Worcester Medicine November 2022

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Electronic Health Records

Editorial: Optimal Use of the Electronic Health Record for All 4

Lawrence Garber, MD

I Like My Electronic Health Record: An Emergency Physician’s Perspective 8

Jennifer Zacharia, MD

We Deserve Much Better: A Small Practice & First-Generation Perspective on Electronic Health Records 9

Peter Zacharia, MD

Friend or Foe: The Electronic Health Record in Practice

Leah Doret, MD; Lloyd Fisher, MD 11

The Critical Role of the Electronic Health Record in Modern Emergency Medical Services 13

Eric Alper, MD; John Broach, MD; Eric Dickson, MD; Caitlin McEachern; David McManus, MD; Laurel O’Connor, MD; Gregory Volturo, MD & Stacy Weisberg, MD

How Electronic Health Records Have Revolutionized the Pharmacy 15 Dinesh Yogaratnam, PharmD, BCPS, BCCCP

Keeping the Focus on the Patient & Their EHR: A Nurse’s Perspective 17 Sarah Romain, RN

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Worcester District Medical Society

321 Main Street, Worcester, MA 01608 wdms.org | mwright@wdms.org | 508-753-1579

wdms officers

President Giles Whalen, MD

Vice President Alwyn Rapose, MD

Secretary Michelle Hadley, DO

Treasurer B. Dale Magee, MD

wdms administration

Martha Wright, MBA, Executive Director

Melissa Boucher, Administrative Assistant

wdms editorial board

Lisa Beittel, MBA

Sonia Chimenti, MD

Anthony L. Esposito, MD

Larry Garber, MD guest editor

Rebecca Kowaloff, DO

Susan Krantz, MD

Julianne Lauring, MD

Anna Morin, PharmD

Nancy Morris, PhD, NP

Thoru Pederson, PhD

Joel Popkin, MD

Alwyn Rapose, MD

Parul Sarwal, MD

Robert Sorrenti, MD

Electronic

on the cover

Health Records

Cover artwork by Drs. Laura Bessette and Lawrence Garber using Midjourney, a computer program that generates images using artificial intelligence.

Improved Care With Electronic Health Records: A Patient’s Perspective 18

Peter Ballantyne

Leveraging Electronic Health Records to Give Patients a Magical Experience 19

Lawrence Garber, MD

The Role of the Electronic Health Record in Medical Research 20 Mara Meyer Epstein, ScD

Reflections on the EHR: Gains, Losses, Opportunities 22

Sonia Nagy Chimenti, MD, FIDSA

From the Curator Getting Into Dr. Weed 6

B. Dale Magee, MD, WDMS Curator Society Snippets 25

Calendar of Events 26

In Memoriam 26 Ronald Dorris, MD

Ram Upadhyay, MD

Martha Wright, MBA

Peter Zacharia, MD

Alex Newbury, MD, Resident Representative

Arunava Saha, MD, Resident Representative

Olivia Buckle, Student Representative

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Inquiries to Martha Wright mwright@wdms.org 508-753-1579

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Optimal Use of the EHR for All

Lawrence Garber, MD

This edition of Worcester Medicine looks at the Electronic Health Record’s (EHR) impact on the healthcare system from many perspectives: Physicians, nurses, pharmacists, first responders, patients, students, and researchers. We hear from those that are receiving incredible benefits from their EHR, and those who are benefiting a lot less from their EHR. We learn about how EHRs can pull us away from our patients as well as make us more connected to our patients. We can see that the EHR principles and vision laid out by Dr. Weed 60 years ago in Dr. Magee’s article have been enjoyed by some EHR users, but certainly not all. If some healthcare providers are efficiently reviewing patient records, identifying and acting on patient needs, documenting encounters, effectively managing the health of their population, and giving patients the convenient-care that is only possible with EHRs, why aren’t we all?

This is a complicated question. Most EHRs today are capable of facilitating efficient and effective healthcare. But not all implementations of the same EHR are of equal quality. Features need to be turned on and properly configured. Users need to be trained, supported and optimized. The optimal hardware needs to be identified, procured, deployed, and maintained. Patients need to be engaged to use the new technologies. This is a lot of work, and EHR vendors aren’t typically incentivized or capable of doing all of this and doing it well. Large organizations have the best shot at doing all of these things well. They can have 1 full-time physician informaticist and 1 full-time nurse/pharmacy informaticist dedicated to look out for the clinical needs of 100 physicians and their staff. And they can have 1 trainer/optimizer, 1 billing expert, 1 clinical build expert, 1 scheduling expert, 1 reporting/analytics expert, 1 network/interface expert, 1 hardware expert, and 1 database expert to support a practice of 100 physicians. That’s 10 humans to properly support a 100 physician practice. If you have a 200 physician practice, then you actually have backup so that some of those people can provide after-hours support or perhaps even take a vacation without hurting the practice.

But what does a 10-physician practice do? It’s hard to hire a tenth of a trainer/optimizer and a tenth of a scheduling expert and a tenth of those other roles. And 1 person can’t be an expert in those 10 areas. The situation is even worse if you are a 1-physician practice! Drs. Fisher and Doret’s article gives great advice on what large practices and hospitals can do to excel, but what does the solo practitioner do to thrive with their EHR?

A decade ago, when Washington rolled out the “Meaningful Use” program to incentivize the deployment of EHRs, they also created “Regional Extension Centers” designed to “hold the hands” of smaller practices and lead them through their EHR implementations. But like most EHR vendors, their success metric was an EHR go-live, not necessarily a highly-optimized system.

It’s now time for an “Optimal Use” program. We need State, Federal, or payer funding to support a new clinician-led EHR optimization industry whose mission is to make a practice’s EHR as efficient as possible. The 10 people that are needed to support 100 providers would instead support ten 10-provider practices, or more smaller practices. They would be dedicated to a single EHR vendor that they have deep experience with. They would be active in that EHR vendor’s user community to learn best practices, as well as to provide feedback to the vendor on needed improvements. They would make sure that all of the bells and whistles are turned on, including efficient documentation tools, appropriate clinical decision

support, and electronic interfaces with other parts of the healthcare system. They would ensure that workflows are optimized and users are properly trained. They would be responsible for timely and smooth upgrades of the software and maintenance of the hardware. Their pay would be partially based on provider, staff, and patient satisfaction.

An “Optimal Use” program isn’t needed because doctors are whining. It’s needed because doctors are needlessly burning out, patients are receiving suboptimal care, and an optimized EHR can help. We have reached the point where EHRs are excellent, technology is powerful and affordable, and patients expect the same convenient experience that they get in other parts of their lives. It’s imperative that we take action now. If you are unhappy in a large practice or hospital system, follow Drs. Fisher and Doret’s advice and get involved. If you are unhappy in a small practice, also follow their advice but talk to your friends in the payer sector or in government to help fund an “Optimal Use” program. And if you are like me, loving my EHR and the experience I give to my patients, then spread the word about how good EHRs can be. +

“ Patients expect the same convenient experience that they get in other parts of their lives.

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From the Curator

Getting Into Dr. Weed

B. Dale Magee, MD Curator

Lawrence Weed, MD (1923-2017) was ahead of his time and set the table for the development of the Electronic Health Records that we are still perfecting today. The clinician-researcher noted in the 1960s that the medical record could become a vital tool in improving medical care rather than the burdensome afterthought it was treated as.(1) At the time, medical records were not created with an eye towards communicating details of clinical care and the thought process behind them. Rather, they often only included a notation that an encounter occurred, a notation of a diagnosis or procedure, a charge and whether or not the charge had been paid. Even with additional information , the handwritten records were often difficult to read (Figure 1). Weed also noted that for chronic conditions, a means of tracking the course of a condition was needed. He recognized that problems were often multiple, leading to complex decision making, remarking that having bright, hardworking, well educated doctors on staff was not adequate for delivering the best patient care in the modern era. Doctors also needed data specific to their patients combined with decision support to enhance their ability to provide care.

Starting in the 1960s Weed began a campaign to revolutionize medical records that was remarkably successful, particularly given the general lack of enthusiasm about the subject by rank-and-file clinicians. It began with the S.O.A.P. (subjective, objective, assessment, plan) format to progress notes and expanded to the Problem Oriented Medical Record (POMR), which added the structure of tying the elements of a note to

each patient problem and, in turn, tying the note to a problem list through a note title. With these innovations he enabled the linking of history, physical, lab data, plans and orders to a particular problem. This allowed for tracking outcomes as well as contributing to the knowledge base of clinical medicine. He eloquently presented this in an historic grand rounds in 1971 (https://youtu.be/qMsPXSMTpFI?t=1). Next in Weed’s evolution was the development of Problem-Knowledge Couplers—an early form of artificial intelligence that allowed clinicians to access up-to-date medical knowledge specific to patients (Figure 2).

Figure 1

All of this was initiated before personal computers, the Internet or widely available databases. Indeed, if we look at Weed through the lens of traditional academics, he accomplished a transformation with fewer than three-dozen articles published over fifty years, many of which appeared in second-tier journals or were interviews. (Weed preferred traveling to medical centers and delivering his message in person.) His publications and presentations were characterized by a crystal clear explanation of the problem with current records and the advantages of his proposed format, as well as a rather searing critique of the state of medical practice and education.

