Report of the AMIA EHR-2020 Task Force on the status and future direction of EHRs

Over the last 5 years, stimulated by the changing healthcare environment and the Health Information Technology for Economic and Clinical Health (HITECH) Meaningful Use (MU) Electronic Health Record (EHR) Incentive program, EHR adoption has increased remarkably, and there is early evidence that such adoption has resulted in healthcare safety and quality benefits.1,2 However, with this broad adoption, many clinicians are voicing concerns that EHR use has had unintended clinical consequences, including reduced time for patient-clinician interaction,3 new and burdensome data entry tasks being transferred to front-line clinicians,4,5 and lengthened clinician workdays.6–8 Additionally, interoperability between different EHR systems has languished despite large efforts towards that goal.9,10 These challenges are contributing to physicians’ decreased satisfaction with their work lives.11–13 In professional journals,14 press reports,15–17 on wards, and in clinics, we have heard of the difficulties that the transition from paper records to EHRs has created.18 As a result, clinicians are seeking help to get through their work days, which often extend into evenings devoted to writing notes. Examples of comments we have received from clinicians and patients include: “Computers always make things faster and cheaper. Not this time,” and “My doctor pays more attention to the computer than to me.” Ultimately the healthcare system's goal is to create a robust, integrated, and interoperable healthcare system that includes patients, physician practices, public health, population management, and support for clinical and basic sciences research. This ecosystem has been referred to as the “learning health system.”19 EHRs are an important part of the learning health system, along with many other clinical systems, but future ways in which information is transformed into knowledge will likely require all parts of the system working together. Potentially every patient encounter could present an …

[1]  David W. Bates,et al.  Viewpoint Paper: A Research Agenda for Personal Health Records (PHRs) , 2008, J. Am. Medical Informatics Assoc..

[2]  Thomas H. Payne,et al.  Evaluating clinical decision support systems: monitoring CPOE order check override rates in the Department of Veterans Affairs' Computerized Patient Record System. , 2008, Journal of the American Medical Informatics Association : JAMIA.

[3]  Joshua R. Vest,et al.  Factors motivating and affecting health information exchange usage , 2011, J. Am. Medical Informatics Assoc..

[4]  Spencer S. Jones,et al.  Health Information Technology: An Updated Systematic Review With a Focus on Meaningful Use , 2014, Annals of Internal Medicine.

[5]  Lena Mamykina,et al.  Clinical documentation: composition or synthesis? , 2012, J. Am. Medical Informatics Assoc..

[6]  Michael W. Smith,et al.  An analysis of electronic health record-related patient safety concerns , 2014, J. Am. Medical Informatics Assoc..

[7]  S. Simon,et al.  Engaging patients in medication reconciliation via a patient portal following hospital discharge. , 2014, Journal of the American Medical Informatics Association : JAMIA.

[8]  Eric G. Poon,et al.  Research Paper: The Extent and Importance of Unintended Consequences Related to Computerized Provider Order Entry , 2007, J. Am. Medical Informatics Assoc..

[9]  Dean F Sittig,et al.  A new sociotechnical model for studying health information technology in complex adaptive healthcare systems , 2010, Quality and Safety in Health Care.

[10]  Rainu Kaushal,et al.  The Patient-Centered Medical Home, Electronic Health Records, and Quality of Care , 2014, Annals of Internal Medicine.

[11]  Farzad Mostashari,et al.  National Coordinator for Health Information Technology Office of the National Coordinator for Health Information Technology Department of Health and Human Services , 2013 .

[12]  Elizabeth T. Toll,et al.  A piece of my mind. The cost of technology. , 2012, JAMA.

[13]  D. Bates,et al.  Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. , 1998, JAMA.

[14]  Kenric W. Hammond,et al.  Are Electronic Medical Records Trustworthy? Observations on Copying, Pasting and Duplication , 2003, AMIA.

[15]  Lauren Vogel,et al.  Cut-and-paste clinical notes confuse care, say US internists , 2013, Canadian Medical Association Journal.

[16]  Sharron L Docherty,et al.  Electronic nursing documentation as a strategy to improve quality of patient care. , 2011, Journal of nursing scholarship : an official publication of Sigma Theta Tau International Honor Society of Nursing.

