A Review of Phr Emr and Ehr Integration a More Personalized Healthcare and Public Health Policy
JMIR Hum Factors. 2018 Oct-Dec; 5(4): e10426.
Clinically Excellent Use of the Electronic Health Record: Review
Monitoring Editor: Gunther Eysenbach
Leah Wolfe, MD, 
ane Margaret Smith Chisolm, Doc,ii and Fuad Bohsali, Doc3
i Division of General Internal Medicine, Johns Hopkins Bayview Medical Middle, Johns Hopkins University School of Medicine, Baltimore, Md, Usa
2 Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins Academy, Baltimore, Md, United States
3 Department of Medicine, School of Medicine, Duke University, Durham, NC, United states
Leah Wolfe, Division of Full general Internal Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins Academy School of Medicine, 5200 Eastern Avenue, Mason F Lord Building, Center Tower, Suite 2300, Baltimore, Md, 21224-2780, Usa, Phone: 1 410 550 0512, Fax: i 410 550 3403, Electronic mail: ude.imhj@eflowel.
Leah Wolfe
ane Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins Academy School of Medicine, Baltimore, Doc, United states
Margaret Smith Chisolm
2 Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, United states of america
Fuad Bohsali
three Section of Medicine, School of Medicine, Knuckles University, Durham, NC, United States
Received 2018 Mar 27; Revisions requested 2018 May ii; Revised 2018 Jun 27; Accustomed 2018 Jul 17.
- Supplementary Materials
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Multimedia Appendix ane.
PubMed search terms and process for literature review for clinically excellent utilise of the electronic health record.
GUID: 59494A72-DA91-4636-85F8-B87305995C16
Abstract
Groundwork
The transition to the electronic wellness record (EHR) has brought forth a rapid cultural shift in the world of medicine, presenting both new challenges likewise as opportunities for improving health care. As clinicians work to adapt to the changes imposed by the EHR, identification of best practices around the clinically excellent utilize of the EHR is needed.
Objective
Using the domains of clinical excellence previously defined past the Johns Hopkins Miller Coulson Academy of Clinical Excellence, this review aims to identify best practices around the clinically splendid use of the EHR.
Methods
The authors searched the PubMed database, using keywords related to clinical excellence domains and the EHR, to capture the English-language, peer-reviewed literature published between January one, 2000, and August 2, 2016. One author independently reviewed each article and extracted relevant data.
Results
The search identified 606 titles, with the majority (393/606, 64.ix%) in the domain of communication and interpersonal skills. 20-eight of the 606 (4.six%) titles were excluded from full-text review, primarily due to lack of availability of the full-text article. The remaining 578 full-text articles reviewed were related to clinical excellence more often than not (three/578, 0.v%) or the specific domains of advice and interpersonal skills (380/578, 65.7%), diagnostic acumen (31/578, v.4%), skillful negotiation of the wellness care organisation (4/578, 0.7%), scholarly arroyo to clinical practise (41/578, 7.ane%), professionalism and humanism (ii/578, 0.4%), knowledge (97/578, 16.8%), and passion for clinical medicine (xx/578, 3.five%).
Conclusions
Results propose that as familiarity and expertise are developed, clinicians are leveraging the EHR to provide clinically excellent intendance. Best practices identified included deliberate physical configuration of the clinical infinite to involve sharing the screen with patients and limiting EHR use during difficult and emotional topics. Promising horizons for the EHR include the ability to broaden participation in pragmatic trials, identify adverse drug furnishings, correlate genomic data to clinical outcomes, and follow data-driven guidelines. Clinician and patient satisfaction with the EHR has generally improved with fourth dimension, and hopefully continued clinician, and patient input will atomic number 82 to a system that satisfies all.