A quote from one of Weed’s interviews provides a look into his perspective and style. His emphasis on data collection and analytics was combined with an insistence that care be customized for the individual patient and that “one size fits all” guidelines did not work:

“EBM (Evidence Based Medicine) is based on a misguided use of statistical knowledge instead of the unique set of details from a given patient. A truly

Lawrence Weed, MD

EBM system could develop if evidence would be used to individualize care rather than standardize it.

Physicians are increasingly expected to apply knowledge derived from large population studies and clinical trials. Referred to as evidence-based medicine, this approach is rightly intended to prevent physicians from following arbitrary local practices and unsupported personal judgments. But this approach systematically excludes the individualized knowledge and data essential to patient care.” (2)

This perspective remains true today and shows how much further we have to go along the path that he started us on 60 years ago. +

references

1. Weed, L.L. Medical records, patient care, and medical education. Ir J Med Sci 39, 271–282 (1964).

2. Jacobs L. Interview with Lawrence Weed, MD- The Father of the Problem-Oriented Medical Record Looks Ahead. Perm J. 2009 Summer;13(3):84-9.

Electronic Health Records

Figure 2: Diagram of individualized Health Care Delivery and Knowledge Development Systems from Medicine in Denial by Dr. Lawrence L. Weed and Lincoln Weed.

Electronic Health Records

I Like My Electronic Health Record: An Emergency Physician’s Perspective

Jennifer Zacharia, MD

As an Emergency Physician, my shift begins when I log into the Electronic Health Record (EHR) and open the trackboard listing the numerous patients awaiting to be seen. First, I assign myself to a 75-year-old man presenting with shortness of breath. With just a few clicks through the patient’s chart, I gain a comprehensive overview of his medical history including a problem list nine miles long, prior presentations to the emergency

first time and have come to expect that most of my patients, particularly in moments of pain, confusion or distress, will not be reliable historians of their own medical histories and medication lists. Fortunately, with instant access to a patient’s prior records and test results displayed in a well-organized format, I am able to gather information and collect data expeditiously. One of my favorite shortcuts is the search function, which enables me to rapidly filter through years of records to retrieve the specific information I need.

The EHR is much more than just a record-keeping system; It enhances safe and effective healthcare delivery through facilitating physician-to-physician communication and collaboration. A shared EHR enables emergency physicians, primary care physicians and specialty care teams to coordinate care by updating and exchanging a patient’s clinical data with each visit. This information- sharing helps to streamline transfer of care, reduce duplicate testing and prevent conflicting clinical advice.

The EHR also facilitates physician-to-patient communication by allowing patients to access their health care records through online patient portals. Patient portals provide the opportunity for patients to gain a better understanding of their medical conditions, review diagnostic studies and adhere to their treatment plans. A major benefit of this accessibility and transparency of information is that patients can be collaborators in their own health care management. Patients may also discover erroneous information in their chart and alert their provider to make corrections. Unfortunately one of the shortcomings of this immediate access to clinical data is the potential for patients to discover grave diagnoses before the provider has a chance to discuss the results and provide counseling. I recall a patient of mine who viewed his CT scan results revealing pancreatic cancer on his smartphone while sitting alone on a stretcher in a busy hallway. I made preparations to bring the patient and his wife into a private family room to deliver the news, but as I approached his stretcher and noticed his eyes glistening with tears, I realized I was too late.

room for congestive heart failure exacerbations, outpatient cardiology visits detailing an ongoing plan to titrate his diuretic dose, and prior echocardiograms demonstrating a reduced ejection fraction. As I head towards the patient’s room, EMS wheels in a 57- yearold man with large-volume hematemesis. I pull up the patient’s chart and discover alcoholic cirrhosis listed on his problem list, as well as a prior endoscopy revealing gastroesophageal varies. My focus is immediately redirected.

In the fast-paced and often chaotic setting of the emergency room, the EHR is an important tool that enhances my efficiency in gathering pertinent information to formulate my diagnostic and treatment plan. I always perform a chart biopsy before entering a patient’s room so that I can tailor my history and exam accordingly. I am constantly meeting patients for the

The practice of emergency medicine is a high-stakes endeavor with each patient encounter involving unique circumstances, yet with multiple interruptions to the workflow there are ample opportunities for errors and oversights. The EHR has the potential to reduce medical errors and improve the quality of patient care through integrating clinical decision support (CDS) tools. CDS tools synthesize and present information to the physician at the time of order entry to support clinical decision-making. These tools vary from simple alerts to prevent administration of inappropriate medications to patients with allergies or renal insufficiency, to pop-up windows suggesting an alternative imaging modality to reduce radiation exposure and costs. These tools also include more complex order sets that improve detection and management of specific conditions such as sepsis and diabetic ketoacidosis in accordance with evidencebased guidelines. CDS tools have been effective in increasing emergency physician guideline adherence and improving patient-centered outcomes including reducing 30-day mortality among patients with pneumonia and reducing unnecessary head CTs in patients with mild traumatic brain injury. (1,2,3) A drawback that must be mitigated is pop-up or alert fatigue, which cultivates override behavior and leads to a low rate of utilization of these tools despite positive outcomes.(4) Therefore these tools

“

The EHR is much more than just a recordkeeping system.

must be implemented judiciously and reevaluated, taking into consideration user feedback and associated health outcomes.

The EHR is certainly not a perfect system and there are several problems that require resolution, including reducing the time burden for documentation and safeguarding data security. However the EHR has evolved to provide numerous benefits beyond record keeping that have enhanced the efficiency and quality of healthcare delivery. +

Jennifer Zacharia, MD is an Emergency Physician and Toxicology fellow at UMass Memorial Health.

References:

1. Patterson BW, Pulia MS, Ravi S, Hoonakker PLT, Schoofs Hundt A, Wiegmann D, Wirkus EJ, Johnson S, Carayon P. Scope and Influence of Electronic Health Record-Integrated Clinical Decision Support in the Emergency Department: A Systematic Review. Ann Emerg Med. 2019 Aug;74(2):285-296.

We Deserve Much Better: A Small Practice and First-Generation Perspective on Electronic Health Records

Peter Zacharia, MD

My single-physician, private Ophthalmology practice is now entering its second decade using electronic health records (EHRs). We went live 10 years ago after about a three-year search process researching software functionality, computer hardware requirements and costs, as well as interviewing vendors who would do the implementation, in order to find the EHR and practice management system that would best meet the needs of my practice. We identified a vendor who provided the programmer with whom I worked over a period of about 18 months to design templates for clinical data entry into the EHR that were customized for ophthalmology, and also provided hosting of our system remotely, as well as software and hardware support. We had an extremely bad experience with the initial vendor, who was insufficiently responsive to our needs, and we subsequently transferred our practice database to an in-house server with the help of a small but outstanding local IT consultant. This consultant configured and has maintained our server so we have smoother access to our EHR without the small delays that followed every click of the mouse and

2. Dean NC, Jones BE, Jones JP, et al. Impact of an Electronic Clinical Decision Support Tool for Emergency Department Patients With Pneumonia. Ann Emerg Med. 2015;66:511–520.

3. Ip IK, Raja AS, Gupta A, Andruchow J, Sodickson A, Khorasani R. Impact of clinical decision support on head computed tomography use in patients with mild traumatic brain injury in the ED. Am J Emerg Med. 2015;33:320–325.

4. McCoy AB, Thomas EJ, Krousel-Wood M, Sittig DF. Clinical decision support alert appropriateness: a review and proposal for improvement. Ochsner J. 2014 Summer;14(2):195-202.

the numerous episodes of down time we experienced with the initial vendor and remote hosting model.

Since going live with the EHR I have had to make small changes to my templates as I determined what would improve workflow, and also as documentation and billing code requirements changed with the implementation of ICD-10, CPT code modifications, and the onerous MACRA mandated Quality Payment Program (QPP), which should probably have been termed the Burdensome Payment Program.

10 years into implementing the EHR, I can state that the experience has been overall positive and provides several advantages over paper records, but also several significant shortcomings. We can and should do much better. The obvious advantages include greater legibility and remote accessibility. We no longer require chart rooms or personnel to file and pull charts, and we no longer need to add pages to manila file folders and stamp blank progress notes with patient names and exam dates. Pages no longer fall out of patient records when the punched holes tear through edges of paper pages. Automatic time stamps more accurately log the course of the clinical interaction. Time savings are gained as a result of smart phrases that allow for shorthand generation of large amounts of commonly-used text. The EHR also carries forward previous observations, as long as they are modified and updated to reflect the current exam.

The EHR also has shortcomings. The carryover feature mentioned above can save a large amount

Electronic Health Records

We Deserve Much Better Continued

of time when clinical descriptions are complex, but unfortunately can result in inaccurate propagation of old information when the examiner is not conscientious enough to review the entry. I have on occasion been guilty of this myself and have frequently received exam notes from previous physicians which carry forward the same exam observations, impressions and plans over numerous distinct visits when the exam descriptions, impressions and treatment plans have no longer been applicable. While smart phrases and carry-forward features save time, in some cases the actual keying in of other information can take more time when compared to data entry in a paper chart. This is especially true when data must

tions of ICD-10 diagnoses. Similar inefficiency characterizes the e-prescribing software I use on a daily basis, for which it is obvious that the software developers have had no exposure to clinical settings and have no appreciation for a clinician’s time by requiring twice the mouse clicks than should be necessary to send or renew a simple prescription.

