Neurology steering board effects change for a major electronic health record vendor

Abstract

Neurologists are among the least satisfied physicians with their current electronic health record (EHR), with many known pain points and great opportunities for improved tools and workflows. Improved EHR functionality can have major implications for patient care, physician efficiency, and prevention of burnout. We describe the advocacy of the American Academy of Neurology for improved EHR usability and the resultant formation and subsequent accomplishments of a Neurology Subspecialty Steering Board at 1 major EHR vendor (Epic).

The electronic health record (EHR) is essential to the practice of neurology. More than 94% of office-based neurologists used an EHR in 2015.¹ Other specialties such as orthopedics and urology have similar EHR use rates,¹ but neurologists may gain the least benefit in efficiency from EHR use. In a study of ambulatory care visits between 2010 and 2013,² neurologists who used EHRs had longer visit times than those who did not. EHR use is associated with lower physician satisfaction with clerical tasks and higher rates of burnout.³ This is even greater for neurologists.³ Optimal EHR use contributes to physician fulfillment, and EHR-centered metrics are incorporated in physician performance reviews by some major health systems.⁴

Many providers feel their EHR is a monolith that they cannot improve to better suit their needs. In a recent survey of US physicians, only a third of respondents reported that their organization or EHR vendor solicited their feedback.⁵ Physicians concerns are unheard, and dissatisfaction with the EHR is rampant. However, efforts are under way by some EHR vendors to address these issues. This paper describes the formation and accomplishments of a Neurology Subspecialty Steering Board that advises 1 major EHR vendor (Epic). Epic staff was aware of the concept of this paper and provided data to the authors. Epic had no input on the manuscript's content.

Board origin, structure, and organization

The Practice Management and Technology (PMT) subcommittee of the Medical Economics and Management Committee of the American Academy of Neurology (AAN) exists to help Academy members use health information technology to enhance patient care and improve physician efficiency. PMT evolved as an entity which provided guidance around EHR implementation and associated regulatory measures to eventually combating burnout through optimizing the EHR for neurologists.

PMT began overtures to EHR vendors because Epic was increasing their focus on specialty development and was very amenable to feedback and advice from the AAN. Epic was perceived as the EHR least suited for use by neurologists and least responsive to their concerns, despite being the vendor used by most neurologists in the United States.⁶ The Neuroscience at Epic Clinician Group formed in 2013 with the goals of improved collaboration between the AAN (representing the interests of neurologists) and Epic, and an increase in neurology-specific content in Epic's Foundation system.

Initial recruitment for the group was informal with no minimum participation or AAN membership requirement. Monthly meetings followed agendas addressing known “pain points” experienced by neurologists using Epic. We were supported by volunteer Epic employees who scheduled the calls, helped craft the agenda, took minutes, and worked on software builds. By 2016, the group had 53 members from 27 health care systems, including international representation, and was working on projects such as improved neurologic critical care tools and EEG documentation workflows. We recruited additional subspecialty members for specific projects as the need arose. AAN membership was not a requirement for participation, although most of the physician participants were active AAN members.

In 2016, this group became the Adult and Pediatric Neurosciences Specialty Steering Boards (SSBs). Epic had formed the SSB program several years ago, populating them with providers with both clinical and EHR experience to partner and assist in developing the best practices for EHR use in their respective specialties. The program was rolled out slowly, with a few specialties joining each year. Epic cemented their commitment to the SSB with dedicated paid (no longer volunteer) staff resources. Epic SSBs have 12 physician members nominated by the Epic user community and Epic employees. Members serve staggered 2-year rotations (without term limits), with half the board up for re-election every year. Nominees vote their top 3 choices for chair, with this position going to the person who receives the most votes. Monthly meetings are mandatory with 2 absences allowed per year. Table 1 shows demographics of the initial Adult Neurosciences SSB. SSB membership is heavily weighted to academia (82% with academic affiliations). This reflects Epic's role as an EHR vendor used mainly by large academic health systems.

Table 1.

Epic neurosciences specialty steering board 2016–2018 term membership characteristics

The Neuroscience at Epic Clinician Group did not receive any compensation for their involvement. Epic SSBs members receive no reimbursement (financial or otherwise) for collaboration or intellectual work product outside of waiving registration fees for Epic User Group meetings where the SSB convenes. The AAN and the Neurosciences Epic SSBs do not have a formalized relationship; there is no requirement for SSB members to belong to AAN or PMT members to sit on the SSB. However, AAN committees and SSB overlap considerably. The current chair of the adult neuroscience board is the chair of PMT, and the chair of the inaugural pediatric board was the vice-chair of the Quality and Safety Subcommittee. Although the AAN does not formally set SSB goals or priorities, shared leadership aids in alignment of the SSB's key goals and priorities with those of the AAN. Of note, a minority of current PMT members use Epic, and the SSBs in no way drive any of the priorities of PMT or other AAN committees. A vision and goals statement was drafted when the board was first formed (appendix e-1, links.lww.com/CPJ/A100).

