR.

The SWAT Team is a high-touch training program at the practice level. Designed and led by the leadership of Internal Medicine and IT, Atrius Health implemented the SWAT Team and several other strategies to optimize the EHR. They lead service line-initiated EHR optimization, such as inbox reduction strategies, annual wellness documentation, and refill automations.

What tools are available to measure overall clinician satisfaction?

There are several validated tools available, including the Mini-Z Burnout Assessment, Well-being Index (WBI), and Maslach Burnout Inventory (MBI).

What tools are available to measure clinician satisfaction with their EHR?

The Mini-Z Burnout Assessment asks specific questions related to EHR burden and includes these responses into the aggregate scoring for the Mini-Z, as well as the subscale for work pace and EHR burden.

I am working several hours more each day, several years after our EHR was implemented. Is that unusual?

Many physicians have found that tasks that previously required a few seconds to accomplish, such as verbally requesting a test or checking off desired labs on a checklist, now take several minutes in the EHR. In addition, work previously done by receptionists, medical records clerks, clinical support staff and others has often been shifted to the physician following the implementation of an EHR.

It is important to be honest and transparent about time. Expecting that the workday will be lengthened to accommodate new or slower work can be counterproductive to an organization's long-term goals of quality, satisfaction, recruitment and retention.

What type of clinician should we include on our EHR committees?

While it may intuitively seem reasonable to invite clinicians who are “computer experts” to lead health IT implementation and optimization efforts, some organizations have found it best to also include “master clinicians.” This allows the focus of the institution to remain squarely on supporting excellent clinical care and prevents policy tilting toward those clinicians. Respected clinicians are also much more likely to gain support from colleagues for the improvements they implement.

Some organizations have found it useful to engage clinicians who struggle with EHR use who can help them understand the optimal interface for the majority of clinicians.

How can clinician informaticists help?

A clinician informaticist, who is not necessarily responsible for achieving the narrow goal of implementing an EHR, but is involved in realizing the larger vision of improving and transforming care using an EHR, can help bridge the clinical and technical worlds.

The clinician informaticist, for example, can work in collaboration with master clinicians to assess common workflows and consider whether current or emerging software solutions exist to improve the workflow or achieve a better result via a new process. This could include: evaluating protocols and software to automate medication renewals; auto-scheduling of follow-up visits; self-scheduling and reminders via a portal; auto-delivery of results to patients and use of a portal, kiosk or other software to capture patient-recorded history.

When should we schedule training—during the workday or after hours?

Some organizations find it best to provide continued training during the workday rather than after office hours.

Providing workday training (with explicit forgiveness of productivity goals) also signals to providers that such work is important. At-the-elbow support when a change is made or opportunity for optimization is identified can be worth the effort. Sending tip sheets or email updates only works if clinicians have the time and mental energy to read them.

Who should we include in training?

The clerical and clinical support staff need to learn optimal use of the EHR along with guided introduction on new upgrades and functionality. This provides an opportunity to optimize the team approach to documentation and to have clear handoffs.

For example, Atrius Health found it useful to engage their medical secretaries, medical assistants (MAs), nurses, advanced practice clinicians and physicians in training for use of the EHR in provision of Annual Wellness Visits.

How does co-location of team members save time?

The MA or nurse can turn to the physician and, in real-time, convey information or ask questions. This eliminates the need for time-consuming electronic messaging. HealthPartners in Minneapolis has found that co-location saves 30 minutes of physician time per day.

How can exam rooms be optimized for collaborative visits?

Exam rooms can be designed with space for an additional staff person who helps with team documentation. The design may include a place for side-by-side seating of the physician and assistant, or space for utilizing stand-up mobile computer stations.

How can exam rooms be designed for information sharing among the team and with the patient?

Exam rooms can be designed to include semi-circular desks that allow face-to-face interactions between the patient and the physician, while still maintaining access to the computer screen. An alternative might be strategically mounted wall screens.

First, I document the visit in the EHR and then I must re-document much of this into the after-visit summary for the patient. How can I avoid this re-work?

Some clinicians populate the entire Assessment and Plan while in the exam room using speech recognition, allowing the patient to hear the plan as it is written. The output can then be directed both to the after-visit summary and the physician's progress note.

One tip with speech recognition is to look at the patient and not the screen and change the tense from third person to second person. This allows synchronizing both verbal and written advice, thus saving time and reinforcing the take-home messages.