Perhaps the greatest shortcoming of the EHR is the lack of standardization among EHR software packages resulting from a monumental lapse in judgement by the regulatory powers which mandated the hurried adoption of the EHR. Had we waited perhaps another decade before requiring or pressuring practices into adopting electronic records, perhaps useful standards may have been defined to facilitate the transfer of data between disparate EHR software, obviating the need for care givers to wade through hundreds of pages of records from previous care givers.

be entered on multiple successive template screens; check boxes and drop-down menus must be navigated, endless CMS-mandated QPP items must be checked (the existence of these facilitated by the requirement to have an EHR), and frequent pop-up warnings (some useful but many unnecessary) must be managed as though playing whack-a-mole. Speech recognition software can help if one is willing to invest the time to train and customize it, but it also is plagued by errors.

Data transfer between physicians is often less efficient and less effective with the EHR. I have seen exam records sent by previous physicians for which each single visit is documented by an EHR note printed to paper occupying six-to-seven pages of endless boldfaced underlined headers, many followed by unnecessary and repetitive lists of information. Before the EHR, documentation for a single exam may have been summarized on one or two sides of a page. I no longer have the benefit of a well-written consultation letter with a well-phrased summary of a physician’s impression, but rather now depend on an impression filled with a list of stock generic descrip-

The cost of implementing and maintaining our EHR unfortunately has not been offset by the meager physician reimbursement increases (and decreases) of the last two decades. For my small practice, startup costs for our EHR and practice management system approached $100,000. My practice’s annual and periodic expenses include EHR software maintenance and support fees, anti virus software updates for multiple devices, operating system and coincident hardware updates when old operating systems fall into planned obsolescence, data back up cost, and high-speed broad band Internet connectivity. Our expenditures for recording and maintaining clinical data are many multiples of previous expenditures on copy paper, manila file folders and shelving to hold charts. The (sometimes) skilled labor required to maintain computerized records is also many times more costly than the labor required to pull, stack and file paper charts. In the case of our EHR software, a venture capital group purchased rights to the software, saw an investment opportunity and conveniently felt free to charge exorbitant software upgrade costs to helpless physicians with the ease of shooting fish in a barrel. There seems to be no regulation of the profit savvy investors can make providing items of necessity to physician practices.

I have heard of practices that have suffered flooded file rooms, and I am sure medical office fires have obliterated many patients’ medical history information over the last several decades. However, there is no greater fear to a practice or a hospital system than having a computer system hacked, and this has afflicted even some of the largest hospital systems staffed by ample IT professionals recently. Security of patient information is beyond a doubt the source of the greatest anxiety with respect to medical records and remains one of the greatest problems which require a solution.

The concept of the EHR is one that is worthwhile and has the potential to improve healthcare. However, in practice and in current form, the EHR has evolved as an amalgamation of rushed and imperfect mandates, a tool that wastes as much time as it saves, and increases practice expenses while facilitating the burdens which bureaucracy places upon medical practices. Thus far, EHR implementation is chock full of missed opportunities to improve healthcare. We can and should do so much better. +

Peter Zacharia, MD is an ophthalmologist in private practice in Worcester who has been on the editorial board of Worcester Medicine for several years.

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Perhaps the greatest shortcoming of the EHR is the lack of standardization among software packages.

Friend or Foe: The Electronic Health Record in Practice

Leah Doret, MD Lloyd Fisher, MD

It was the family medicine dream: She was delivering care in her hometown. Her practice included some multi-generational families, many of whom she had known from childhood. She was energized by seeing her patients, enjoyed being a participant in their life stories and loved the ability to find out “what happens next” with each new visit. She was working for an organization who valued the importance of primary care physicians and had built a system to provide supports for all the complexities of primary care. Nonetheless, Leah left a thriving practice in December of 2019 to take on a primarily non-clinical role. There were many reasons why she made this change, but not one of them involved the electronic health record (EHR).

Burnout is one of the top concerns in health care today, and so often, the EHR is blamed as the source of physician burnout. (1) Physicians often reminisce about “the old days,” remembering paper charting with fondness. We both started out in practice using paper charts. While documentation was easier in some ways, it came with burdens. Notes from other providers weren’t always available in a timely manner, depending upon how quickly notes and/or dictations were completed. The chart could only be in one place at a time, so if a patient had another appointment on the same day, only one office had access to the chart. Reports could be misfiled or stuck to the back of another page, running the risk of important information being missed. It wasn’t possible to quickly identify whether a patient had had a particular test without poring through voluminous charts.

Enter the EHR. The incorporation of computers and other digital tools has revolutionized many industries and professions with obvious improvements. For many physicians though, the transition from paper charting to EHRs has not lived up to promises or expectations. In many studies, physicians identify increased time spent in the EHR system as a significant contributor to burnout, and this increase in time spent utilizing a computer takes away from the time spent with the patient. (2) “Pajama time” (defined as the time a clinician spends either documenting or reviewing information in the EHR outside of work hours) has been implicated as a contributor to burnout. As a result, physicians are choosing nonclinical roles, retiring early or avoiding careers in certain specialties, particularly primary care. This is causing a significant shortage in the physician workforce, a shortage that is projected to worsen over the coming decade. (3)

The nature of the problem is multifactorial and complicated. While some physicians may long for the days when a patient’s entire medical

record could fit on a three-by-five-inch index card, legal, regulatory and billing requirements make that no longer possible. The complexity of delivering high-quality healthcare to patients necessitates that we utilize electronic clinical decision support (CDS) tools in our provision of this care. An appropriately designed and utilized EHR system can be an effective tool to reach the quadruple aim of high-quality, cost-effective care and a positive patient and physician experience. Unfortunately, many EHR implementations have failed to achieve that goal.

So, what is the goal of the EHR? First and foremost, it serves as the record of a patient’s medical history and health care story, communicating clinical information to other care providers involved in treating the patient, as well as a reminder of past encounters. The note also serves other purposes including justification of billing, defense when there is a liability concern and data collection for reporting metrics necessary to meet quality and pay-for-performance measures. Many physicians complain that these purposes, which should be secondary, have become the primary goal, and many EHR systems are built solely to support those secondary concerns and sacrifice both ease of documentation and ease of reading later. A documentation template should be easy to complete and allow the physician to automatically meet all of these goals simply in the course of their normal workflow.

What many clinicians may not realize is that an EHR can and should serve as far more than electronic paper. The practice of medicine is extremely complex today and clinical “best practices” are constantly changing such that no physician can keep up with all the literature relevant to their practice. CDS tools embedded within the EHR, when part of the clinician’s usual workflow, can help drive better and more consistent care while reducing the cognitive load of the physician. The details and intervals of preventive care; appropriate billing codes and modifiers to meet the variable rules of each insurance payer; the seemingly infinite number of drug-drug, drug-disease, drug-age or drug-allergy interactions; as well as reminders for appropriate drug monitoring with labs and other testing are just some examples of the many tasks that can be automated by a computer, allowing the physician to spend more time doing what only a physician can do. Why should the physician need to memorize the nuances and intricacies of the immunization schedule or the extensive follow-up intervals and treatment plans for pap smears when the EHR system can help ease that cognitive burden?

Electronic Health Records

Friend or Foe Continued

So why aren’t we there yet? Why do so many physicians still struggle to get through their day? What needs to be done to achieve the promise of the EHR? First and foremost, physicians and other clinicians must be intimately involved in the design, build, training and optimization of the system both at the vendor and practice levels. The biggest mistake made by many large health care systems is not considering the day-to-day workflows that clinicians go through. The system should be built with this in mind so the computers work for the clinician rather than the other way around. Investment in physicians on EHR teams is a costly endeavor but it has a positive return on investment.

Another mistake frequently made is skimping on training. Taking physicians out of patient care to train on the EHR means fewer patients and less revenue during training time. However, it is even more costly if that physician indefinitely spends five extra minutes per visit navigating the EHR system because they are not trained appropriately. Costs increase even more when that physician burns out, leaves the practice and needs to be replaced . The return on investment occurs very quickly with proper training; saving a properly trained clinician 30 minutes per day will show a return on investment in 16 days. Continuing to provide ongoing optimization also helps. At our organization, preventing even one physician from leaving resulted in our ability to fund the provider optimization program for three-tofour years.

While the world of medicine now requires vast amounts of data collection and reporting which the EHR has made possible, but also now couldn’t be completed without its help, we are required to function in a world in which we need to focus on the EHR as a friend rather than a foe. Clinicians can take steps to help in this process. We offer the following advice:

1. Involve clinical personnel, including physicians, in the design, build, training and optimization of your EHR system. If your system doesn’t currently do this, advocate for that change.

2. Build the system with clinical workflows in mind. Make the system work for the providers, not the other way around

3. Attend training sessions when offered. It doesn’t matter how busy your clinical practice is; poorly trained clinicians with ineffective workflows will ultimately be worse for the day-to-day practice experience and long-term mental health of the clinician.

4. Build workflows to utilize the expertise of every member of your team. Paper labs used to be reviewed by MAs or nurses prior to clinician review, and that workflow can remain even in an electronic setting. MAs can also help to document HPI, review systems, and perform med reconciliation and other documentation tasks. Make sure each member of your team works up to licensure to help distribute the burdens more equally.