Board achievements

The Neurosciences Epic SSB has pursued EHR optimization for neurologists by prioritizing and guiding implementation of tool development to benefit neurologists in their daily practice, with the intent of serving the broadest needs first. The most prominent among these projects was the redesign of the default neurologic examination as an easy-to-use interface capturing key information a general neurologist needs during an initial patient visit.

The SSB had several goals: consistency of data acquisition across practitioners, creating a platform for quality improvement, and facilitating data sharing between individuals and institutions. Additional benefits include avoiding underbilling from insufficient category documentation⁷ and overbilling by documenting examination components not actually performed. Discrete capture of neurologic examination components would also improve the quality of data research.⁸ The neurologic examination documentation project lasted from 2015 to 2017 and led to the foundational build incorporated into Epic's current 2018 update. The design was accomplished through bimonthly evening web conferences with the Epic neurosciences build team and 2 board volunteers.

The SSB has completed projects improving stroke data capture, botulinum toxin injection documentation, and dementia coding. Table 2 depicts project status and origination, including canceled projects not deemed to have enough benefit to neurologists or patients. Projects still in development include facilitation of data acquisition by the AAN's Axon Registry. The Axon Registry may improve neurologic care by capturing adherence to national quality guidelines, where the SSB can serve a critical liaison role between the AAN and Epic.

Table 2.

Epic neurosciences specialty steering board projects—active, completed, and canceled

Future directions/Conclusions

Optimization of the EHR is of paramount importance to neurologists and their patients. Standardized work flows and documentation tools with embedded quality measures that conform to practice guidelines can help ensure neurologists provide high-quality, efficient care. Partnering with EHR vendors combines vendor's technical expertise with neurologist's knowledge of our clinical needs to build tools that can effect change on a broad scale. Ultimately, when neurologists are using similar tools and documenting similar clinical content, any resulting data will have greater generalizability in future research endeavors.

The authors acknowledge limitations of the work of the steering board and the ability to assess the consequences for neurologists. Enhancements designed by the SSB and incorporated into the Epic Foundation may be rolled out to end users at times particular to their institution, resulting in variability in time from the completion of a project by the SSB to when a particular tool is available to practicing neurologists.

Furthermore, we recognize that documentation in the EHR will evolve over time. Tools built today may be inadequate in the future, but by becoming partners with EHR vendors, neurologists will have a say in the direction of those future changes. We acknowledge that our initial efforts may have only modest effect on workflows but will hopefully improve neurologists' EHR user experience. Full implementation of new tools may take years, and formal outcomes studies on physician adoption rates or satisfaction will be the focus of future efforts.

The AAN has long encouraged neurologists to become involved in advocacy, whether locally or on a national level, with payers and policy makers. It is equally important that neurologists advocate with their EHR vendors. There may be a misperception that neurologists are not able to have a say in what large software companies do, but the creation and efforts of this steering board prove otherwise. PMT is actively attempting to replicate these efforts with other EHR vendors, such as Cerner, and encourages neurologists using other EHR platforms to work with their vendors to form similar steering boards. These various steering boards could then work together on common goals, expanding the influence of these groups. Only by pushing software developers to engage with neurologists can we hope to advance our goals of making the EHR a more clinically useful tool which promotes quality care while simultaneously improving efficiency, in turn resulting in increased physician well-being.

Author contributions

A.L. Weathers: study concept and design and drafting or revising the manuscript for intellectual content. I.U. Haq, D.M. Ficker, J.P. Ney, and S.L. Meyers: analysis and interpretation and drafting or revising the manuscript for intellectual content.

Study funding

No targeted funding reported.

Disclosure

A.L. Weathers receives honoraria for speaking from the AAN and for work as a question writer for Continuum. I.U. Haq receives salary support from NINDS R01NS058949, NINDS 1U24NS107197-01, and NIAA: P30 AG049638. He has performed research for Allergan, Boston Scientific, Great Lakes Neurotechnology, and Pfizer, and has consulted for Boston Scientific and Medtronic. J.P. Ney serves on the editorial board of Neurology: Clinical Practice and is a consultant for CeriBell, a medical device company, SpecialtyCare, a surgical services company, and JEM Research Institute. D.M. Ficker receives honoraria for speaking from Greenwich Biosciences and Lundbeck. He has received compensation for consulting from Best Doctors. S.L. Meyers reports no disclosures. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.