• Implementing  “Open Notes” so that the patient has access to the entire note, precluding the need to repeat instructions in an after-visit summary.

• Optimize EHR use and configuration to filter large amounts of information for the particular task and user.

What are some examples of optimizing EHR configuration?

There are many examples to consider:

• Some EHRs can be configured to simplify and collate disease-specific metrics to reduce “searching” through the chart.

• Some EHRs can be used for problem-based charting, so sequential plans can be viewed easily over months, for one disease.

• Graphical flow sheets can be used to combine vitals, labs, patient-reported outcomes and medications all in one view.

• Chart filters can be deployed to focus on specific parts of the patient chart to reduce scrolling.

• Use of APSO notes (replacing SOAP notes) puts ASSESSMENTS and PLANS at the top of the note to reduce scrolling.

• Linking to “my last progress note” can reduce searching and bring up continuity concerns from last visit.

• Other options include the use of the Health Maintenance module and assigning tasks to other team members and other departments (e.g., gynecology, gastrointestinal, pediatrics, medical specialties).

Can states' Prescription Drug Monitoring Programs (PDMPs) be integrated into my EHR so that I can check controlled substance history without leaving the chart?

Several organizations, such as the University of Colorado and MedStar Health – the DC-Maryland region – have integrated their state's PDMP within their EHR, enhancing efficiency and precluding the need to sign in and out of multiple programs. Achieving this level of integration is not without challenges: it requires local programming and can be vulnerable if the state changes its PDMP vendor.

Each state's PDMP is different, which may result in additional software/hardware changes and costs to support PDMP integration into your EHR. You should first consult with your EHR vendor and ask to see a demonstration of the EHR with an integrated PDMP.

How can we implement standing orders without generating an actual order for the physician to sign?

Some organizations have defined standing orders as organizational policies rather than an EHR function. For example, Atrius Health has a policy to centrally “order” influenza vaccines by protocol. The nurses document per the standing order listed in the organization's flu vaccine policy, but no longer manually enter the actual “standing order” in their EHR. Making organizational changes such as this are key to removing unnecessary double work, double documentation and note bloat.

Are other team members allowed to enter orders? We thought this was not allowed under Meaningful Use rules.

In 2017, the requirement for Computerized Provider Order Entry (CPOE) was eliminated from the Medicare EHR incentive program.

CPOE objectives remain in the Medicaid EHR incentive program. Within this program, “any licensed health care provider or a medical staff person who is a credentialed medical assistant or is credentialed to and performs the duties equivalent to a credentialed medical assistant can enter orders in the medical record, per state, local and professional guidelines.”

Our compliance officer tells us that physicians must enter all orders and billing codes. Is this accurate?

While the physician is responsible for making the clinical diagnosis and selecting the level of service, there is no requirement that the physician physically enter the billing and diagnosis codes into the computer.

Please see the Question above regarding entering orders.

How much physician time is saved by team order entry per day?

Available evidence suggests that team order entry directly saves 30-60 minutes per day. Completing all of the orders for a patient can take two to five minutes per patient. An organization can use EHR-audit data to calculate the amount of time spent by physicians on order entry.

Team order entry also saves time indirectly by facilitating the implementation of pre-visit laboratory testing. Labs and other tests performed before the visit eliminate the need for inbox review and post-visit results reporting, saving another hour or more per day.⁴

How does having another team member in the room with the physician save time required for information gathering during the visit?

If additional information is needed during the course of the patient visit, such as the results of a previous imaging study or the patient's prior medication use history, the MA or nurse can find that information and verbally communicate it or pull it up for the physician's review. Physicians don't need to break their interaction with their patients or break their concentration to hunt for this information.

How does having another team member in the room with the physician save time on visit note documentation and other administrative tasks?

A time-motion study² found that physicians spend over one-third of their time in the exam room with patients doing computer tasks. Most of this can be eliminated with in-room teamwork.

I've heard that the MA or nurse must sign in and out of clinical and clerical roles. Is this true?

The Joint Commission has explicitly stated, “There is no Joint Commission requirement stating that a licensed or certified professional signs in and out between clerical and clinical work.”⁵ To the best of our knowledge, there are no CMS requirements for team members to sign in and out of roles.

What other forms of documentation assistance are available?