Keywords: clinical excellence, electronic health tape, electronic medical record, technology, advice skills, interpersonal skills, professionalism, humanism, patient care
Introduction
Use of the electronic health record (EHR) during clinical encounters is now a standard role of gimmicky medical practise. The EHR—like other medical technologies—is designed to optimize the efficiency and quality of health care delivery, and ultimately—one hopes—amend patient outcomes. However, every bit anyone who has ever used or seen his/her health care provider use the EHR during a clinic visit knows that use of the EHR in a fashion that preserves or enhances clinical excellence is challenging. The Johns Hopkins Miller-Coulson Academy of Clinical Excellence (MCACE) has previously identified the post-obit domains of clinical excellence: (one) communication and interpersonal skills, (2) diagnostic acumen, (3) skillful negotiation of the health care system, (4) scholarly arroyo to clinical do, (5) professionalism and humanism, (6) knowledge, and (seven) passion for clinical medicine [ane]. To identify all-time practices around the clinically first-class use of the EHR, the authors conducted a literature review of the MCACE domains and the EHR.
Methods
The concepts of the clinical excellence domains and the EHR were divers using a combination of controlled vocabulary terms applicable to PubMed and keyword terms and phrases to capture the English-language, peer-reviewed literature published betwixt January 1, 2000, and August two, 2016 (Multimedia Appendix one). Citations were imported into a citation direction organisation, and duplicates were removed. The authors ensured the search strategies captured a previously published review [2] on the topic. I author (LW, FB, or MSC) independently reviewed each article and extracted relevant data. The study was submitted to the institutional review lath and accounted exempt from farther review.
Results
Overview
The search identified 606 titles (Figure one), the majority (393/606, 64.ix%) were in the domain of communication and interpersonal skills. 20-8 of the 606 (4.6%) titles were excluded from full-text review, primarily due to lack of availability of the full-text commodity. The remaining 578 total-text articles reviewed were related to either clinical excellence more often than not (iii/578, 0.5%) or to the specific domains of communication and interpersonal skills (380/578, 65.7%), diagnostic acumen (31/578, five.4%), proficient negotiation of the health intendance system (four/578, 0.7%), scholarly approach to clinical practice (41/578, seven.i%), professionalism and humanism (2/578, 0.3%), knowledge (97/578, 16.eight%), and passion for clinical medicine (20/578, iii.five%).
Flowchart for search strategy and review of English-language, peer-reviewed articles on clinical excellence and the electronic health record betwixt January 1, 2000 and August two, 2016.
Advice and Interpersonal Skills
Within the communication and interpersonal skills domain, the following practice-based themes emerged from the literature, yielding the following clinical "pearls."
How Clinicians Practice
Clinicians' baseline communication styles are the main determinants of how nosotros communicate in the presence of EHR implying that continuing education on the bones skills of clinician-patient communication is essential as nosotros implement the EHR [3-5]. Clinician attitudes toward the EHR tin bear on the attitudes of patients and the quality of clinician-patient communication in its presence [6]. It tin can exist useful for clinicians to larn to touch type and consider the use of scribes to help optimize contiguous communication [7-12]. Quieter keyboards can also be less disruptive to the menstruum of communication [ii]. It is helpful for clinicians to exist more than transparent about their use of the EHR and to accost its presence in appreciative tones [thirteen-xvi].
Impact on Patients
Generational, cultural, and socioeconomic differences can impact patients' attitudes toward and date with the EHR [17]. When working with patients who speak a different linguistic communication, the EHR may exist both an asset and a hindrance (translation capability inside the EHR can potentially mitigate this, but can be tricky) [eighteen,19]. For instance, Ratanawongsa and colleagues [xix] constitute that increased EHR utilize past clinicians was associated with more biomedical statements and less positive effect from patients with depression English language proficiency and depression wellness literacy. This group advocated for further research on whether the increased utilise of technologies like the EHR are reducing or increasing the confusion of patients with language and health literacy barriers. Studies of patient attitudes toward the EHR generally testify more than favorable attitudes than clinicians or researchers anticipate [5,twenty-23].
