Looking Forward: Maximizing Efficiency From Electronic Health Records

The transition to electronic health records from traditional paper charting was touted as a way to increase efficiency, billing and cataloging; however, for some, it has made practice overly burdened with notes and information.

For psoriatic disease specialists specifically, some question if these electronic resources could be revamped to do more and increase not only efficiency, but patient care as a whole.

“In the past 10 years we’ve witnessed the transition from paper to digital notes. That’s been very binary, handwriting to typing, and now it’s pretty mainstream,” Nicholas K. Mollanazar, MD, MBA, assistant professor of clinical dermatology and co-chair of Electronic Medical Records Governance at Penn Medicine, said. “In the next 10 years what we’re really interested in is an increase in productivity.”

As EHRs began taking root in the medical community, dermatology as a specialty was slower to make the switch. A 2012 article regarding EHRs in dermatology found their use had grown significantly from 2004 through 2009 when the American Academy of Dermatology helped develop EHR certification criteria for the specialty. Another survey found dermatology second to last in the growth of EHR use by specialty between 2003 and 2010, with psychiatry being the only specialty slower to adapt to the new systems. Additionally, with nurses and medical assistants often checking patients, EHRs have to be easily usable by individuals with varying education levels, the article continued.

In order to improve these systems, research and design needs to be conducted to maximize the best practices for efficiency, and this means having the right people at the helm, according to Mollanazar.

“There is a time and place for the more research-focused individuals to give us guidance on standards and treatments, but the actual functionality and the way it interacts with clinical practice, if it’s going to be effective and meaningful, it really needs to come from the front line,” he said.

Efficiency barriers

In 2020, the Journal of the American Academy of Dermatology published an update regarding EHR use and data collection in dermatology practices.

“The federal mandate for electronic health record keeping for health care providers impacted the burden placed on dermatologists for medical documentation,” Andrew J. Park, MD, MBA, and colleagues wrote. “The hope that EHR would improve care quality and efficiency and reduce health disparities has yet to be fully realized.”

The mandates for keeping records electronically have actually added more administrative costs and burden and reduced practice productivity, Park and colleagues continued.

In order to counteract this lack of efficiency, the authors recommended using patient-reported outcome measures in documentation, attempting to structure data that are normally recorded in an unstructured way and working with stakeholders to mandate data interoperability and collection.

“We need to begin using EHR instead of free texts. We should be selecting from a menu of options in an efficient way,” Mollanazar said. “The EHR needs to enter a phase of optimization and needs to option how providers provide and deliver.”

When asked if the transition to EHR has increased productivity, Robert A. Swerlick, MD, chair of the department of dermatology at Emory University School of Medicine, said it has been “arguably a complete disaster.”

The notes in EHR have become a burden on practitioners as too much information floods the charts, turning the search for useful information into a “Where’s Waldo book,” according to Swerlick.

“There might be two or three morsels of useful information in a given encounter that you really need,” he said. “Theoretically it may be extremely helpful because the amount of information that we’re now required to manage is beyond what we can maintain in our brains. But then the question is, ‘How do you use the tool and leverage it appropriately so it enhances care and makes us more efficient?’ I think it can be done.”

Coproduction

A collaborative effort between physicians, patients and industry is necessary for success, according to an editorial published in the International Journal of Women’s Dermatology.

In addition, a 2020 survey of 187 patients and 44 dermatologists found patients to be more optimistic about the use of EHR’s potential benefits, with practitioners showing more skepticism.

As a multi-stakeholder process, the study’s conclusion recommended the involvement of both patients and providers in the collection of data and implementation of EHRs. It also concluded that having patients provide data is necessary, but in order to do so the programs and processes need to be intuitive and easy to use.

“Over the past 20 years we’ve been trying to figure out how we can capture structured information as part of our care. And to capture outcomes, not as a sort of separate project, but as part of care,” Swerlick said.

Medicine is a co-produced product, he added, meaning that patients and physicians work together to deliver care; however, the EHR systems do not adequately reflect that.

“So much of the information necessary to figure out whether or not a patient with psoriasis has been adequately treated, we actually capture from the patient,” he said. “The way we can do this and make practice much more efficient is we delegate tasks to patients, then they help us co-produce the outcome.”

And much of this information can be captured before a physician visit with an efficient EHR system. Patients filling in questionnaires regarding disease severity, quality of life and other patient-measured outcomes could save hours of clinic time.

“Patients need to understand that their care will be better if they come to clinic prepared and do the homework ahead of time,” Swerlick said.

One way he has implemented this in his own practice is by using a short Standardized Dermatology Outcome Measures questionnaire that patients can fill out via text or email before their clinic visit.

Personalizing EHR

In order to do this, personalizing EHR systems for an individual practice and specialty is necessary. EHR systems were built mostly for billing purposes and to connect billing through health care systems. But there is potential built into some programs to maximize care within the specialty.

“These tools were really built for billing, so they’re not really designed to help you care for the patient,” Alexis R. Ogdie-Beatty, MD, MSCE, associate professor of rheumatology and director of the Center for Clinical Epidemiology and Biostatistics, at Penn Medicine, said. “But there are many features that you can use in order to make this a better experience for both you and the patient, hopefully.”

This includes using personable templates. At Penn, the psoriatic disease team and the spondylitis disease team use a template that standardizes care patterns by collecting data necessary to the care of these diseases.

Additionally, the Psoriasis & Psoriatic Arthritis Clinics Multicenter Advancement Network (PPACMAN) templates have been created and designed using the Epic EHR system specifically for dermatologists or rheumatologists treating psoriasis and psoriatic arthritis.