Other forms of assistance include:

• Dictation to transcriptionist

• Speech recognition software

• Hybrid speech recognition-transcriptionist approach

We work with medical students. Does the faculty have to re-document any Evaluation and Management (E/M) service documentation entered by the medical student for Medicare patients?

No. CMS published a clarification “to allow teaching physicians to verify in the medical record any student documentation of billable [E/M] services, rather than re-documenting the work.”^6,7

Isn't dictation to a transcriptionist too costly?

While many EHRs were implemented with the expectation that costs for transcriptionist services would be reduced, it is possible that the costs of reduced productivity and access to care when physicians are responsible for data entry, either manually or via voice recognition software, outweigh the cost of transcriptionist services.

In addition, there are hidden costs associated with a poorly configured or difficult to decipher notes, including greater time needed to develop situational awareness and a greater chance for errors.

Will speech recognition software save time?

Speech recognition software has received mixed reviews, with some finding it a time-saver compared with typing and others finding it more time consuming, and thus ultimately more costlier, than dictation to a transcriptionist.

Potential challenges of speech recognition software to consider:

• Additional time required for clinicians to proofread and edit the output errors.

• Difficulty in subsequently reading documentation that contains errors that were not caught by the clinician at the time of data entry.

• Difficulty in reading text that has not been formatted for ease of review.

Some organizations take a hybrid approach. In this model, the clinician dictates into a speech recognition software program, and the output is then edited and formatted for readability by a transcriptionist.

What about using mobile devices with speech recognition software?

Some organizations have found that this can add flexibility, mobility and improved functionality to the documentation process.

Our notes are long and difficult to read. It is hard to find the few nuggets of useful information in a colleague's lengthy note. Is all of this information helpful?

There are a few topics to consider:

• Documentation templates, auto-text, and smart phrases are often used to streamline the documentation process. There may be circumstances where such boilerplate text is useful, but organizations may want to reconsider the value to patient care such text output provides. Organizations and physicians should also be cautious to verify auto-populated data to avoid documentation and other errors that could increase liability.

• A longer note is not necessarily better, more defensible, or more compliant than a shorter note. Longer notes composed primarily of generic text and tick-box documentation can contribute to a hazardous care environment by adding to the cognitive work of sorting through the note for important information, and by conditioning clinicians to engage with patients in a more generic fashion.

• Some EHRs include features that allow a user to collapse or hide sections that may not add to the clinical history, for example, text added to a note for regulatory or billing purposes.

A combination of narrative and coded data is optimal. Whatever documentation model is chosen, it is important that it captures both the patient's story and discrete (coded) data. A delicate balance by thoughtful clinicians is vital.

Why is narrative data important?

Narrative data tells the story of the patient. Patient stories help us and our colleagues understand the struggle, the challenges, the suffering and the disease burden for a particular patient. Over-designing the EHR to emphasize clicks and checklists obliterates the patient's story and makes it more difficult to customize care to the individual patient.

Why is coded data important?

Coded, discrete data is fundamental to spotting patterns, running reports, improving quality, improving consistency and removing gaps in care. Some health IT experts predict that artificial intelligence and natural language parsing will reduce the need for clinicians to create coded data.

I frequently receive copies of tests ordered by another physician that I do not need to review. Is there a way to turn this feature off?

Some organizations have significantly reduced physician time on inbox work by turning off automatic notifications of test results ordered by other providers, hospital reports and other indirect communications.

At the University of Colorado, the primary design principle is single delivery of test results (i.e., delivery of the test results to a single team) for 2 reasons:

1. To decrease message volume,

2. To avoid diffusion of responsibility (and increasing the risk that no one responds to a test result, because it is assumed someone else will respond)

Adding a colleague as a test result recipient just to be friendly is strongly discouraged unless there is a specific action requested.

Our physicians routinely have 50-100 inbox messages per day. What are some other ways that we can reduce this volume of work?

Consider the following strategies to support this work:

• Empower teamwork: Empower a nurse or MA, rather than the physician, to be the first responder to the inbox, passing on to the physician only the minority of messages that require the physician's engagement, and accomplishing this via the more efficient format of verbal messaging.

• Use standing orders: Clinical support staff can renew medications by standard protocols, precluding the need to route renewal requests through the physician. Synchronized, bundled renewals of stable chronic medications will relieve a large amount of the prescription renewal burden for the team.

