Primary Care–Leading the HIT Revolution, Part II: Listening to Clinicians

The Institute of Medicine report on the computer-based patient record (CPR) described two types of application users: primary and secondary (1). Primary users are those involved in direct patient care. Secondary users make use of the data captured or generated by primary users. Obviously, the two groups have different views of what constitutes a “good” system.

Primary users want systems that are easy to use and that help them in some measurable way. A system that enables a primary user to do more work in the same time interval without compromising quality would be considered a good system. Likewise, systems that make it easier to meet regulatory/legal requirements or increase income would be considered good systems. Secondary users, being interested in analysis, are more concerned about how well systems capture, store, and export data.

When it comes to designing clinical systems, primary and secondary users see things differently, which is why it is so absolutely wonderful when clinicians involved in direct patient care take a turn at clinical care system design.   Over the last two years, three excellent papers have appeared that discuss functionality from the clinician’s perspective. The information they contain is worth much more than their weight in gold.

One of the most difficult aspects of software design is collecting requirements.   For complex systems, this is particularly difficult because rarely are there pre-existing examples to draw from–the initial requirements are often little more than wish lists.   The problem with wish lists is that often people dream up things they do not need and leave out critical functions. After all, how can one know what is really needed absent any prior experience?   What makes these three papers so valuable is that they represent the comments and inputs from clinicians who are engaged in clinical care AND who have used EHR systems enough to know what they hate and what they like. Even better, MU has forced clinicians to think about how they interact with systems—usability has become a casual conversation topic. MU has helped to morph clinicians into informed consumers of HIT, and that makes their opinions more focused and actionable.

The paper by Krist et al. (2) is a consensus statement from the American Academy of Family Physicians, American Academy of Pediatrics, American Board of Family Medicine, and the North American Primary Care Research Group.   Participating clinicians were drawn from a diverse group.

Initial work was carried out by the 43 members of the NAPCRG Health Information Technology (HIT) working group (primary care HIT leaders from 38 institutions internationally). Practicing clinicians were identified from four practice-based research networks and included family physicians (n=78), internists (n=16), pedia- tricians (n=18), mid-level providers (n=12), nurses (n=15), and informatics staff (n=9) from 15 states in urban, suburban, and rural communities. Participant consensus was sought during each step.

Primary care support needs were cross-referenced to MU Stage 1 and 2 objectives as well as to an IOM report on primary care (3).   The outcome was a series of functionality requests that make for a great start toward defining the features of a clinical care system for primary care.   For the sake of brevity, I will discuss only those requests related to two out of the seven IOM attributes: partnership with patients and integrated.

Primary care attribute: partnership with patients
Incorporate the patient’s perspective into EHRs
– Document issues that are important to the patient (e.g., patient goals, what life activities give meaning, what outcomes would be worse than death) – Allow prioritization of patient goals
– Capture and track the patient’s presenting complaint and symptoms as well as their evolution over time
– Allow patients to enter information into EHRs about their goals, values, beliefs, behaviors, and psychosocial factors

Support patient–clinician shared decision-making
– Identify who makes decisions, how decisions are made, and available social support
– Provide patients with educational material, decision aids, and value-assessment tools tailored to decision needs

Many of these functions sound like what used to be referred to as a “personal health record.” However, that thinking presumes an application that lives outside the EHR. Instead, what is being requested is an integrated system that patients can access as readily as clinicians. This functionality set mirrors the CPC+ Track 2 requirement regarding tracking outcomes and tying them to care plans (4).   Notice the number of times “tracking” is requested. Tracking is nothing more than following processes over time. What is being requested, essentially, is a virtual timeline of the patient that can be consulted and updated by both clinician and patient so that an intimate picture of the patient –his/her story–is captured.   Such a timeline is very much in opposition to the patient “snapshots” that exist in paper records and current EHR systems.

Primary care attribute: integrated
Integrate care settings
– Support the integration of clinical care and mental health – Support the integration of clinical care and public health

Support the individual needs of practices
– Allow for local tailoring of content, display, and functionality while maintaining necessary standardization – Embed functionality and tools for continuing medical education and maintenance of certification

Support national health recommendations and priorities
– Ensure that patient health information is collected with adequate detail to support national guidelines – Integrate national guidelines into the EHR
– Supply clinicians and patients with timely prompts to support care

Allow population management
– Provide tools to track patient population health, adjusted for illness severity, and nationally/regionally benchmarked – Provide tools to identify and reach out to patients overdue for care
– Include bidirectional flow of information to and from public health, cancer, immunization, and specialized registries – Integrate local and national benchmarking into outcomes reports

Promote accountability for care
– Document important outcomes to patients and public health entities
– Allow information sharing and collaboration with population health partners

Within this function set are nods to population health management, tracking, and the ability to adjust the system to local users.   One also gets a view of which processes clinicians think deserve support. Integration of mental and public health information makes the patient’s full health state easier to assess and share. Note the request for prompts for care interventions.   As with all attributes mentioned in the paper, processes are just as important as data.

