Case Scenario: A healthcare system recognizes the value of implementing an electronic health record (EHR) system to improve patient care across the continuum. There are numerous vendors from which to choose, and several vendors have dramatically increased market share. How does the system select a vendor?
Their consultants and leadership have discussed this in great detail, and they are aware of certain requirements. The EHR needs to be certified, user-friendly, and reasonably priced. There is also a need to standardize care among the acute care, ambulatory care, and long-term care facilities in the healthcare system, as well as to have the ability to interface with other healthcare systems.
What are the applications needed to help provide quality care? What can be done to reduce physician “pajama time” and improve physician satisfaction and engagement? Finally, what are the organization’s requirements for manpower (health informaticists, information technologists, clinical leadership), and how will the organization maximize opportunities to improve the quality of care of their patients?
Physician leaders must understand the process of incorporating electronic health records and other technology applications into the day-to-day care of patients. Certainly, chief medical information officers (CMIOs) must have a detailed knowledge of these tools and work hand in hand with their organizations’ chief information officers (CIOs).
In addition, chief medical officers (CMOs) and other members of the C-suite should have more than a passing knowledge; they should have an awareness of technology lifecycles and a clear grasp of policies and regulations because these cross over into every area of healthcare from the bedside to the business office.
Healthcare Technology Applications
Patient care is complex, and physicians have developed workflows over decades to maintain records of treatment plans and care. Consequently, the implementation of the electronic health record in U.S. healthcare has not been easy. During the early years of transition, the introduction of technology into the day-to-day life of a physician was disruptive, but the potential to introduce a wide variety of applications could not be overlooked. In particular, the EHR was seen as a tool that could be applied in several key areas:
Standardization and evidence-based care.
Communication across the healthcare continuum, including between patients and providers.
Electronic prescribing of medications and tests.
Control of medical costs.
Reduction of medical errors.
With these applications in mind, the Centers for Medicare & Medicaid Services (CMS) instituted an EHR incentive program known as Meaningful Use. The program was introduced in 2009 as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act. Initially, physicians were given incentives to “get on the train.” Over time, penalties and payments have been linked to the use of technology. The program is now called Promoting Interoperability and requires providers to show that they are using certified EHR technology to ensure quality care.
Without a doubt, there have been tremendous advances since 2009, but it is beyond the scope of this article to provide a detailed summary of that journey. In light of some of the noted benefits, it is important to discuss two major barriers to success: the cost of the technology and the impact on physician workflow and job satisfaction.
Regarding cost, the leading vendors in the EHR space are quite different, but there is one area where they are consistent. Depending on size and scope, the cost to implement and maintain an EHR can range from several million dollars to hundreds of millions of dollars.
As great as the cost of equipment and implementation might be, the cost can be greater when it comes to physician engagement and job satisfaction. A National Academy of Medicine report estimated that more than 50% of the typical workday of a doctor or a nurse is devoted to “treating the screen” rather than the patient.(1)
Many studies reveal that EHRs have been cited as a leading cause of physician burnout.(2) Researchers at Mount Sinai Health System studied the impact of so-called “pajama time” (time working on medical records at home), and their findings suggested that more than 90 minutes on an EHR outside of the typical workday was associated with burnout.(3)
There have been improvements over time, however.(4) There is no doubt progress is being made and artificial intelligence may be a key factor in reducing pajama time as well as onerous “scribing” during patient visits.(5)
Technology Lifecycles
Like other technology tools, EHRs have a technology lifecycle. The early challenges of efficient EHR system development and physician adoption have been replaced by maintaining and optimizing them. In 2021, the National Center for Health Statistics reported that 88.2% of office-based physicians were using any EHR system and 77.8% of these systems were certified.