“This really helps you click through quickly to help make a comprehensive management plan,” Ogdie-Beatty said.

Ogdie-Beatty would like to see EHR systems be customizable for patients, such as having the ability to track psoriatic disease flares and have plans ready to go when a flare occurs.

“Having some way to track and manage flares remotely rather than having to wait to get a visit with the practitioner can help patients when they have a flare,” she said.

Balancing idealization with reality

One of the main complaints from practitioners when it comes to EHR systems is the amount of clicking needed to navigate the patient chart to review and enter new data.

Oftentimes the same information has to be entered multiple times in a single patient encounter. Newcomers to the electronic medical record may struggle with the amount of laboratory orders, prescriptions and clinical note entry required to care for their patients.

Increased charting time and less face-to-face clinic time with the patient, can lead to both burnout and suboptimal patient care.

Practitioners hope personalized features are included in software updates, such as the ability to order the same labs.

“For the advanced electronic medical record user, utilizing efficiency measures such as note templates and preference lists to quickly order commonly used labs and prescriptions, can mean the difference between seeing your family on time for dinner or burning the midnight candle at work,” Harry Dao, MD, associate professor and chair of dermatology at Loma Linda University School of Medicine, said. “With specialty-specific modules coming out in some electronic medical record systems, the hope is to claim back time lost to clerical work so that it can be better spent on important patient care initiatives.”

Close collaboration with the teams managing the electronic medical record to achieve these same goals for other aspect of care could increase both productivity and efficiency, according to Dao.

Communication pros and cons

The biggest draw to EHR systems is how they can be used to coordinate care and communication between not only physicians and patients but also between members of the patient care team.

If a majority of the patient care team utilizes the same electronic medical record, leveraging communication tools to have multiple members of the care team discuss the nuances of a case and to coordinate care, may make or break the case. “Sometimes the most important part of the visit happens after the patient visit has concluded,” says Dao, and he reports that he always strives to emulate his mentors who never hesitated to pick up the phone to make an important call to coordinate patient care. Truthfully, today, Dao says that “it feels like a miracle to get another busy clinician on the phone. It may be a sign of the times, but EMR technology to facilitate communication may make many of the prior mentioned pain points of EMR technology bearable.”

Patients are often able to use these systems to directly communicate with their care teams; however, some clinicians have complained that this leads to non-billable work hours that take directly from care time of other patients.

“One of the hot topics recently has been the billing of patients for MyChart messages that take up a significant amount of clinician time in reviewing the case, documenting in the record and communicating with the patient,” Dao said. “That’s a big debate right now and some institutions have adopted that.”

The Cleveland Clinic and the University of California San Francisco systems are two examples of institutions that have begun billing patients for messages they send through the EHR system that require medical expertise.

According to the Cleveland Clinic’s website, messages in the system could cost patients up to $50, with insurance companies often being charged.

Optimizing EHR

The American Academy of Dermatology has recommendations on how to best optimize EHR for specialized practice. Using templates, digital health tools and patient portals are three of the suggestions from the AAD, but so is having adequate and abundant training for all staff.

“Training can help identify any gaps that may impact productivity, which can cause delays in patient care,” Swapna Bhatia, MPH, manager for health technology and informatics, wrote for the AAD.

More research is also needed in order to maximize EHR efficiency; however, how to design studies in this field has proved difficult.

“This is really not hypothesis-driven research. It’s more an iterative look at where and how it’s deployed and then tweaked. So, the question is, ‘What’s good enough to deploy and test and utilize going forward in real practice?’” Swerlick said. “I think this is a heavy lift. Patients don’t want to deal with one more questionnaire, and for most practicing dermatologists, they’re skeptical of the value.”

• References:
• EHR Optimization 101. https://www.aad.org/dw/monthly/2020/august/answers-in-practice-ehr-optimization. Published Aug. 1, 2020. Accessed Feb. 28, 2023.
• Kaufmann M, et al. Semin Cutan Med Surg. 2012;doi:10.1016/j.sder.2012.06.008.
• Klein TM, et al. BMC Med Inform Decis Mak. 2020;doi:10.1186/s12911-020-01302-y.
• Kokkonen EWJ, et al. J Am Med Inform Assoc. 2013;doi:10.1136/amiajnl-2012-001609.
• MyChart Messaging. https://my.clevelandclinic.org/online-services/mychart/messaging. Accessed Feb. 28, 2023.
• Park AJ, et al. J Am Acad Dermatol. 2020;doi:10.1016/j.jaad.2019.10.064.
• Roberts WE, et al. Int J Womens Dermatol. 2017;doi:10.1016/j.ijwd.2017.10.008.

• For more information:
• Harry Dao, MD, can be reached at Loma Linda University School of Medicine, 25865 Barton Road, Suite 101, Building D, Loma Linda, CA 92354; email: hadao@llu.edu.
• Nicholas K. Mollanazar, MD, MBA, can be reached at Penn Medicine, Perelman Center for Advanced Medicine, 3400 Civic Center Blvd., South Pavilion, 1st floor, Philadelphia, PA 19104; email: nicholas.mollanazar@pennmedicine.upenn.edu.
• Alexis R. Ogdie, MD, MSCE, can be reached at Penn Medicine, Perelman Center for Advanced Medicine, 3400 Civic Center Blvd., South Pavilion, 1st floor, Philadelphia, PA 19104; email: ogdiea@pennmedicine.upenn.edu.
• Robert A. Swerlick, MD, can be reached at Emory Clinic at 1525 Clifton Road, 1525 Clifton Road, Atlanta, GA 30322. Email: robert.swerlick@emory.edu.