[17]  Christine A Sinsky,et al.  Expanding primary care capacity by reducing waste and improving the efficiency of care. , 2013, Health affairs.

[18]  Mara Reichman,et al.  Optimizing referrals & consults with a standardized process. , 2007, Family practice management.

[19]  D. Blumenthal,et al.  Achieving a Nationwide Learning Health System , 2010, Science Translational Medicine.

[20]  Daniel R. Verdon.  Physician outcry on EHR functionality, cost will shake the health information technology sector , 2014 .

[21]  Roger B. Davis,et al.  Overrides of medication alerts in ambulatory care. , 2009, Archives of internal medicine.

[22]  Isaac S Kohane,et al.  Tectonic shifts in the health information economy. , 2008, The New England journal of medicine.

[23]  A. Wu,et al.  In the Wake of the 2003 and 2011 Duty Hours Regulations, How Do Internal Medicine Interns Spend Their Time? , 2013, Journal of General Internal Medicine.

[24]  E. Hess,et al.  Electronic medical records and physician stress in primary care: results from the MEMO Study. , 2014, Journal of the American Medical Informatics Association : JAMIA.

[25]  Brian E. Dixon,et al.  An informatics approach to medication adherence assessment and improvement using clinical, billing, and patient-entered data , 2014, J. Am. Medical Informatics Assoc..

[26]  Charlene R. Weir,et al.  An exploration of the impact of computerized patient documentation on clinical collaboration , 2011, Int. J. Medical Informatics.

[27]  T. Meriden.  A Piece of My Mind , 1988, Diabetes Care.

[28]  Daniel R. Verdon,et al.  EHRs: the real story. Why a national outcry from physicians will shake the health information technology sector. , 2014, Medical economics.

[29]  Kevin B Weiss,et al.  Evaluating Physician Performance at Individualizing Care: A Pilot Study Tracking Contextual Errors in Medical Decision Making , 2007, Medical decision making : an international journal of the Society for Medical Decision Making.

[30]  Tosha B. Wetterneck,et al.  Technology Evaluation: Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety , 2008, J. Am. Medical Informatics Assoc..

[31]  David W. Bates,et al.  Comparing Electronic Health Record Portals to Obtain Patient-Entered Family Health History in Primary Care , 2013, Journal of General Internal Medicine.

[32]  Paul Hyman.  The Day the EHR Died , 2014, Annals of Internal Medicine.

[33]  Robyn Tamblyn,et al.  Review Paper: The Impact of Electronic Health Records on Time Efficiency of Physicians and Nurses: A Systematic Review , 2005, J. Am. Medical Informatics Assoc..

[34]  Daniel J. Vreeman,et al.  Automated Mapping of Local Radiology Terms to LOINC , 2005, AMIA.

[35]  Sue E Bowman.  Impact of electronic health record systems on information integrity: quality and safety implications. , 2013, Perspectives in health information management.

[36]  Christine A. Sinsky,et al.  Electronic Health Records: Design, Implementation, and Policy for Higher-Value Primary Care , 2014, Annals of Internal Medicine.

[37]  Dean F. Sittig,et al.  Computerized Provider Order Entry Adoption: Implications for Clinical Workflow , 2008, Journal of General Internal Medicine.

[38]  A. Localio,et al.  Role of computerized physician order entry systems in facilitating medication errors. , 2005, JAMA.

[39]  Robert H. Brook,et al.  Factors Affecting Physician Professional Satisfaction , 2013 .

[40]  References , 1971 .

[41]  Devin M Mann,et al.  Efficacy of an evidence-based clinical decision support in primary care practices: a randomized clinical trial. , 2013, JAMA internal medicine.

[42]  K W Kizer,et al.  From the Veterans Health Administration. , 1996, JAMA.

[43]  Erika L. Abramson,et al.  A statewide assessment of electronic health record adoption and health information exchange among nursing homes. , 2014, Health services research.

[44]  Valter Sundh,et al.  Interviews or medical records, which type of data yields the best information on elderly people’s health status? , 2006, Aging clinical and experimental research.

[45]  Jonathan S Einbinder,et al.  Copy/paste documentation of lifestyle counseling and glycemic control in patients with diabetes: true to form? , 2011, Archives of internal medicine.