5. Try to make the mental shift away from blaming the EHR for current issues in the practice of medicine and, when possible, work constructively to offer alternatives to make practicing of medicine better and easier for all. +

Leah Doret, MD is a family-medicine trained physician who currently provides services for disability review and works per diem in primary care.

Lloyd Fisher, MD is a primary care pediatrician, clinical informaticist and Associate Medical Director for Informatics at Reliant Medical Group.

References

1. Gardner RL, Cooper E, Haskell J et al. Physician stress and burnout: the impact of health information technology, J Am med Inform Assoc 2019;26 (2): 106-14.

2. Gesner E, Gazarian P, Dykes P. The burden and burnout in documenting patient care: an integrative literature review. Stud Health Technol Inform 2019; 264:1194-8.

3. AAMC. The Complexities of Physician Supply and Demand: Projections From 2019 to 2034. Washington DC: AAMC; 2021. https:// www.aamc.org/media/54681/download. Accessed July 31, 2022.

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The Critical Role of the Electronic Health Record in Modern Emergency Medical Services

Eric Alper, MD John Broach, MD Eric Dickson, MD Caitlin McEachern

David McManus, MD Laurel O’Connor, MD Gregory Volturo, MD Stacy Weisberg, MD

location, and several innovations in EMS practice have necessitated that the record be available to these out-of-hospital providers.

The use of the electronic health record (EHR) has fundamentally reshaped the practice of medicine since the first systems were designed in the 1960s and 70s. (1,2) Yet even today, practitioners routinely struggle to get complete health records if a patient has been seen in multiple health systems, especially if their information needs to be transferred between different states or countries. (3,4) This disconnect between possibility and reality is currently playing out across the divide between prehospital and emergency department (ED) care. Most emergency medical services (EMS) agencies have some form of an EHR system, but these rarely interface in real time with hospital records, and critical data from a prehospital encounter is usually delayed in being integrated into the record of an ED and hospital encounter.(5) When it is integrated, it is often stored in an obscure space in the EHR and critical data such as laboratory values or vital signs are not integrated with hospital- acquired data. Equally, EMS services are often practicing without detailed knowledge of a patient’s medical history, allergies and critical background health information despite performing medical treatment at times of critical decompensation. (5) Just as the rise of computing power in the 1960s made these systems possible, newer technologies and standards were required to bridge this most recent gap between EMS practice and the continuation of patient care in brick-and-mortar facilities. (6)

By making versions of the health record available as mobile apps, EHRs can easily be accessed by a field provider with a secure Internet connection. The driving force to complete this transition was the need to perform more advanced care outside the hospital and to ensure that this care was being delivered safely and in alignment with the rest of the patient’s clinical course. This need became even more evident during the COVID-19 pandemic, in which an already overburdened hospital system needed to expand capacity rapidly.(7) Without time to expand the physical footprint of hospital space, alternate care sites were established and, importantly, created renewed interest in the treatment of patients at home.(8) The function of the EHR has always been to allow critical health information to travel with patients regardless of their

First and foremost, EMS is increasingly providing much more advanced care in the community and establishing care for critical diagnoses prior to arrival at the ED. The more complex the care, the greater the need for easy access to patient history to ensure that accurate and appropriate care is being delivered. For example, in 2020, Worcester Emergency Medical Services (WEMS), the EMS agency of UMass Memorial Health, became the first EMS agency in Massachusetts to administer prehospital antibiotics for severe sepsis and septic shock.(9) For the sickest patients, early administration of antibiotics is critical, but without access to the patient’s record, it is nearly impossible to check for medication allergies or ensure that they are being given to the correct patient. Therefore, UMass Memorial Health first ensured that their paramedics had access to a mobile version of their health system’s EHR. This mobile app also facilitates transmission of clinical images, such as EKGs, prior to patient arrival and allows preregistration of patients so their detailed record is available in the hospital prior to their arrival in the ED. As EMS provides more sophisticated medical care for emergency patients , this type of connection and sharing of information becomes increasingly important.

Second, the role of EMS and the possibilities of home treatment are expanding rapidly. Mobile integrated healthcare (MIH) is a concept that allows paramedics, with an interdisciplinary support team including online physician medical control, to assess and treat patients in their homes and help them avoid ED visits.(10) The Massachusetts Office of Emergency Medical Services (MAOEMS) established a formal licensure process for MIH in 2018 and several programs have grown out of this effort.(11) At UMass Memorial Health, Worcester EMS runs such a program, and it depends heavily on the use of the patient’s EHR to ensure that the patient’s treatment is correct and that it is visible to the patient’s primary

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The Critical Role of the Electronic Health Record in Modern Emergency Medical Services

care physician and care coordination teams. Afterall, the value of this type of home- based intervention is its incorporation with other outpatient care efforts.

This integration between healthcare settings becomes increasingly important as the level of service delivered increases in sophistication, necessitating ever- closer amalgamation with the health record.(12) Indeed, the Centers for Medicare and Medicaid Services (CMS) created a program to deliver complete inpatient care in the home as part of its Public Health Emergency (PHE) response to the COVID-19 pandemic. (13) Several organizations in Massachusetts have deployed Hospital at Home programs which rely on EHR data and functionality to provide complete hospital- level care for complex patients in their homes.

As more care is delivered outside of the hospital, the need for an electronic health record system that allows EMS and other disciplines to effectively access and contribute to the patient’s health record will be ever more important. Hospital capacity will continue to be a challenge, but delivering care in the home and preventing unnecessary hospital admissions is both the right thing for patients and the right thing for the healthcare system. Effective use of EHRs is and will continue to be critical to this newest shift in modern healthcare delivery. +

The authors would like to acknowledge the following individuals who have worked tirelessly to make the above referenced programs successful:

Dr. Eric Alper

Jack Bailey

Kerry Clark

MIH Paramedic Julie Inzerillo

Dr. Constantinos Michaelidis

Brendan Monahan

Dr. Apurv Soni

WEMS Chief Norman Soucie Candy Szymanski, RN

Dr. Gregory Volturo

Eric Alper, MD is SVP, Chief Quality Officer / Chief Clinical Informatics Officer at UMass Memorial Health.

John Broach, MD, MPH, MBA, FACEP is Associate Professor of Emergency Medicine at UMass Chan Medical School and Director of the Division of EMS and Disaster Medicine at UMass Memorial Medical Center .

Eric W. Dickson, MD, MHCM, FACEP is President and CEO of UMass Memorial Health, and Professor of Emergency Medicine at UMass Chan Medical School.

Caitlin McEachern, PMP is Program Manager for the Hospital at Home program at UMass Memorial Health and UMass Memorial Medical Center.

David D. McManus, MD, ScM, FACC, FHRS, FAHA, FACP is Richard M. Haidack Professor and Chair, Department of Medicine, UMass

Continued

Chan Medical School and UMass Memorial Health.

Laurel O’Connor, MD is Assistant Professor of Emergency Medicine in the Division of Emergency Medical Services and Disaster Medicine at UMass Chan Medical School.

Gregory A. Volturo, MD FACEP is Professor of Emergency Medicine and Medicine at UMass Chan Medical School and Richard V. Aghababian Endowed Chairman, Department of Emergency Medicine at UMass Memorial Health.

Stacy N. Weisberg, MD, MPH, FACEP, FAEMS is Professor Emergency Medicine and EMS Fellowship Director at UMass Chan Medical School, and Associate Medical Director of Worcester EMS/ Life Flight at UMass Memorial Medical Center.

References:

1. Gillum RF. From papyrus to the electronic tablet: a brief history of the clinical medical record with lessons for the digital age. Am J Med. 2013 Oct;126(10):853-7.

2. Evans RS. Electronic Health Records: Then, Now, and in the Future. Year Med Inform. 2016 May 20;Suppl 1(Suppl 1):S48-61. doi: 10.15265/IYS-2016-s006.

3. Kruse CS, Kristof C, Jones B, Mitchell E, Martinez A. Barriers to Electronic Health Record Adoption: A Systematic Literature Review. J Med Syst. 2016 Dec;40(12):252.

4. Fennelly O, Cunningham C, Grogan L, Cronin H, O’Shea C, Roche M, Lawlor F, O’Hare N. Successfully implementing a national electronic health record: a rapid umbrella review. Int J Med Inform. 2020 Dec;144:104281.

5. Martin TJ, Ranney ML, Dorroh J, Asselin N, Sarkar IN. Health Information Exchange in Emergency Medical Services. Appl Clin Inform. 2018 Oct;9(4):884-891.

6. Landman AB, Lee CH, Sasson C, Van Gelder CM, Curry LA. Prehospital electronic patient care report systems: early experiences from emergency medical services agency leaders. PLoS One. 2012;7(3):e32692.

7. Litchfield I, Shukla D, Greenfield S. Impact of

COVID-19 on the digital divide: a rapid review. BMJ Open. 2021 Oct 12;11(10):e053440.

8. Mann D, Chen J, Chunara R, Testa Paul. COVID-19 transforms health care through telemedicine: Evidence from the field, J. Am. Med. Inform. Assoc. 2020 7(1132–1135).

9. Cunningham CT, Sanseverino A, Reznek M, Borges E, Beth Urhoy M, Gross K, Broach JP, O’Connor L. A pilot study of prehospital antibiotics for severe sepsis. Acad Emerg Med. 2022 Feb;29(2):231-233.