How to Set up for a Visit
Information technology is helpful for clinicians to review the record alee of time to identify interval events and data, and to review the patient's social history and so that advice during the patient visit is more valuable, personalized, and less superfluous [x,12,24,25]. Clinicians tin can use the EHR to remind them of current life events of patients, to assistance personalize the visit and couch discussion of health care issues in the context of their lives [26]. Clinician-patient communication through patient portals can heighten both inter-visit and in-visit communication [27-29].
How to Organize the Room
Screen sharing is a pregnant theme in the existing literature, for the promotion of patient date, facilitation of communication during the visit, transparency, and patient empowerment and pedagogy. It is helpful if clinicians ensure the screen is visible to both the clinician and patient so that they share a "joint focus of attention" [2,13,25,30-36]. It is imperative that the brandish be big enough for the patient to view. Optimally, the room should be organized to allow middle contact betwixt the clinician and patient at all phases of the visit [24,32,33,37-39].
How to Engage Patients with the Electronic Wellness Record in the Room
Multiple strategies can exist used to improve patient engagement in visits through conscientious use of the EHR. One of these is the use of "transition phrases" or "signposting" when moving from the patient to the EHR and back [2,12,xvi,xxx,31,xl-42]. Information technology is also wise to utilize a language of collaboration when discussing the EHR and to address openly any problems of confidentiality [23]. Information technology can be helpful for both patient and clinician if clinicians repeat what they write in the EHR verbally while typing—to emphasize information and messages, and to maintain a shared focus on the topic [2,40,41]. Sharing the screen with patients tin can facilitate communication as well—through review and verification of content, as well as through visual display of data (eg, graphics) to brainwash and empower [ii,iv,13,sixteen,31,41,43-47]. It can even be valuable to have patients input information [12,xiii,48].
Clinicians should limit the utilize of the EHR during difficult and emotional topics [four,12,49,50], and attempt to maximize eye contact to avoid missing nonverbal cues and to enhance the relationship [2,four,24,25,41,51-53]. Clinicians do not desire to lose the narrative and patients must have time to express their concerns, and tell their story [42,53-57]. Several studies have highlighted ways in which EHR utilize can facilitate provider-patient dialogue and partnership strategies, even in the context of conversations around difficult topics [ii,58,50].
How to Use the Electronic Health Record to Enhance Intervisit Advice
Patient portals for email communication are an opportunity to heighten the menses of information and to build relationships [26,27,39,59-62]. Multiple studies exist on the utilise of the EHR for patient cocky-direction of chronic disease and health behaviors [39,61,63-65]. Tasks that took time during traditional office visits can be achieved through intervisit use of the EHR, freeing up more than time for meaningful communication in the office. Direct admission to test results past patients tin can enhance the quality and safety of care [39,61,62,66,67]. Information technology is important to remember, however, that non all patients volition take access to or identify the means of bridging that gap. The EHR has significantly increased opportunities for interprovider communication and has demonstrated benefit in transitions of intendance, and in the coordination of care, especially for patients with complex health needs [68-71].
Diagnostic Acumen
Review of the literature revealed several means in which the EHR tin assist a clinician'due south diagnostic acumen, such as instant access to historical records, and automation of risk score algorithms. The EHR makes access to past medical history automatic inside the sphere in which the EHR operates. Retrieving outside data are the slowest area of progress, but is notwithstanding improving with the EHR. The EHR's ability to provide interconnected and immediate point-of-care admission adds a new dynamic to the health intendance system, expanding the background of clinical cognition and enhancing diagnostic acumen and speed of diagnosis [72].
The EHR also brings the potential to use calculated risk scores to the user's fingertips. Physicians albeit a patient with non-ST-top myocardial infarction can take immediate admission to the thrombolysis in myocardial infarction score. An outpatient provider can accept an automatic atherosclerotic cardiovascular disease gamble score calculated as soon as vital signs are measured. While argue exists around the utility of these scores [73,74], they have and will continue to exist ever-nowadays in our understanding of affliction. The EHR gives clinicians the added functionality of automatically calculating and providing this data as an added input to the clinician, another tool in the toolbox.