In looking at the remaining papers, one is reassured to see similar functionality requests across groups.   O’Malley et al. looked at the problem of coordinating clinical work among clinicians (5). The researchers set out to determine how EHR systems help or hinder work among primary care teams. Here is a recounting of their methods.

Practices in this qualitative study were selected from those recognized as patient-centered medical homes via the National Committee for Quality Assurance 2011 tool, which included a section on practice teamwork. We interviewed 63 respondents, ranging from physicians to front-desk staff, from 27 primary care practices ranging in size, type, geography, and population size.

The results reflect the feature set of current EHR products.

EHRs were found to facilitate communication and task delegation in primary care teams through instant messaging, task management software, and the ability to create evidence-based templates for symptom-specific data collection from patients by medical assistants and nurses (which can offload work from physicians). Areas where respondents felt that electronic medical record EHR functionalities were weakest and posed challenges to teamwork included the lack of integrated care manager software and care plans in EHRs, poor practice registry functionality and interoperability, and inadequate ease of tracking patient data in the EHR over time.

Here are the specific suggestions offered by participants.

1) Ensure the EHR includes a clinically useful practice patient registry or integrates seamlessly with the practice’s registry.

2) Create functionalities to permit easy tracking of an individual patient over time (e.g., prior hospitalizations).

3) Create functionalities to permit tracking of population subgroups over time.

4) Build care management software into the EHR or ensure seamless communication between such software and the EHR.

5) Create a clear place for care plans in the EHR to include agreed upon goals, steps to reach those goals, as well as changes in the care plan over time, as the patients’ needs change.

6) Ensure EHRs permit the creation of a huddle sheets and pre-visit planning tools that can be populated with important patient data (eg, medications, problem list).

When compared with the Krist paper, the similarities are clear and consistent–tracking functions, registries, and integrated care plans are common to both.   Primary care requires that one keep all the plates spinning, and, for that, process support is essential. More data alone is not the answer.

Finally, let’s look at the Sinsky paper (6). The authors state their findings grew out of 100 presentations and shadowing 50 clinicians. Their findings are offered under the rubric of “Principles of EHR Design, Implementation, and Policy.”

Patient-centered design
The use of an EHR should add value for the patient.
The primary function of an EHR is clinical care.

Health care professionals
The use of an EHR should improve, or at a minimum not reduce, the well-being of health care workers.
The use of an EHR should align the work with the training of the worker.
The EHR is a shared information platform for individual and population health.

The use of an EHR should minimize waste.
Electronic workflows should align with clinical work.
Various methods of communication, including non-electronic forms, will be necessary for optimal patient care.

Regulation and payment
Sufficient resources should be available for the new work associated with the advanced use of an EHR.
Policies around EHR use should reflect the strength of the evidence base supporting them.
Regulatory balance between often competing values (i.e., clinical quality vs. security or efficiency vs. performance measurement) should be sought.

Once again, specific themes are evident. EHR systems should support clinical processes through better alignment with clinical workflows. Patients should have access to EHR systems not only for reading, but also for communicating as well.   There is also a request for systems that improve efficiency, not systems that generate more work.

The primary users of EHR systems are speaking out. They want systems that make them more productive through better communication with colleagues and with patients. They want help in managing patients over time with support for user-defined prompts, population health features, and care plans.   The challenge for the designer is turning these feature requests into working systems.

Clinicians want help managing processes. Who needs an appointment? Who was just discharged? How is the patient with the back pain recovering? Is the patient who was depressed doing better? Tracking a population of patients over time and coordinating care with everyone who supports or provides services to those patients is time-consuming, stressful, and poorly reimbursed. There is a reason burnout has become a hot topic among clinicians.

No, HIT alone cannot solve all the care delivery issues peculiar to primary care, but, properly designed, HIT can make practice more productive and less stressful. The key, of course, is that clinical care systems must be designed for those who are taking care of patients–FIRST.   When that principle is ignored, you get what we have now—EHR systems designed to collect and display data, not clinical care systems that assist with clinical work. Clinicians are speaking out; will EHR designers listen?

  1. Dick RS, Steen EB (eds). Institute of Medicine:The computer-based patient record: an essential technology for health care. Washington DC: National Academy Press, 1991.
  1. Krist AH, Beasley JW, Crosson JC, Kibbe DC, et al.Electronic health record functionality needed to better support primary care. J Am Med Inform Assoc. 2014 Sep-Oct;21(5):764-71.
  1. Donaldson MS, Yordy KD, Lohr KN, et al. Primary Care: America’s Health in a New Era. Washington, DC: National Academy Press, 1996.
  1. The Centers for Medicare and Medicaid Services. Comprehensive Primary Care Plus, Request for Application. April, 2016
  1. O’Malley AS, Draper K, Gourevitch R, Cross DA, Scholle SH. Electronic health records and support for primary care teamwork. J Am Med Inform Assoc. 2015 Mar;22(2):426-34.
  1. Sinsky CA, Beasley JW, Simmons GE, Baron RJ.Electronic health records: design, implementation, and policy for higher-value primary care. Ann Intern Med. 2014 May 20;160(10):727-8.

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