7 questions about the future of EHRs

Physicians often see the EHR as the bane of their professional existence, complaining about awful user interfaces and a lack of interoperability with other systems that forces them to access multiple platforms to get the information they need on one patient.

But they also understand that potential remains. Most doctors don’t want to go back to the days of paper records, nor is every part of the EHR beyond salvaging. There are many issues that need to be addressed before doctors will be satisfied with them, so Medical Economics spoke with Rob Tennant, director of Health Information Technology Policy, Medical Group Management Association, to talk about EHRs and what improvements physicians can expect to see soon.

Note: The transcript has been edited for clarity and brevity.

Medical Economics: Looking out over the next 12 months or so, do you see any major milestones in the area of interoperability for EHRs?

Rob Tennant: I think we're starting to see the regulations come out from both ONC and CMS in support of the 2016 Cures Act. I think when we look at the next few months, we'll start to see things like the TEFCA— the trust exchange framework and common agreement regulation—which should help create the highway that allows health information exchange to occur more effectively nationwide. We're also looking at more information from both ONC and the office of the inspector general in terms of information blocking, and certainly on the idea around enforcement—can there be additional enforcement levers placed on providers? We're also looking for the hospital requirement on admit-discharge-transfer, the ADT requirement, we're looking for that to come forward, and that has a real potential of giving practices, critical data on their patients. So they would know for example, if a diabetic patient of theirs ended up in the ER on the weekend, it would allow them to follow up with the patient on Monday morning, and make sure that did they don't end up back in the ER the following weekend. So I think we're looking for the Cures Act regulations to come forward. Again, a lot of excitement, but a lot of work ahead as well.

Medical Economics: The number of EHR vendors has declined over the years. Do you see any activity as far as either mergers or vendors that might leave the market?

RT: Every time the government issues new regulations, new requirements, on software developers, we start to see some vendors fall by the wayside, or we start to see some merge. It’s not surprising, as it's very expensive for these companies to redevelop their products. So I think we've seen some consolidation, and I expect there to be more candidly, because the new Cures Act regulations put a lot of heavy burden on software developers to meet new certification requirements. And because of that, I suspect we'll see some vendors not be able to meet these new requirements. I think the challenge for practices, of course, is if their vendor of choice is not recertified to the new standard—what they're calling the 2015 Cures edition—then they at some point, probably in 2023, they would not be eligible to continue participating in the promoting interoperability component of MIPS. So we're going to watch that very closely, because it could have an impact on whether or not practices can participate in the quality reporting programs.

Medical Economics: There's been a lot of talk about apps and how they could improve EHRs. What's happening in that arena?

RT: A lot. I think this has the potential—and I use that word potential—of absolutely transforming the care delivery process, both on the clinical side, and on the administrative side. I think the vision for the government, and I've seen Dr. Rucker [Rucker is the head of ONC] literally hold up his smartphone and say, the future of health care is exactly how we use our smartphones by using apps. And all apps are avenues to data. So he often uses the analogy of Travelocity or Expedia, where you want to take a flight. Your app allows you into the database of these airlines to get the information and the pricing information that you need. The potential for apps to do something similar in health care is very exciting. For example, on the clinical side, the HL7 Da Vinci folks are working on a number of use cases. One is sharing data between care settings, and it could be between labs and practices, between a health plan and a health plan, or between health plans and providers. The idea is by leveraging the health care interoperability resources standards, you're able to use data at the point of care. I think that's the most exciting feature here. The idea that the practice could have apps that allow it to, for example, do a prior authorization, perhaps even in real time. The goal for us is to both decrease the volume of prior auths, but also, if it is required, to make it as easy as possible for both the practice and the patient. The idea is apps simply move data from point A to point B, and it also opens up doors. For example, for quality reporting, for things like social determinants of health, so, you know, ideally, when the practice is speaking to the patient, they would have access to drug formulary data to prior auth information, but also potentially to the local food banks, and perhaps to mental health services in the area that they could direct the patient to. The opportunities are there for the EHR to really be the platform where physicians and their staff can receive data and send data seamlessly, that helps the patient and of course, helps them with their practice as well. So huge opportunities, but we're not quite there yet.

Medical Economics: Usability has been a major complaint of doctors for many years. What are EHR vendors doing to improve the user experience?

RT: Frankly, I've never talked to a physician who said, “Boy, I just can't wait to get on my EHR in the morning.” They understand their functionality, their utility, they know how important they are. They know, in some form, the capabilities that these software programs have. But boy, they're just not intuitive. And, it goes across the board. It's not just one or two vendors. Part of the problem has been that the vendors have been focused very much on meeting government program requirements. And they've spent less time candidly working on interfaces to make the user experience for both the clinician and the administrative staff easier. I think, hopefully we’re moving in that direction a little more. Because it's not just that the usability is a hassle factor, it can also bleed into the area of patient safety. If things aren't captured easily, if the information isn't presented in an effective way, it can actually impact patients’ safety. This should be, and I think is, a priority. And we're certainly encouraging the government to work closely with the EHR vendor developers to make sure that usability is improved, and patient safety is maintained.