10. Thurman WA, Moczygemba LR, Tormey K, Hudzik A, Welton-Arndt L, Okoh C. A scoping review of community paramedicine: evidence

and implications for interprofessional practice. J Interprof Care. 2021 Mar-Apr;35(2):229-239.

11. Massachusetts Office of Emergency Medical Services. “Learn about MIH and Community EMS.” Massachusetts Department of Public Health. < https://www.mass.gov/service-details/learn-about-mihand-community-ems>. Accessed 1 August 2022.

12. Choi BY, Blumberg C, Williams K. Mobile integrated health care and community paramedicine: an emerging emergency medical services concept. Ann Emerg Med 2016;67;361-6.

13. The Centers for Medicare and Medicaid Services. “Acute Hospital Care At Home”. The Centers for Medicare and Medicaid Services. <https://qualitynet.cms.gov/acute-hospital-care-at-home>. Accessed 1 August 2022.

How Electronic Health Records Have Revolutionized the Pharmacy

Dinesh Yogaratnam, PharmD, BCPS, BCCCP

It’s 2 a.m., and you are the only pharmacist working in the hospital at this late hour. The fax machine whirs to life and spits out a physician orders form. You grab the paper and decipher the blurry handwriting, which reads, “Cipro 400 mg IV q12hr.” Other than the patient’s name, medical record number and date of birth, there’s no other information provided. You start asking the typical questions to determine the appropriateness of the medication order: Why ciprofloxacin? Why intravenous? Why this dose and frequency? Fortunately, the answers to some of these essential questions can be found in the patient’s medical chart. Unfortunately, the patient is all the way up on the sixth floor, while you are all the way down in the basement pharmacy. However, you have access to the patient’s electronic health record (EHR)! This means no waiting your turn to read or document within a single paper chart. All the information you need is at your fingertips. With a few quick clicks, you scan the history of drug allergies, interactions, pre-existing conditions, providers’ notes, nursing flow charts, medication administration records and laboratory results, confidently confirming that the antibiotic is safe and appropriate for your patient.

Quick decision-making is especially important in an emergency room setting. The EHR enables instant access to pertinent patient data, allowing pharmacists to quickly provide detailed drug therapy recom-

mendations. According to Mike Dinapoli, an emergency room pharmacist at UMass Memorial Medical Center, “In a matter of seconds, I’m able to quickly access a patient’s medical history, including records at outside hospitals that use a similar EHR. We receive a ton of questions about patients with penicillin/cephalosporin allergies,” Mike explains, “I’m able to dig into the chart and quickly see if they have

previously tolerated cefazolin or ceftriaxone. This helps prevent the unnecessary use of broader spectrum agents.” The EHR also gives pharmacists the ability to better scrutinize the accuracy of a patient’s

“

The EHR allows pharmacists to provide a broader range of drug therapy services on a scale that simply wasn’t possible in the age of paper charts.

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How Electronic Health Records Have Revolutionized the Pharmacy Continued

medication list. “As an ED pharmacist,” Mike explains, “this helps tremendously with medication reconciliation. For example, access to a patient’s dispense history at an outside pharmacy can help verify whether an unconscious trauma patient with an intracranial hemorrhage may have been taking Eliquis. Of course, we still call pharmacies to confirm this info, but this gives us a better starting point.”

The EHR also allows pharmacists to provide a broader range of drug therapy services on a scale that simply wasn’t possible in the age of paper charts. Drug dosing services, medication discharge counseling and other labor-intensive pharmacy tasks are now facilitated by computerized processes and templates, drastically reducing the time needed to gather, communicate and document pertinent information. With the EHR, Mike explains, “we’ve been able to customize the ED trackboard to focus on the pharmacists’ workflow. We can quickly see which patients need a medication reconciliation, a vancomycin dosing adjustment or a review and approval for a restricted antibiotic.”

Not only does the EHR allow for a more streamlined approach to clinical pharmacy services, it also simplifies pharmacy operations and drug formulary management. Lorie Gull, a Pharmacy Manager at UMass Memorial, describes how the EHR helps with pharmacy operations, formulary management and patient safety. “The EHR allows for barcode scanning when receiving, storing, preparing and administering medications.” This helps to ensure safety and accuracy at each critical step of the medication use process. Furthermore, Lorie explains, “the EHR helps drive the provider towards preferred formulary agents.” By leveraging the EHR system’s computerized physician order entry (CPOE) feature, we can more rapidly communicate updates regarding formulary-preferred agents and evidence-based drug therapy guidelines. In addition, the EHR helps the pharmacy quickly react to drug shortages. Lorie appreciates how much the EHR helps in this regard, noting that “it alerts providers of new or worsening drug shortages and guides them towards alternatives. It also allows better reporting capability to assess usage of an agent in different patient populations or within different service lines and guides our mitigation strategies to where they will be most impactful.”

The outpatient pharmacy has benefited from EHRs as well. Electronic prescribing and renewal

requests for medications, including controlled substances, has reduced the risk of transcription error and prescription tampering. Electronic cancellation notices from the EHR have reduced the risk of inappropriate refills. And with more advanced pharmacy systems, patients have enjoyed the ability to request refills online and automatically be notified when their prescriptions are ready.

Despite the EHR’s positive contributions to both clinical and operational pharmacy services, there are still areas where it could be improved. The EHR often presents redundant, pre-populated information. As a result, pharmacists spend unnecessary time hunting for pertinent information in order to perform drug therapy services. There is also a constant blaring of irrelevant drug alerts, which can lead to alert fatigue and a potential for accidentally overriding important drug safety checks. The EHR also has a frustrating reliance on inflexible electronic templates that limit the ability of the pharmacist to create more personalized medication care plans. The ease of creating errors can also be amplified with an EHR. Mike Dinapoli explains, “The simple click of something makes life easier. However, that also means that with a simple click you can completely order the wrong drug, frequency, et cetera.” According to Lorie Gull, the EHR could do a better job at helping to streamline pharmacy inventory management by “increasing interoperability between inventory and patient care systems, which would allow for better forecasting the need for increasing or decreasing certain agents based on utilization.”

By allowing access to a complete medical record, the EHR gives pharmacists the ability to provide timely medication reviews and deliver comprehensive, evidence-based drug therapy recommendations. The EHR allows for more efficient communication, both among pharmacists and between pharmacists and healthcare staff, which allows for a more efficient resolution of medication related problems. Drug safety and formulary management have also been revolutionized by the EHR with the incorporation of CPOE, bar-code assisted medication administration and formulary management systems. While far from perfect, the EHR is still a step in the right direction for pharmacists. As Ifeoma Asoh, a critical care pharmacist from UMass Memorial asserts, “Has it truly been game-changing? Perhaps. If one counts the higher accuracy in medication prescribing as a result of prebuilt order sets, the improved accessibility to pertinent data, such as vital signs, the increased flow of data from outside sources…then yes . The current state is a far cry from the days of pen and paper that saw us squinting at illegible handwriting, chasing down patient charts and wondering what effect the metoprolol we recommended had on the patient’s heart rate. I still prefer how tables or algorithms are displayed on paper. However, my fondness isn’t strong enough to return to the old days.” +

Dinesh Yogaratnam, PharmD, BCPS, BCCCP is Associate Professor of Pharmacy Practice at Massachusetts College of Pharmacy and Health Sciences’s School of Pharmacy.

Keeping the Focus on the Patient and Their EHR: A Nurse’s Perspective

Sarah Romain, RN

As a bedside nurse I had several objectives for every shift. First: Provide safe and excellent care for my patients. I aspired to make a connection with each patient and use our relationship to gain insight into their needs, as well as to help them understand their health. Second: Document accurately and get out on time. No matter how busy the shift was, the warnings of my mentors haunted me: If you don’t document it, it didn’t happen. I was often much more successful at attaining my first objective. I frequently found myself documenting well after my shift was over, with resentment building for the redundancies that came with documenting in the Electronic Health Record (EHR).

Throughout my career as a nurse, I have experienced the benefits and challenges that the EHR presents while caring for patients. At times, it functioned as intended: to improve safety, quality, and communication. (1) However, patient care is nuanced and individualized, so it did not always align with the interface of the EHR, which caused unnecessary frustration and distraction. My cognitive focus was pulled in different directions, one with a focus on the patient, and the other on the demands of the EHR. (2)

my patient. The ability to share critical information across many users in real time helped reduce delays in decision-making and allowed the multidisciplinary team access to the same information, no matter their location.