• Verbal messaging: In-person communication between physician and staff can significantly reduce the volume of inbox messages and save time. This can be facilitated by co-location or by setting aside 5-10 minutes at the start or end of each session for the nurse or MA to go over messages with the physician.

• Analyze high-volume tasks: use team huddles or regular meetings to strengthen the team culture and agree to eliminate or use alternate methods to communicate.

• Revise the information flow between specialties and primary care: Review the automated feeds from hospitals and emergency rooms, as well as other sources of inbox items, with the goal of eliminating waste and duplication and increasing the value of the inbox content. Then delegate inbox responsibilities within the local team.

• Evaluate the source of inbox messages. If many inbox messages represent contacts from patients requesting test results, consider this an opportunity to improve processes. For example, pre-visit lab testing allows the patient to receive lab results in person at the visit and obviates the need for the patient to contact the practice for results.

When can we start medication reconciliation?

Some organizations find it effective to do this via a phone call one or two days before the patient's appointment.

Can we engage our patients in medication reconciliation at check-in?

Yes. The receptionist can print the patient's medication list at check-in and ask the patient to update it while in the waiting room or exam room. It is often easier for a patient to review their medicines listed on a piece of paper while staff is viewing the same list on the computer screen.

Patient-initiated medication reconciliation can also be done electronically from a kiosk or with a hand-held tablet in the waiting area, or via the patient portal in advance of the visit.

Is there any requirement that only the physician perform medication reconciliation?

No. CMS regulations provide that an “Eligible Professional” can perform medication reconciliation for Medicare patients. The Joint Commission standards do not specify who can perform medication reconciliation, and “expects that the clinician performing this process is qualified, competent, and working within their licensure or scope of practice and in accordance with applicable laws and regulations.”⁵ To the best of our knowledge, there are no CMS regulations that prohibit MAs or nurses from performing medication reconciliation.

A summary of scope of practice laws for MAs by state can be found here.

Should every provider perform comprehensive medication reconciliation at each patient visit?

Some organizations recognize the risk inherent in a provider reconciling medications with which they are not familiar. In these settings, a provider reconciles the medications for which they are responsible and acknowledges (but does not modify) the other medications.

Should all patient messages go directly to the physician? Our physicians are already overwhelmed with inbox work and are concerned that use of the patient portal will increase their inbox work.

It is inefficient to designate the physician as the first responder to the patient portal. For greater efficiency, a staff person, such as a nurse or MA, can review messages, manage them by protocol, research as needed and then review in person with the physician those messages that require the physician's input.

We've had some patients write lengthy portal messages, covering multiple issues, and these can be difficult to sort out. How can we handle this?

Consider some of these suggestions for managing lengthy portal messages:

• Some organizations have found it useful to limit the length of the patient's inbound communication to encourage proper use of the portal and to direct more extensive discussion to a more appropriate encounter (e.g., phone or in-person visit). Others have found that it is better not to apply a word limit.

• In the words of one physician, “If a patient writes ‘please read these 12 websites and let me know what you think,' my response is ‘You are very thoughtful about your care! Please bring the most useful pages to our next visit so we can discuss this complicated issue in person.'” Directing patients to science-based websites that often end in .edu, .org, or .gov may be helpful.

• Review the length of time that a message can remain active in the portal. Patients sometimes use old messages to start a new conversation, which can cause confusion as the message header does not convey the most recent content.

Some of our patients are not interested in using the portal. Is there anything we can do to increase engagement?

Consider the following suggestions to increase engagement:

• Make it easy. Some clinics routinely help patients enroll in the patient portal during check-in or check-out. For example, at the Ambulatory Practice of the Future at the Massachusetts General Hospital, automatic kiosks for check-in have freed up time for the receptionist to help patients enroll in the patient portal. The staff have found that sometimes it just takes a little extra encouragement and assistance—it takes just 30 seconds to sign up for the portal. For patients who may initially feel reluctant, a few words from their provider can help them develop a better sense of how helpful it is to both them and their care team.

• In some practices, a clinician or assistant will close the EHR and log into the portal sign up page while in the exam room. The staff person leaves the room and lets the patient complete the sign-up process on the spot.

• Other organizations have built functionality within the EHR such that a team member clicks a button while with a patient that sends the patient a text message prompting them to sign up right then.

• Ask teams to tell their patients that portal use is preferred and will allow the team to respond to their needs more efficiently.