Good Negotiation of the Health Care System
The EHR can help clinicians more deftly navigate the health care arrangement to provide high-quality, cost-conscious care. One way the EHR helps clinicians meliorate care is by promoting adherence to guidelines. Despite knowing that guideline-directed care improves outcomes, chronic and astute-care patients receive guideline-directed care only nigh l% of the time [75], and 1-third of health care expenditure is wasteful [76]. Clinical determination support (CDS) is the set of prompts that highlight information that could change clinical intendance and is the answer to the gap in guideline-based care. CDS relies heavily on input from clinical staff who are upwards-to-date with guidelines. However, when done correctly, CDS has the potential to facilitate the delivery of high-quality care, improving the health of patients and avoiding unnecessary care [77,78].
Further, the Office of the National Coordinator for health care information technology is moving toward national knowledge-sharing for CDS prompts with the intent of eventually standardizing and classifying the importance of CDS. Together, these represent methods for ensuring that we are navigating our health care surroundings to provide succinct and curtailed care.
Every bit the utilise of the EHR grows, data-sharing is being enhanced beyond networks in regional data exchange systems called health data exchanges (HIEs). With these, clinicians tin can share pertinent patient information, labs, and notes, also as communicate direct virtually essential details. HIEs are the vehicle for creating seamless and secure data-sharing between networks.
Scholarly Approach to Clinical Exercise
Use of the EHR facilitates the creation of patient databases and undertaking of pragmatic trials [79]. Through automation of the processes of patient screening, patients tin can be assessed for participation in businesslike trials directly through diagnostic codes and demographic information, and messaged at abode or asked in the part if they would consent to a study. For patients with the ability to access a computer, investigators have provided informed consent via online videos which tin be viewed in the condolement of the patient's own home. Further, the addition of the figurer to the clinical setting means that the networks for starting a pragmatic clinical trial are primed and gear up. The information are already being collected in the organisation, and need only to exist consented to appropriately and shared.
Professionalism and Humanism
The human being price of the EHR is the distraction. CDS popups alert clinicians to a clinical need, an incorrect allergy alert may alarm while entering a prescription, and vital signs may flag a sepsis alarm inappropriately. In the rapidly advancing world of the EHR with its increased distractions, it is imperative that clinicians maintain strong bonds with patients and cease the intrusion into clinician-patient relationships [25]. Best practices described in the Communication and interpersonal skills domain can back up humanistic attitudes and professional behaviors in the face of the EHR.
The electronic interface of drove is transforming the field of Patient Reported Outcomes (PROs). Many patient portals are set up to ask and record PROs, which tin seamlessly integrate into the patient'due south record. These PROs provide the ability to compare treatments and add together patient-centered outcomes to the inquiry. These data are being mobilized for employ in decision making by groups like the Patient-Centered Outcomes Research Institute, the National Institutes of Wellness Collaboratory, and the American Social club of Clinical Oncology.
Knowledge
The EHR brings a new manner to interface with the knowledge that clinicians generate. Two of the nigh heady changes to knowledge will be the discovery of new patterns and the incorporation of genetic data to patient records via "big data" methodology. In calculating, big information refers to the use of extensive datasets that are analyzed computationally to reveal previously unknown trends and associations. With enough information points, data scientists suspect that computers will eventually be able to generate prediction models for individual cases based on repositories of onetime case information [eighty]. For case, a computerized model of hyponatremia correction in newborns has been created based on big numbers of observations by computers [81].
On the forefront, data scientists and geneticists hope to contain patient genomic information into the EHR to help identify patterns and uncover new genetic connections. Once genetic data has been added to a patient's contour, the EHR could theoretically learn what cistron loci predispose a patient to angioedema, interstitial lung disease, or whatsoever number of previously poorly understood disease states [82,83].