Despite the many benefits of the EHR, there are pitfalls as well. With so much information available in the EHR, the patient is at risk of being reduced to a collection of information. There is a value in physical assessment, knowing the patient, and trusting one’s instinct. (3, 4) I often observed overstretched and overwhelmed physicians who didn’t always come to see their patients, instead relying on the medical record to assess the situation. This created incomplete context for the patient’s situation and misinformed direction for their care. This forced me to value my own assessment and judgment, and to trust that there is some information that can’t be transcribed perfectly into a medical record. At times I felt at odds with the information in the EHR, insisting that providers come in person to assess the patient, even if only based on my intuition that something “just didn’t look right.” Spending time with a patient builds a personal and intimate knowledge that nurses use to inform care. What concerned me about a heavy reliance on the EHR to make decisions is that there was no standard form that could capture what that knowledge provided. The more time spent documenting, the less time there was to build upon these relationships which informed my intuition about them. (3)

In the past decade, EHRs have been widely implemented with goals to improve quality, safety, and communication across healthcare systems.(1) With mobile computers always available and computer stations built into the bedside of patients’ rooms, I came to rely on always having the EHR available at my fingertips. Safety features assisted in the prevention of medication errors, as the EHR required verification of the correct dosage and route for every medication administered. Data could be entered and accessed in real time, which allowed me to multitask patient care and documentation. This was a great benefit for my professional practice and patients, as I could work efficiently to find medical history, notes from providers, trend lab values, and make decisions based on many data points. I was able to be an effective advocate for my patients by using the communication tools built into the EHR, which allowed me to alert my healthcare team to problems and ask questions while staying with

The intangible dissatisfaction and frustration I’ve experienced have been described as the unintended consequence of a loss of cognitive focus. (2) Navigating the EHR to find the necessary information was not always intuitive, and synthesizing it all on a screen was not easy. Focus was also lost when “to do” items would pop up, with mandatory forms to complete and alerts that tasks were not yet documented. At times, this split my attention between the patient in front of me and their data next to me. The demands of the EHR often felt more like an obstacle than a tool while striving to build authentic and healing relationships with my patients.

“

There is a value in physical assessment, knowing the patient, and trusting one’s instinct.

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Keeping the Focus on the Patient and Their EHR Continued

A few years ago, I left my role as a bedside nurse to work as a research nurse in clinical trials. This position introduced me to new ways to use the EHR, and I developed a profound appreciation for how the information is used to impact meaningful change in practice. The details of care are heavily examined and scrutinized at every level, from local researchers to (at times) federal agents. These data are so valuable, and it’s typically the nurses who contribute so much of it to the patient’s chart. The mantra of my mentors continues to ring in my ears, but now I add my own line to it when I speak to my fellow nurses: “Please, document it all. It matters.” +

Sarah Romain, RN is a clinical research nurse at Baystate Medical Center and is earning a PhD in Nursing from the Tan Chingfen Graduate School of Nursing at UMass Chan Medical School.

References:

1. HealthIT.gov, 2014. EHR Incentives and Certification. http://www.healthit.gov/providers-professionals/meaningful-use-definition-objectives

2. Wisner, K., Lyndon, A., & Chesla, C. (2019). The electronic health record’s impact on nurses’ cognitive work: An integrative review. International Journal of Nursing Studies, 94, 74-84. https://doi.org/10.1016/j.ijnurstu.2019.03.003

3. Price, A., Zulkosky, K., White, K., & Pretz, J. (2017). Accuracy of intuition in clinical decision making among novice clinicians. Journal of advanced nursing, 73(5), 1147-1157. https://doi. org/10.1111/jan.13202

4. English, I. (1993). Intuition as a function of the expert nurse: a critique of Benner’s novice to expert model. Journal of advanced nursing, 18(3), 387-393. https://doi-org.umassmed.idm. oclc.org/10.1046/j.1365-2648.1993.18030387.x

Improved Care With Electronic Health Records: A Patient’s Perspective

Peter Ballantyne

My wife and I are in our mid-70s and have seen quite a bit of change in healthcare over the course of our lives. I remember in the old days there were thick folders containing our paper records that were brought into the exam room for the doctor to read through. Once, I remember as he was reading he looked at me and said “you’re in remarkably good health for a man of 70,” so evidently they had brought in the file for a different person! In the paper world, everything in my medical record was a mystery to me. I would never know what the doctors were writing or even whether they truly listened to me. Now the electronic health record (EHR)has changed all that. There are a whole host of features offered to us through our physician’s EHR system and patient portal:

• We found the EHR an asset to improving our experiences in the exam room. Not only can our healthcare provider enter notes and readily find information, we find it useful to see test results like our eye OCT or X-ray images.

• We have access to our full medical records through the online patient portal. We can review the providers’ notes after visits, which more consistently detail their instructions than the aftervisit summaries do. As we age, it’s harder to remember all the details of a visit, so the notes are a great reference. Sometimes we don’t understand some medical terminology but we can always look up anything that’s confusing. Seeing the notes also reassures us that we did get the correct point across and the provider understood us correctly. I remember a friend telling me that they could not seem to get the right understanding with their provider. Misunderstandings in diagnosis can be serious and I would want to know immediately if the history of my illness did not accurately match what I told the doctor, so the patient portal helps with that.

• Another useful feature is the “Messages” option, which gives us the ability to communicate directly with our healthcare team for medical or customer service questions. I know that I can directly schedule some appointments like video visits and mammograms for my wife, although I wish all visits could be self-scheduled online. The message tool also works well for prescription renewals and simple questions about a health issue like dry eyes or a minor rash, or to request an order for PT. However, we found that for more urgent or complicated issues we ran into lots of misunderstandings or slow responses, so a phone call was more efficient.

• The system does generate a lot of messages, reminders and alerts which can seem excessive at times. Scheduling an appointment immediately generates two emails and two patient portal alerts for both myself and my wife as we have shared access to our accounts. We’ve gotten used to it, though, and it doesn’t bother us as much anymore. It’s difficult to see how to fine-tune these to get the proper level of attention without missing anything. My iPhone is set to alert me from the patient portal app if a message comes in, but I might be busy and miss it, so the email is a useful reminder. One thing the system does not notify us about is the need for upcoming tests or lab work, which would be very valuable since these are almost always required before a visit.

• The system also notifies us of test results, which is great, but I’m concerned that we get results before the providers see them. This means we are faced with the possibility of learning of a potentially serious diagnosis without the benefit of a doctor’s interpretation. This is a wellintentioned ruling that misses a critical point and can lead to extreme distress in a patient. Sometimes apparently serious test results can in fact be benign, so having a doctor call to interpret the result in a simple and reassuring way is far more important and less worrying than getting the result the instant it’s released. We now get test result alerts in the middle of

the night and have had to set the iPhone to “do not disturb” to avoid being woken up with an alert saying “test result normal.” We always get a follow-up message from the PCP first thing the next morning to comment on the result, so that is most helpful.

• The patient portal offers the ability to get health information using the Health Reference Library menu option. This provides access to a wide range of information on things like medications, procedures and medical conditions by connecting to the MedlinePlus website. However, I seldom use it as I usually search Wikipedia or Google, Healthline.com, Mayoclinic.com or WebMD.com. Friends have told me they do the same.

• Another feature I like is how the EHR system allows us to link our accounts with other medical systems that use the EHR system from the same company. This is a brilliant idea and potentially very valuable, however I don’t feel it’s implemented as well as it could be. Critical data like medications, conditions, allergies and immunizations do not seem to propagate across organizations automatically. Recently my wife connected her Reliant Medical Group account to her new account on the Mass General Brigham (MGB) system, but MGB didn’t show her Reliant information so we had to enter all of the most important Health Summary data by hand, and of course made mistakes. I understand that MGB providers could manually pull in history from Reliant, but this data should flow automatically in both directions.

Yes, healthcare is much different today because of EHRs, but for the most part it’s much better for patients. We are more informed, connected, engaged, safer, and probably healthier because of EHRs. +

Peter Ballantyne has been a member of the Fallon Clinic/Reliant Medical Group Patient Advisory Council for 11 years.

Leveraging Electronic Health Records to Give Patients a Magical Experience

By Lawrence Garber, MD

We live in an age where almost anyone can pick up a phone, instantly see what’s happening with all of their friends, discover and research activities, make travel or restaurant reservations, and get the best directions based on mode of transit, traffic, and financial preferences. You can order something, watch where the delivery truck has your package and have it delivered to your home the same day. In most industries we are provided with almost magical services which feel like we are getting them for free. Of course, nothing is free. Some require us to give up our privacy and share data about ourselves or our friends. Others provide these tools to give them a competitive advantage for your purchase. But whatever the cost, we enjoy the experience and tell

our friends to do the same. So why can’t healthcare provide similar magical experiences? While we can’t sell patient data to fund these services, we can leverage the electronic health record (EHR) to provide these services in order to attract and retain patients, as well as improve the quality, safety, efficiency, and effectiveness of healthcare.

Patients are starting to experience the same conveniences that they’ve enjoyed in other parts of their lives because of the EHR. If they have symptoms, at any time of day or night they can go online to a website or app that already knows their medical history, answer a few questions, and within five minutes learn about the possible conditions that could explain their symptoms, how to do self-care when appropriate and when to seek professional help and where. They can schedule online to be seen for a video visit or an in-person visit, or they can send along

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photographs to facilitate asynchronous messaging care (AKA e-visits). A quarter of the people who use this service have their problems completely handled without a visit or even involving anyone at the provider’s office. (Reliant Medical Group Data, 2022).

When patients need to come into the office for a visit, they too can have an enhanced experience because of the EHR. They can get appointment reminders, check in, pay co-pays and update their medical history from the convenience of their phone or home computer. In the waiting room they can see real-time updates of the wait time for their healthcare provider. Staff can see in the EHR exactly what the patient looks like so they can walk right up to the patient in the waiting room and privately invite them to come to the exam room. While waiting for the provider in the exam room, they can view a personalized educational slideshow based on the EHR’s problem list and overdue health maintenance. The provider knows exactly why the patient is there and what needs to be done based on scheduling and referral information, as well as alerts elucidated from EHR data. Information from the state immunization registry, pharmacies, outside providers and other healthcare organizations are readily available through the EHR so there can be shared decision making where both the provider and patient are well informed. And after the visit, the patient can access the EHR through their portal to see the provider’s notes and after-visit summary so they can better understand and follow their treatment plans.