[46]  Sean W. Smith,et al.  Healthcare information technology's relativity problems: a typology of how patients' physical reality, clinicians' mental models, and healthcare information technology differ , 2014, J. Am. Medical Informatics Assoc..

[47]  J Michael McCoy,et al.  The SMART Platform: early experience enabling substitutable applications for electronic health records , 2012, J. Am. Medical Informatics Assoc..

[48]  F. Collins,et al.  A new initiative on precision medicine. , 2015, The New England journal of medicine.

[49]  D. Berwick,et al.  The triple aim: care, health, and cost. , 2008, Health affairs.

[50]  E. Siegler,et al.  Copy and paste: a remediable hazard of electronic health records. , 2009, The American journal of medicine.

[51]  Suzanne Bakken,et al.  The clinician in the driver's seat: Part 2 - Intelligent uses of space in a drag/drop user-composable electronic health record , 2014, J. Biomed. Informatics.

[52]  Fiona M. Callaghan,et al.  Use of internist's free time by ambulatory care Electronic Medical Record systems. , 2014, JAMA internal medicine.

[53]  Adam Wright,et al.  Graphical display of diagnostic test results in electronic health Records: a comparison of 8 systems , 2015, J. Am. Medical Informatics Assoc..

[54]  Leigh Ann Backer,et al.  The medical home: an idea whose time has come ... again. , 2007, Family practice management.

[55]  Aziz A. Boxwala,et al.  Demonstrating Cloud-based Clinical Decision Support at Scale: The Clinical Decision Support Consortium , 2013, MedInfo.

[56]  Elliott S Fisher,et al.  Building the path to accountable care. , 2011, The New England journal of medicine.

[57]  Alejandro Rodríguez-Molinero,et al.  Physicians' impression on the elders' functionality influences decision making for emergency care. , 2010, The American journal of emergency medicine.

[58]  Charlene R. Weir,et al.  Characterizing "information transfer" by using a Joint Cognitive Systems model to improve continuity of care in the aged , 2012, Int. J. Medical Informatics.

[59]  Joan S. Ash,et al.  Research Paper: Types of Unintended Consequences Related to Computerized Provider Order Entry , 2006, J. Am. Medical Informatics Assoc..

[60]  Philip R. O. Payne,et al.  Evidence generating medicine: redefining the research-practice relationship to complete the evidence cycle. , 2013, Medical care.

[61]  S. Goodrich,et al.  A Piece of My Mind , 2014 .

[62]  Isaac S. Kohane,et al.  Technical desiderata for the integration of genomic data into Electronic Health Records , 2012, J. Biomed. Informatics.

[63]  Catherine L. Liang,et al.  Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial. , 2009, Archives of internal medicine.

[64]  John W. Beasley,et al.  Texting While Doctoring: A Patient Safety Hazard , 2013, Annals of Internal Medicine.

[65]  Colin P. West,et al.  Time spent on clinical documentation: a survey of internal medicine residents and program directors. , 2010, Archives of internal medicine.

[66]  David W. Bates,et al.  Development of a tool within the electronic medical record to facilitate medication reconciliation after hospital discharge , 2011, J. Am. Medical Informatics Assoc..

[67]  Mark W Friedberg,et al.  Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. , 2013, Rand health quarterly.

[68]  Kent J Moore.  Documenting history in compliance with Medicare's guidelines. , 2010, Family practice management.

[69]  George Hripcsak,et al.  Use of electronic clinical documentation: time spent and team interactions , 2011, J. Am. Medical Informatics Assoc..

[70]  D. Coplen.  Types of Unintended Consequences Related to Computerized Provider Order Entry , 2007 .

[71]  Lucila Ohno-Machado,et al.  Natural language processing: an introduction , 2011, J. Am. Medical Informatics Assoc..

[72]  Charlotte A. Weaver,et al.  Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA. , 2013, Journal of the American Medical Informatics Association : JAMIA.

[73]  Ben Shneiderman,et al.  Twinlist: Novel User Interface Designs for Medication Reconciliation , 2013, AMIA.

[74]  Lena Mamykina,et al.  The future state of clinical data capture and documentation: a report from AMIA's 2011 Policy Meeting , 2013, J. Am. Medical Informatics Assoc..