The use of electronic health records (EHRs) has skyrocketed—in less than a decade, the number of hospitals adopting the technology surged from fewer than 10% in 2008 to nearly 84%, in 2015 according to federal data. But adoption is only the first step health care providers must take to harness the full power of EHRs to improve people’s health.
“We’re in the infancy of using EHRs to improve patient care,” said Keith Horvath, MD, senior director for clinical transformation at the AAMC. “Obviously, adoption was the first step that needed to happen, and it basically took analog paper charts into digital form. Another main goal was to improve billing and collection—it’s been a good tool from that perspective, too. But it hasn’t yet been optimized for improving quality of care.”
Although more hospitals are using EHRs, a 2016 study reported mixed results in efforts to leverage EHRs to improve patient outcomes. To help spur such innovation, the AAMC teamed up with the Patrick and Catherine Weldon Donaghue Medical Research Foundation to identify researchers on the cutting edge of such work. In 2013, the foundation awarded grants to two promising EHR projects: one directed at boosting provider capacity and another targeting improved clinical care.
Using EHRs for team training and heart health
Jeffrey Gold, MD, a professor in the Division of Pulmonary and Critical Care Medicine at Oregon Health & Science University School of Medicine, first began his EHR research in 2011, using simulations to train physicians in ICUs to use EHRs effectively in their decision making. With the Donaghue Foundation grant, Gold expanded that research and training to include interprofessional teams of physicians, nurses, and pharmacists.
Essentially, Gold and colleagues used the EHR to imitate rounds, placing simulated patient records in the EHR and embedding the records with a variety of safety issues. Each member of the interprofessional team saw the same record and then came together for review. For example, one simulated case involved a pneumonia patient who had been in the ICU for about five days. According to the chart, the patient had been given a significant amount of opioid medications and was experiencing declining oxygen levels and worsening kidney function. But to gather all those pieces of information, the providers had to know where to look in the EHR. In other words, the providers needed to use the EHR effectively to paint the clearest possible picture of the patient’s circumstance before coming to any conclusions as a team.
Results showed that teams often missed critical pieces of information. For instance, only one-third of teams identified a possible opioid overdose, and a number of teams ordered unnecessary medical tests because the information gathered was incomplete. However, Gold said teams typically performed better than individuals, underscoring the benefits of collective wisdom. While individuals often gravitated toward different parts of the EHR—nurses often reviewed vital signs, pharmacists reviewed medication histories, and physicians reviewed summary notes—working as a team often allowed them to compensate for one another’s weaknesses.
“The EHR is certainly here to stay. Now, it’s time to see how we can use it to improve how we care for patients.”
Keith Hovarth, MD
“We realized that if we’re going to work together as a team, we have to understand how each of us uses the system so we can maximize our unique skill sets,” Gold said. “It’s tough enough that we all see a different part of the elephant. But if we’re all going to different zoos, it makes it even more difficult.”
At Wake Forest School of Medicine, Simon Mahler, MD, MS, an associate professor and director of clinical research in the Department of Emergency Medicine, embedded a clinical protocol known as the HEART Pathway into the EHR system, with support from the Donaghue Foundation grant. The HEART Pathway is designed to help physicians identify patients who come to the emergency department with acute chest pain but don’t need to be hospitalized. According to Mahler, about half of emergency department patients with acute chest pain are admitted for evaluation, but only 10% are diagnosed with acute coronary syndrome, leading to billions in over-triage costs.
“About five years ago, the standard approach was to admit everybody—do a stress test on everyone [who presented with acute chest pain],” Mahler said. “But it’s pretty clear that is not the best care from the patient’s perspective and it’s not optimal from a health care perspective. It crowds our hospitals with patients who don’t need to be there and who don’t derive any benefits from being there.”
In a 2015 study of the pathway, which Mahler coauthored, researchers found that it reduced cardiac testing and reduced lengths of stay, without any early discharge patients experiencing major adverse cardiac events in the next 30 days. Mahler used the Donaghue Foundation grant funding to embed the tool into EHR systems at Wake Forest Baptist Health’s main hospital and at two affiliate hospitals. It went live in November 2014 and was fully automated in February 2015. Now, when providers use the EHR system to order a troponin test, which detects heart damage, the HEART Pathway tool pops up on the screen, guiding providers through the assessment. The tool also pulls together all of a patient’s history and information to help providers make the most informed decision.
Mahler emphasized that the tool is meant to provide guidance, not to replace clinical judgment.
“The important part about putting it in the EHR is that it’s within a provider’s normal work flow,” Mahler said. “With trends moving toward value-based purchasing and delivering high-value care, this is really in line with that model.”
While this Donaghue Foundation grant cycle has ended, the foundation has a continuing partnership with the AAMC. Mahler, Gold, and other stakeholders will come together at an October 2017 AAMC meeting to share their EHR innovations and discuss how to use them as a tool to enhance patient care. “The EHR is certainly here to stay,” Horvath said. “Now, it’s time to see how we can use it to improve how we care for patients.”