• Engage family members. In many EHRs, a patient may designate a proxy so that family members have access to the portal and can help coordinate a patient's care. It can be useful to set up a standardized process during check-in or check-out where a patient can designate a family member as a proxy.

• Recognize that the portal is not for everyone. Some patients will not want to use it.

How can the printed medication list be helpful?

A print copy of the medication list for use in the exam room allows for quick review and re-review while speaking with the patient or considering other data fields in the EHR.

How can the printed last progress note be helpful?

A print copy of the last progress note can lead to less back and forth between screens when in the room with the patient. It also facilitates a connection between the current visit and the prior visit.

Are the paper checklists or questionnaires scanned into the chart?

No, checklists and patient questionnaires are used in order to be more efficient, decreasing the work of the staff and increasing the engagement of the patient, but do not need to be scanned into the record.

Are there other examples of printed information that improves workflow?

Consider these printed documents that can improve workflow:

• PHQ-9: Some organizations ask patients who are receiving anti-depressants to complete a PHQ-9 at each visit while in the waiting or exam room.

• Pain questionnaire: Patients can be asked to diagram and characterize pain on paper.

• Vaccine information statement (VIS): This can be given to patients due for vaccines upon check-in, allowing patients time to read about the immunizations that will be recommended.

How can we facilitate peer-to-peer learning?

Consider these options for peer-to-peer learning:

• Include a time to share tips and tricks at each department meeting

• Conduct training by physicians for physicians in the optimal use of the EHR, often segmented by specialty (i.e., internists training other internists, surgeons training other surgeons). A general surgeon can train multiple other types of surgeons, and an internist can train multiple subspecialties within internal medicine.

How can we facilitate learning within the practice team?

It can be helpful to train the practice unit as a whole in a new EHR functionality or workflow. In this way, the clerical staff, MAs, nurses and physicians can work out the physical and virtual workflows, handoffs, communication pathways and distribution of tasks.

How can we identify users most in need of intensive training?

Some organizations use EHR-use data to identify clinicians who would benefit from intensive training.

Such training might involve learning how to create a patient overview report, use the auto-correct dictionary, customize smartphrases, use reminders, and use the Social History field to track something personal about a patient.

What are some examples of reducing information flow that organizations have instituted?

Consider some of the following examples to implement in your practice:

• Send test results only to the ordering physician, and do not routinely send to all other physicians involved in the patient's care or to the primary care physician. Sending test results to multiple physicians creates confusion and ambiguity about responsibility for responding to the result. It also clutters the inbox with results for which the receiving physician may not have the knowledge or responsibility for responding. More is not always better here.

• Not all referral notes are of clinical utility to the other physicians involved in the patient's care. Some organizations therefore do not routinely send all referral notes back to the referring physician. These organizations let these notes be proactively pulled rather than reflexively pushed.

• The practice of sending all hospital test results and daily notes to ambulatory physicians can create confusion about responsibility and contributes to unmanageable information overload. Some organizations choose not to routinely send all inpatient data to ambulatory physicians involved in that patient's care.

• Some EHRs allow the physician to individually turn on or off notification of tests other physicians have ordered on a mutual patient.

We just turned on our EHR's EHR-use data. How can we use it?

This data can be used at a high level to understand where clinical resources are being directed. For example, an organization can identify the amount of time physicians in their organization are doing inbox and documentation work during their personal time, and then develop organizational countermeasures to reduce this time.

The data can also be used to identify individuals who are especially efficient, from whom others can learn; alternatively, the data can identify those in need of assistance and for whom increased staffing, training or both may be prudent.

Why measure “Work After Work”?

This measure highlights one of the main work–life balance issues associated with EHR use. It is also referred to as “Pajama Time” and indicates work often done at night.

An organization that minimizes Work After Work will very likely have lower burnout rates, which is associated with higher patient safety and satisfaction, better care quality, and better financial success. Data illustrating minimal Work After Work in an organization can be influential in workforce recruitment and retention.

How can “Click Counts” be used?

This measure can guide local changes, such as badge login in place of keyboard login, or identification of optimal pathways for high-volume tasks.

Inadequate usability is a key criticism of the EHR, and this metric is an objective measure that can drive improvements at the local, institutional and vendor levels.

How can the “Teamwork” measure be used?

This measure can be used to track the impact of workflow innovations such as team documentation, team order entry and expanded rooming and discharge protocols.