In a similar vein, the EHR can automate the reporting of adverse drug reactions to newly prescribed drugs. By reporting early trends in side effects from a new agent, EHRs might accelerate the detection of untoward side effects—like myocardial infarction associated with cyclooxygenase enzyme inhibitors (ie, COX-2) [84].
Passion and Professional Satisfaction
The introduction of the EHR was fraught with underprepared EHR platforms and unrealistic expectations. Clinicians were initially confronted with decreased efficiency, increased burnout, and loftier turnover. Early, physicians using computerized order entry and electronic documentation were thirty% more than likely to report burnout after decision-making for other variables [85]. The only intervention that routinely improved satisfaction was employing scribes, which suggests that the merely positive feel associated with the EHR was minimizing its use [85]. Further analysis into trends of physician satisfaction reveals that a more than robust platform is more than correlated with satisfaction. Clinical notes, diagnosis function, and off-site capability were all associated with college satisfaction. There was a tendency that younger physicians were more likely to exist satisfied than their elder peers [85]. Finally, and most promising of all, physicians who had access to their EHR for at least two years were two.78 times more than likely to be satisfied with their EHR compared to those with less than two years' feel [86].
Much of the literature in other domains touched on the EHR'south potential to ameliorate the interface with clinicians. Tools are beingness introduced to provide the clinician with medical references on need for reading well-nigh developing medical data [87-89]. Finally, natural language processing is some other advancing technology in which the computer attempts to interpret the clinician's intention when writing. As an example, when a clinician diagnoses a patient with pneumonia, the EHR could ask if it should open the pneumonia order ready [34,90,91]. This technology is nonetheless in its infancy and volition likely crave years to be gear up for implementation. That said, it is i of the exciting transformations of the EHR that would produce a more fluent interface between the clinician and calculator, allowing clinicians to focus back on the priority—patients.
Discussion
Many articles published afterward our literature review cite the EHR as a meaning gene in clinician exhaustion. For instance, in their 2017 commentary, Shanafelt and colleagues [92] talk over clinician burnout in the era of the EHR and its bellboy clerical, regulatory, and workload implications. They outline the potential broader impacts of clinician burnout for the quality of care and the health care system at large. They also emphasize the importance of measures to address the increasing documentation brunt particularly performance and documentation of components of care that are justifiable for billing purposes alone and practise not contribute meaningfully to the episode of care. A contempo systematic review by West and colleagues [93] highlights the evidence supporting both organizational and private interventions to address burnout. Though across the scope of our review, clinician burnout is critical amongst factors that should exist considered in the pattern, implementation, and utilize of the EHR going forward.
The EHR has completely transformed the clinical landscape. Its arrival and integration take been fraught with challenges, including having noticeably contradistinct clinicians' communication with patients. That said, clinicians are gradually transforming their arroyo to, and interaction with, the EHR in a way that attempts to minimize distraction and raise the quality of the clinician-patient connection again. Computerizing this work has effectively put clinicians "on the grid" and hopefully will continue to bring positive changes to the fashion that clinicians gather and collaborate with patient data to further heighten diagnostic acumen, scholarly approach to medicine, professionalism, knowledge, passion for clinical medicine, and the power to negotiate the health care system to provide clinically first-class treat patients.
Acknowledgments
We wish to acknowledge the Miller-Coulson Academy of Clinical Excellence and Johns Hopkins University Schoolhouse of Medicine.
Abbreviations
| CDS | clinical conclusion support |
| EHR | electronic health record |
| HIE | health information exchange |
| MCACE | Johns Hopkins Miller-Coulson Academy of Clinical Excellence |
| PROs | patient reported outcomes |
Multimedia Appendix i
PubMed search terms and process for literature review for clinically first-class use of the electronic health tape.
Footnotes
Conflicts of Interest: None alleged.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6231887/
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