Medical Economics: As we move toward the next generation of EHRs, what are the biggest changes doctors can expect to see?

RT: We talked about and I'll get into something I call point of care. When you're dealing with data, really, what you want is the data at your fingertips. If I go back to the Travelocity app, if I get on it and I say, “OK, I want to know what the cost is for a flight to New York” and it gets back to me in two weeks, that's really not helpful. At the point of care, data flow is going to be the biggest change in health care, I believe, over the next year to two years. For example, already there are a number of vendors that offer point of care solutions on the medication side. So if the patient is standing, or sitting in front of the physician, and physician says, “Well, we need to put you on medication A,” they can immediately check with this software program. It pings the health plan formulary to see if it's in the formulary, it indicates whether or not it requires a prior authorization. It provides the patient’s out-of-pocket expense, and it can provide the therapeutic alternative. If drug A is not in the formulary and requires a prior auth, it's a $500 out-of-pocket cost for the patient. But there's a therapeutic alternative, which is in the formulary and doesn't require a prior auth, and is $20 out of pocket, and has the same efficacy as drug A. It allows that conversation to take place with the patient immediately, rather than in sort of the traditional approach, where the prescription is written, the patient goes to the pharmacy only to find out there that the cost is $500. And they say, “No thanks,” they walk away and they don't get the medication, or they've got to make a follow-up visit back to the physician to get a new script. This streamlines that process tremendously.

The question becomes, can we merge that technology in with medical services? Now you want to send your patient for a particular test. Wouldn't it be nice to know immediately, whether or not that is not only clinically appropriate through clinical decision support technology, but also whether or not the health plan is going to pay for it, and what the out of pocket expense will be. In the future, there will be an API feed that will tell the physician, there are, for example, 10 MRI vendors in the area, and here are the costs out-of-pocket for the patient, and allow the physician to have that conversation and keep costs lower for the patient. I think the point of care data flow is the next exciting thing to happen, and so we're looking for that over the next few years.

Medical Economics: Has the pandemic had any effect on EHR development or changed existing offerings in any way?

RT: The pandemic has had an impact on everybody. I think, when you're looking at it from the practice perspective, this is a terrible time to go to a practice and say, “Oh, great, it's time for an upgrade, and here's what the cost is going to be,” or, “Oh, you're looking for new technology? Great, here is a list of available resources.” They've had to pinch their pennies. Patient volume has decreased and off course, we've seen a shift over to telehealth. We've seen frontline workers get sick and and even die. So I think sort of the technology acquisition phase is on hold, and that impacts software developers, of course, as they're dealing with the same pandemic. They may not be as fully staffed as they were. Does that mean they will not be able to meet the government requirements in a timely manner? That will remain to be seen. But the pandemic has sort of put the brakes on a lot of things. And we just saw recently the ONC send a rule to OMB, looking to delay enforcement of information blocking. I think that is in response to the focus of practices and other providers on COVID-19. So we don't need them to be worrying about, frankly, arcane government regulations. We need to have them focused very much on their patients and their staff and making sure everybody is safe.

Medical Economics: How well do most EHR handle telehealth, and do you see better integration of the two in the future?

RT: When the pandemic hit in April, May, we saw an enormous increase in the use of telehealth services. This was coupled by health plans on certainly the Medicare side, but also on the commercial side, stepping forward to reimburse for those services. As some states move to reopen and relax some of the restrictions, we started to see more and more patient encounters switch back to face-to-face. I think that it’s important to recognize that we are not going to stay at 90% telehealth visits for the next 10 years, but I think a lot of both practices and patients saw the tremendous utility of having a telehealth visit. It will not solve all of health care, but for certain circumstances, it can be a very effective tool to maintain careful coordination and make sure that the patient has that interaction with the health care system. The challenge has been they don't always sync up nicely with the EHR. A lot of times, the telehealth vendor is completely separate from the EHR, and so it is a different silo for the practice. In some cases, I've talked to some practices where they literally toggle back and forth on their computer between the patient and their EHR, trying to keep up with the notes to make sure that they document the encounter. I think one of the things the pandemic has showed us is that telehealth is probably here to stay. Maybe not at the level that we saw early in the pandemic, but I think as one health care executive said, the genies out of the bottle. We need to be able to integrate the telehealth service with the EHR, so there's not that manual rework of moving the data from one to the other. I think that will be a challenge for the vendors, and hopefully, they'll be able to meet that that challenge. But again, it's a huge change for health care, but I think a change for the better. And again, for certain clinical scenarios, it can be a very effective way to interact with the patient.