Between visits, patients are starting to get access to new tools because of the EHR. In the past, diabetic or hypertensive patients would have to call in their home readings, which was a laborious task. Now, remote patient monitoring allows these and other measurements to automatically populate the EHR and alert the healthcare team if any of the findings are significantly abnormal. Patients can use “digital therapeutic” apps integrated with the EHR to help them manage anxiety, depression, substance use disorders, pain, COVID-19 symptoms, diabetes, pregnancy, surgery aftercare and many other conditions while automatically alerting the healthcare team of concerning trends. Patients are alerted when they are due for a test or procedure and can use self-service tools to, for instance, schedule their own mammogram or eye exam. Medication refill and renewal requests can be done online and medications can be delivered directly to the patient’s home. Patients automatically receive test results as soon as they are available to the provider. And the parents of children or the adult children of elderly patients can share in the care of their family members through the EHR’s patient portal.

EHRs have indeed made it possible to offer the same magical experience in healthcare that patients have grown to expect in other parts of their life: getting the information or performing the tasks they want or need whenever they want or need it. And just like in other industries, delivering this experience is how healthcare organizations compete for patients today. For patients, it’s no longer a question of whether your healthcare provider has an EHR, but rather, how well does your provider leverage their EHR to improve your care and experience? +

The Role of the Electronic Health Record in Medical Research

Mara Meyer Epstein, ScD

Electronic health records (EHRs) have changed the landscape of medical research by efficiently identifying, recruiting and consenting participants to facilitate larger studies of more diverse populations. As a clinical tool, EHRs allow for the electronic exchange of health information, leading to improved patient care, enhanced patient-provider communication and increased access to patients’ own health information. These benefits translate directly to research, where the EHR has become an important setting for studies ranging from pragmatic clinical trials to observational studies, and serves a key role in the translation of research into practice. Indeed, with the expanded adoption of the EHR there has been a rapid acceleration in the number of registered clinical trials (Figure 1). However, the use of the EHR for medical research has required a great deal of effort to implement, and also has some drawbacks, including the burden placed on providers in EHR-based intervention studies, and potential limited generalizability to people without access to technology or healthcare.

An increasing number of multi-site studies and research networks, including the National Institutes of Health (NIH) funded All of Us Research Program and the National Patient-Centered Clinical Research Network (PCORnet) rely on EHRs as a primary source of data collection. These networks—with participating sites across the United States including integrated healthcare systems and community health centers—must normalize large amounts of EHR-derived data before starting to analyze it. The structure, format and content of raw EHR data vary widely between organizations and institutions; however, tools exist to standardize EHR data across sites through the adoption of common data models. While some of these common data models are shared only among partners of a research network, others, like the international Observational Medical Outcomes Partnership (OMOP) model, may be applied more broadly beyond a specific research study. For example, the NIH All

Lawrence Garber, MD is an internist, the Medical Director for Informatics, and the Associate Medical Director of Research at Reliant Medical Group.

Leveraging the Electronic Health Record to Give Patients a Magical Experience Continued

of Us Research Program standardizes participants’ EHR data collected from healthcare provider organizations across the United States using the OMOP common data model. Through this important step of aligning data sources with a common structure, and following vigorous data quality and integrity checks across participating sites, datasets derived from the All of Us Research Program can efficiently facilitate studies on a wide variety of topics using data collected from diverse populations. Importantly, observational and epidemiological studies using EHR data often do not rely on providers or patients for additional input and can be completed without a burden on the healthcare system.

Electronic Health Records

on the part of providers or patients—for example, receiving additional EHR alerts or integrating patient-generated health data in the EHR— may contribute to feelings of burnout, particularly in the era of the COVID-19 pandemic.

EHRs have great potential to change the way medical research is conducted. However, researchers must also remember some key facts about the nature of EHRs to make sure research questions can be appropriately answered. By definition, EHR data are collected from people seeking healthcare, and are unlikely to capture the health of people without access to care. If a study relies on the use of patient portals or electronic messaging, the enrolled population may be limited to those who have access to the internet. As a result, we must be aware of the representativeness of the study population, and how it may affect the interpretation of study findings. Furthermore, EHR data are collected with the purpose of providing care to a patient, and not for a research study. As a result, certain information may be missing or incomplete (for example, data on patients’ diets or exercise habits), and that may introduce bias to a research study, depending on the question being asked.

The EHR is also an important tool for conducting clinical trials. Through patient data readily available in the EHR, and with proper approval in place, investigators can efficiently identify eligible participants for proposed or planned trials. The EHR is particularly useful for pragmatic clinical trials, which aim to test an intervention in a real-world clinical setting. Many studies also use the features of the EHR, including patient portals and electronic messaging, to recruit participants, initiate the consent process and even conduct the actual intervention. Electronic recruitment can reach a wide range of patients and may be cost- and time-effective. However, studies based in the EHR may rely on providers to initially contact potential participants, or participate in an EHR-based intervention themselves, which could add to the burden of already overwhelmed healthcare workers. Interventions requiring extra efforts left

In summary, EHRs have made it possible to conduct large, multisite studies with detailed clinical data, including in populations underrepresented in traditional medical research. These studies may require considerable efforts to standardize data from different health systems and different EHRs prior to analysis, including through the adoption of a common data model. Furthermore, the availability of data should be considered when deciding whether EHRs are the appropriate setting to answer a particular research question. In addition, the burden on providers and patients should be considered when an EHR-based intervention is being planned, both during the study, and when considering how the intervention will apply in the real world. Despite these potential drawbacks, with the proper procedures in place, EHRs represent a rich resource with the potential to assist in all aspects of medical and population health research, from assessing the feasibility of observational studies, to conducting pragmatic clinical trials and translating findings into practice. +

Mara Meyer Epstein, ScD is a cancer epidemiologist and an Associate Professor of Medicine in the Division of Health Systems Science at the UMass Chan Medical School.

Figure 1: Number of studies registered at CinicalTrials.gov compared with EHR adoption over time.

Electronic Health Records

Reflections on the EHR: Gains, Losses, Opportunities

Sonia Nagy Chimienti, MD FIDSA

Afew months ago, I completed training on the electronic health record (EHR) at my new place of employment. Given that I have used electronic health records for more than 15 years and had familiarity with this particular system, the EHR training should have been easy. Here’s the thing: it wasn’t easy. As I participated in the training, I had to pay close attention in order to remember where to click to complete certain tasks. My brain needed to be attuned to the task, not the clinical decision I was making. This contrasts starkly to my early days as an attending physician, when I could easily write notes by hand while actively thinking about the patient and their medical issue. The neurons in my brain would fire and jump from one issue to the next, as I was thinking about what I was missing, wondering about the esoteric as well as the commonplace, making sure that I had it all down in my typical lengthy infectious diseases consult note, without needing to think about how my reasoning was being communicated on the page. Similarly, writing the orders was easy; I just had to remember to make sure that the dial on the chart was on the right color, so that the desk clerk could see that there was a new order to convey. When rounding on the consult service, I used to be able to manage a list of 25 consult patients without a problem; but with use of the EHR, despite my familiarity with the system, it was difficult to manage the work for 10-15 patients in a timely manner.

My primary role these days is in education and administration. My inpatient rounding days are over, and I typically precept students and fellows in clinic. It occurred to me recently that I have not once heard our trainees express concern or dismay regarding the function of the EHR system, other than being locked out because of password issues. This got me thinking: Is there a generational issue at play here impacting my love-hate relationship with EHRs?

To try to understand differing perspectives on the EHR, I asked trainees at all levels, together with early-, mid- and later-career physicians, how the EHR impacted their work with patients, if at all. Here’s what I found.

For the most part, all providers I spoke with valued the EHR because of improved coordination of care and ease of communication across teams, specialties and institutions. Many were able to access information from outside of their own department or organization with a click of a button, enabling timely review of laboratory results and notes without frustrating delays waiting for faxed and mailed medical information. A seasoned physician noted that “in the past, communicating with specialists was time consuming, inconsistent, and at times aggravating. Now for the most part it is fantastic.”

In this sense, all of my colleagues felt that EHRs had the potential to improve patient care. One senior physician noted, however, that actual improvement in care depends on how the provider uses the EHR system. Even though communication is easier, and data are readily available, this does not necessarily mean that a patient will receive better care; the provider still needs to be present, acting on the data, listening to the patient, discerning the correct clinical information and applying all of that knowledge to sound clinical decision-making. He astutely noted that, “The EHR hasn’t made things more complicated or complicated things, it has made it clearer that care is complicated by having it all documented better...it has neither improved nor worsened care. The EHR is a tool, used by practitioners who deliver the care, so use of this is only so good as the caregivers. It creates the possibility of safer, better care but doesn’t guarantee it.”