The challenge we face today is developing an evaluation framework for EHR-integrated innovations to support evaluation activities at each of the four information technology lifecycle phases: planning, development, implementation, and operation. Informaticists at the University of Utah and UC San Diego have proposed an evaluation framework called ELICIT — evaluation in life cycle of IT.(6) The detailed framework covers the four lifecycle phases with a focus on three measure levels: society, end-user, and IT. The developers of ELICIT present their tool as just one option but stress the fact that as healthcare evolves and technology improves, there will be a need for evaluation of these systems.
As tools are developed to collect data, we risk drowning in a sea of too much information. Providers complain that they receive pages of extraneous data regarding their patients that can hide the information they need to provide optimal treatment. In a similar manner, the evaluation of the lifecycle of IT depends on randomized controlled studies or RCTs.(7) There needs to be a careful review of data as well as consistent evaluation of the tools to collect data. Data are not limited to provider’s notes or hospital-based summaries, and there are now a wide variety of tools used to collect information. The advances seen in wearable devices used for real-time health monitoring and their linkage to the patient health record adds to data that can affect clinical decision-making.(8,9)
By definition, a lifecycle is “the series of changes in the life of an organism.” In the past, it may have been considered a liberal use of the term “lifecycle” when it was applied to technology. The emergence of generative artificial intelligence is making the term much more applicable.
Artificial intelligence (AI) has the potential to fundamentally transform the practice of medicine and the delivery of healthcare.(10) As generative AI is introduced into physician practices, it is opening the door for doctors to spend more time with their patients. There are concerns, however, that some day AI may replace physicians.(11) AI has the potential to transform medicine but serves as an example of the need to monitor the ever-changing lifecycle of information technology.
Technology Policies and Regulations
Today, the EHR is highly regulated, but it was not always that way. In the early 1960s, the Mayo Clinic, Massachusetts General Hospital, and several other academic inpatient and outpatient medical facilities developed primitive EHRs. Billing and scheduling systems such as COSTAR and PROMIS were developed.(12) At the time, there was a need for large mainframe computers with limited storage. Even at this early stage, it was apparent there would ultimately be a need for clinical support.(13)
The early years of the EHR provide a glimpse at the ingenuity of the pioneers in this area. A review of the literature also reveals a recognition that there was a need for standardization as well as some sort of regulation related to the tools being developed.(14-16)
By the 1990s, paper records clearly needed to be replaced, but the transition to electronic medical records appeared cost-prohibitive, and there were many who felt the best-case scenario would be to use electronic records to “complement and not replace” the paper record.(17) From the earliest stages, the electronic health record was seen as a complex web of data — data that needed to be extracted in an organized fashion. Furthermore, the exchange of data needed to be efficient, and this required standards to be implemented.
As early as 1992, Health Level Seven (HL7) was being used by both homegrown and larger vendors.(18) As advances continued and the personal computer became an integral part of the workplace (and home), the expectations grew. Information was being shared from labs, medical devices, and the ambulatory setting. As technology improved, there were additional needs such as picture archiving and communication systems (PACS).(19) By the turn of the century, it became apparent that technology policies and regulations were required.
After years of discussion and debate, funding for the conversion from paper records to the electronic health record was secured as a provision of the 2009 American Recovery and Reinvestment Act (ARRA). Shortly after, CMS adopted what has been called “The Final Rule” on July 28, 2010. According to the document, there would be incentive payments to eligible professionals (EPs), eligible hospitals and critical access hospitals (CAHs) participating in Medicare and Medicaid programs that adopt and successfully demonstrate meaningful use of certified electronic health record (EHR) technology.
This final rule specifies the initial criteria EPs, eligible hospitals, and CAHs must meet to qualify for an incentive payment; calculation of the incentive payment amounts; payment adjustments under Medicare for covered professional services and inpatient hospital services provided by EPs, eligible hospitals and CAHs failing to demonstrate meaningful use of certified EHR technology; and other program participation requirements.