Almost all of the physicians with whom I spoke felt that the EHR changed how they interacted with patients, and not always for the better. For instance, a Chief Resident enjoys “pulling up notes and results via the EHR and reviewing them live with the patient, which they often appreciate.” Yet the EHR adds a dimension, regardless of training or stage of professional practice, that can lead to a disconnect from the patient. Paying attention, being present and connecting with patients requires extra effort when the computer is in the room. One resident noted that “The EHR can impede interactions with patients... it can be difficult to break away from the habit of trying to type a note at the same time as I gather a history. I prefer to face my patient and give them my full and complete attention rather than attempting to review a patient’s chart while also listening to their needs.” A new intern wrote, “When I am in a patient room and have a computer in front of me, while I am being more efficient, I sense the disconnect, even as a ‘millennial’ who grew up with the Internet. I try to be very mindful of this and intentionally make eye contact and avoid fixating on the computer screen... There was once a time when I asked a patient how they were doing, and they expressed that times were difficult because they had recently lost a loved one. It took a few moments for their words to hit me; I was still typing away their response to the previous question and let out a reflexive ‘I’m so sorry to hear that’ without really just taking it in and being present with them at that moment. Once I caught myself, I closed my laptop and turned my attention to them.”

Not surprisingly, some physicians commented on the “fluff” that is carried forward, in notes and

Electronic Health Records

Reflections on the EHR: Gains, Losses, Opportunities Continued

problem lists, that can make it difficult to figure out what truly is important. A resident wrote, “I have found I miss the simplicity of notes in a pre-EHR practice. Now it is very easy to pull information into documentation in a way that makes notes feel lengthy and unhelpful. Oftentimes I wish for a succinct assessment and plan statement rather than… templated notes that lack any nuance or true ability to communicate a patient’s current experience.” Similarly, multiple senior-level physicians noted that the ease of copying forward prior notes exacerbates this problem and that “Once something is in, it is seemingly in forever.” They did also note, however, that “wading through too much information is better than not having it.”

In terms of training, all the providers I connected with expressed satisfaction with their EHR training. There were a few best practices that I found interesting and potentially valuable. One of the residents indicated that their program has a Housestaff Information Technology Enhancement Council that provides monthly email updates regarding new features in the EHR system and new workflows. Similar monthly updates do occur at some hospitals, distributed by “super user” teams from clinical informatics. Some systems also include “skills practice” in a “sandbox,” together with the online training modules.

Finally, a surprising theme that was shared was the unintended negative impact of the EHR on the close and collegial relationships that are the hallmark of clinical care. This concern was noted by providers at all levels of practice, from a new intern to a seasoned physician. When we interact primarily with the EHR rather than each other, the nuanced reasoning that leads to our specific recommendations may be lost, and the critical relationships that we build across specialties and providers can be eroded. One resident lamented, “We have built this system in such a way that doesn’t require us to engage with the people we ask many things from throughout the day. Everything is assumed to be as easy as a click of a button. If you don’t spend time speaking to nursing staff, you can’t appreciate how frustrating it is to draw labs at 6 a.m., then 7 a.m., then 8:30 a.m. for a patient when they could have all just been drawn at 7 a.m. This lack of a relationship and understanding of the nuances in everyone’s experience contribute to burnout and overall dissatisfaction in the workplace.” A department Chair concurred, noting that EHRs “seem to have had a negative impact on teams really getting to know each other. Colleagues can work together for years and never get to know each other in shoulder-to-shoulder, elbow-to-elbow ways. Without this, the personal humanity of sharing stories about kids, family, life experiences is missing. It is a barrier to cohesion and teamsmanship.”

When I embarked on this exploration, I thought that I might find some generational or specialty-specific opinions on the impact of EHRs on clinical care, but this was not the case. My colleagues universally felt that the EHR system helps to streamline communication and can decrease medical errors in ordering and prescribing. There was general agreement that notes seem a bit too long, and that it is hard to weed through carried-forward information to find what really matters. Notably, the EHR may have a very real impact on our interactions with each other, and potentially contributes to the burnout that is prevalent in healthcare today. I recognize that this is a complex issue, but the connections that we forge across disciplines and specialties as

we care for patients can have a profound and positive impact on our sense of satisfaction in healthcare, as was shared by my colleagues. It is possible that the time we spend connecting with EHRs has negatively impacted our opportunities to connect with each other in real time, in person, learning from each other, understanding recommendations from consultants, and appreciating the nuanced reasoning that leads to clinical care decisions. +

Sonia Nagy Chimienti, MD FIDSA is Senior Associate Dean for Medical Education at Dartmouth’s Geisel School of Medicine

The author would like to thank, with deep gratitude, those physicians quoted in this piece. These connections were forged through in-person conversations, although technology did facilitate data gathering for this particular piece. Quotes above were shared, with permission, from the following treasured colleagues:

Falen Demsas, MD, Intern in Vascular Surgery, Massachusetts General Hospital, Harvard Medical School

Laura Desrochers, MD, Chief Resident, Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School

Shernaz Dossabhoy, MD, Resident in Vascular Surgery, Stanford University Hospitals/Stanford Medical School

Phillip Fournier, MD, Professor of Family Medicine and Community Health, Medical Director of Student Health Services, UMass Chan School of Medicine/ UMass Memorial Health

David Hatem, MD, Professor of Medicine, Co-Director of the Learning Communities, UMass Chan Medical School/UMass Memorial Health

Tiffany A. Moore Simas, MD, MPH, MEd, FACOG, Donna M. and Robert J. Manning Chair in Obstetrics and Gynecology, Professor, Obstetrics and Gynecology, Pediatrics, Psychiatry and Population and Quantitative Health Sciences, UMass Chan Medical School/UMass Memorial Health

Society Snippets

Annual Women In Medicine Leadership Forum

Building A Family: A Dialogue About Fertility and Pregnancy in Medical Trainees and Faculty Held on Wednesday, May 25, 2022 Co-Sponsored by Physicians Insurance

WDMS Guided Medical Historical Bus Tour Through The City Of Worcester Held on Sunday, June 26, 2022 Interested in the history of WDMS? Visit our website: www.wdms.org and click the History Tab

Lynda Young, MD Heidi Leftwich, DO

Moderator

Chair, Women’s Caucus Panelists

Armando Arroyo, MD Jennifer Yates, MD Christine Van Horn, MD

Here To View The Event Video

Here To Learn More About The Moderator And Panelists

Worcester State Hospital Clock Tower

Calendar of Events

2022 Events

Virtual Fall District Meeting and Awards Ceremony

November 15, 2022, 6:30 p.m.

The meeting includes the Dr. A. Jane Fitzpatrick Community Service Award, WML Student Achievement Award and Medical Student Scholarship Award Presentations.

HOD Opening Session (Virtual)

November 21, 2022, 6:30-8:30 p.m.

All WDMS members are invited to attend as guests and may submit a resolution to MMS.

HOD Second Session

December 10, 2022, 9:00 a.m. to close of business

All WDMS members are invited to attend as guests and may submit a resolution to MMS.

Second Annual Holiday/Med Moth Program

December 13, 2022, 5:30 p.m., UMass Albert Sherman Center, Multipurpose Room

Medical and experiential Storytelling and sharing led by student members: Eve Manghis and Sean Boyden.

In Memoriam

Ronald Dorris, MD

2023 Events

227th ANNUAL ORATION

February 8, 2023, 5:30 p.m.

Beechwood Hotel Orator: Anne Larkin, MD Title: “What Medical Students Need to Know”

Annual Doctor’s Day March 30, 2023

Student Event Spring 2023 (Date TBD) “Day of Caring, Night of Fun”

Annual Business Meeting April 11, 2023, 5:30 pm

Beechwood Hotel Meeting includes presentation of the 20023-2024 Slate of Officers, 2022 MMS/WDMS Community Clinician of the Year, President’s Award and WDMS Career Achievement Award.

Women In Medicine Leadership Forum May 3, 2023, 5:30 p.m. Mechanics Hall

The Power of Food, The Power of the Pause: How lifestyle medicine, plant based nutrition, and biological self-awareness build stronger selves, and help us empower our patients.

Speakers: Michelle Dalal, MD and Harikirin Khalsa, MD

2023 Mms Annual Meeting and House Of Delegates May 13, 2023 Waltham, MA

All WDMS members are invited to attend as a guest and may submit a resolution to MMS.

Humanities/Meet the Author May 2023 (Date TBD)

UMass Chan Medical School faculty conference room. Meet Dr. Mark Vonnegut

Ongoing Events:

• WDMS Open House(s)

• Medical History Book Club With Dr. Magee

• Worcester Music - Please watch for available tickets to ALL shows at https://musicworcester.org!

Dr. Ronald Dorris died Tuesday, August 16, 2022 at St. Vincent Hospital.

He was born in New York City, son of George and Beatrice (Kirshner). He earned a bachelor’s degree from Harvard, graduating Magna Cum Laude. He attended Weil Cornell Medical School where he earned his MD degree. After a fellowship in pulmonary medicine at the University of Pennsylvania, he moved to Worcester in 1963, where he founded the pulmonary group at St. Vincent Hospital.

Ron practiced internal medicine, specializing in pulmonary medicine and allergy at St. Vincent for 55 years. He was elected President of the Massachusetts chapter of the American Lung Association, which bestowed on him a Lifetime Achievement Award.

Ron was married to Carol Reevman Dorris for 65 years. He is survived by Carol, his devoted wife, a son and three daughters, and five grandchildren.

Those of us who worked with Ron knew him to be a devoted clinician and a fun-loving and affable colleague. The Worcester medical community will miss Ronald Dorris. +

Sidney P. Kadish, MD WDMS Memorials Committee

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