Also, the Office of the National Coordinator for Health Information Technology (ONC) will be issuing a closely related final rule that specifies the Secretary’s adoption of an initial set of standards, implementation, specifications, and certification criteria for electronic health records. ONC has also issued a separate final rule on the establishment of certification programs for health information technology.”(20,21)
Regarding the use of the EHR, many of the recommendations, guidelines, and rules are authorized by the Health Information Technology for Economic and Clinical Health (HITECH) Act. This federal law that promotes the use of health information technology was originally passed in 2009 as part of the American Recovery and Reinvestment Act.(22)
HITECH established the Office of the National Coordinator for Health Information Technology, and the Congressional Research Service provided a document on March 17, 2023, that detailed focus areas of ONC.(23) These focus areas include interoperability, trusted exchange, United States core data for interoperability, health IT certification program, information blocking, health information exchange, and a Health Information Technology Advisory Committee. ONC often works in conjunction with CMS to manage these focus areas.
Social Media Trends
There was a time when a patient’s medical record was kept in a chart stored in a doctor’s office. In the 1950s and 1960s, a general practitioner kept notes on an index card. In the 1970s, internist Lawrence Reed developed the SOAP note (subjective/objective/assessment/plan). Today, he is known as the father of the problem-oriented medical record.(24)
Reed also was an early adopter of primitive electronic health records. In addition to a focus on problem-oriented medical care, he was one of a growing number of physicians who advocated not only informing patients about their personal health issues, but also encouraging them to play an active role in their care.(25,26)
Patients had very limited access to their personal records in the paper world. Now, patients view health information in real time through a personal patient portal. The federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) sets standards for medical records and personal health information (PHI). Leaders in healthcare need to know these fundamental rules, and most health organizations have guidelines in place, but the world of social media presents a near and present danger for those involved in healthcare.
Healthcare leaders are obligated to maintain the privacy of patient information while ensuring trust in the medical profession and establishing appropriate boundaries.(27) In addition, connectivity need not come at the expense of professionalism.(28)
The American Medical Association does not pull any punches in their Code of Medical Ethics when it comes to the use of social media:(29)
“When using the Internet for social networking, physicians should use privacy settings to safeguard personal information and content to the extent possible, but should realize that privacy settings are not absolute and that once on the Internet, content is likely there permanently. Thus, physicians should routinely monitor their own Internet presence to ensure that the personal and professional information on their own sites and, to the extent possible, content posted about them by others, is accurate and appropriate.”
Three crucial points physician leaders and administrative leaders who offer clinical guidance to providers should abide by are:
Do not use social media to give advice to individual patients. This should be provided in the exam room, by telephone, and/or through the patient portal.
Never share patient information or photos.
Do not attempt to change online patient reviews or use friends and family to improve results.
The final point is in response to physicians and healthcare organizations who are being reviewed on social media sites. If someone on social media provides a negative review, it should be taken seriously and objectively analyzed. The reviewer should not be challenged, and the content should not be altered in any way.
The top social media platforms in the United States are always in flux; the percentage of users for each can vary from month to month. At the time of this writing, Facebook, YouTube, and Instagram are the top three social media sites. X/Twitter and LinkedIn are still popular but have seen declines.
Social media sites also vary by the age of the consumer. For instance, Facebook is the most popular social media platform for people over 28, but TikTok is Gen Z’s favorite.(30) It is important to not focus on specific social media sites when providing leadership. Rather, focus on organizational policies.
Everything posted on the internet is accessible forever and it is discoverable in a legal environment; thus, social media content has been used in malpractice cases.(31) The present use of social media has been compared to use of private investigators in years past. There is little debate that the rapid emergence and exploding usage of online social media networking forums are frequented by millions and present clinicians with new ethical and professional challenges.(32)
Some of the advantages of a social media presence are connectivity, image building, information sharing, and keeping up with the competition. The warnings and concerns shared in this article are designed to inform leaders about the need to avoid critical errors but should not discourage them from using these tools to build a brand, educate patients and the public, publicize research, and potentially attract patients.
Excerpted from Healthcare Administration, Leadership, and Management (HALM): The Essentials First Edition edited by Daniel A. Handel, MD, MBA, MPH, CPE.
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