Measurement and automation of workflows for improved clinician interaction: upgrading EHRs for 21st century healthcare value

In this editorial, we highlight 5 manuscripts that address aspects of clinician interaction with the electronic health record (EHR). A Perspective describes the efforts of the Office of the National Coordinator for Health Information Technology (ONC) in establishing priorities for workflow automation in healthcare settings.¹ A second Perspective summarizes a panel sponsored by the American College of Medical Informatics (ACMI) at the 2021 AMIA Symposium that examined a provocative question: Are EHRs dumbing down clinicians?² Three manuscripts focus on what can be learned from EHR audit log data.^3–5

First, Zayas-Cabán et al¹ describe how the ONC led a multidisciplinary effort of stakeholders from industrial engineering, computer science, and finance to investigate automation in health care. They define automation as “the creation and application of technology to monitor and control the delivery of products and services.”⁶ The process of key informant interviews, focus groups, and a review of pertinent literature identified 6 priorities and their related strategies for advancing workflow automation. These priorities focused on leveraging high quality, interoperable data, and engaging clinicians in the EHR design, implementation, and evaluation processes. Then, relevant, and effective workflows could be identified that add value, not a burden, in clinician processes. The supporting strategies revolved around education, convening multiple interested parties, prioritizing appropriate workflows, and using policies and the market to incentivize automated solutions' development, testing, and evaluation. Examples of priority workflows for automation include reimbursement and prior authorizations, medication reconciliation, care management for newly diagnosed patients, and public health and adverse event reporting. The goal is to upgrade EHR technology to increase efficiency, improve health outcomes, and deliver more value for patients, caregivers, clinicians, and staff involved in healthcare. These priorities and strategies provide some solutions to the inadequacies of EHRs as outlined by Melton et al.²

Melton and other ACMI panelists² discussed the unintended consequences⁷ of EHR use that have led to impaired care delivery and reduced clinician efficiencies, reasoning abilities, and knowledge. The authors identified myriad ways that clinician notes and patient information is obscured through a confusing obstacle course of categorized EHR entries, menus, and flowsheets that lack the details originally found in clinician paper documentation. Clinician reliance on EHR clinical decision support and alerts has led to errors of commission and omission when they don’t integrate their expertise into the decision-making process. In one large healthcare organization, nurses’ documentation over a 3-month period had 739 000 interruptive EHR alerts (stopped their workflow until response entered), with only 4% being valid and nurses performed from 400 to 500 clicks with a new patient admission.⁸ Considering these unintended consequences, the authors also presented potential future solutions for EHRs in 4 categories: (1) institutional and end-user readiness and competency, (2) EHR design and capabilities, (3) regulatory policies and closer healthcare system-vendor partnerships, and (4) decoupling clinical documentation from billing and regulatory requirements so that clinical notes contain only that information necessary to care for the patient.⁹ For these improvements to happen, the authors emphasize collaborative multidisciplinary work such as a so-called “Getting Rid of the Stupid Stuff in the EHR” crowd-sourcing initiative¹⁰ and better measurement of “real-time human-computer interaction factors.” One mode of collecting these measures is using EHR audit logs, as discussed in the following highlighted manuscripts.^3–5

EHR audit logs capture a time sequence of clinician interactions with the EHR and have been used in examine topics such as documentation burden and influence of EHR proficiency tools on documentation time.^9,11 In an update of a previous scoping review,¹² Rule et al³ compared the aims, measures, methods, limitations, and scope of studies (2019–2021) that employed vendor-derived and investigator-derived measures of EHR use and assessed the consistency of measures across studies. Of 102 studies, more used investigator-derived measures (n = 61) than vendor-derived measures (n = 40) with one study using both. As compared to studies that used investigator-derived measures, studies employing vendor-derived measures were statistically more likely to focus only on ambulatory care settings, include only physicians and advanced practice providers, and measure durations of EHR for different activities. The review identified multiple weaknesses across studies including poor validation of measures, inconsistent measure definitions, and significant differences between studies that employ vendor-derived versus investigator-derived measures.

In a Perspective, Kannampallil and Adler-Milstein draw upon the Review by Rule et al.³ and their own work and insights to argue that there is a need to overcome current challenges in EHR audit log-based measures and advance progress toward measures that are: (1) transparent and validated, (2) standardized to allow for multisite studies, (3) sensitive to meaningful variability, (4) broader in scope to capture key aspects of clinical work including teamwork and coordination, and (5) linked to patient and clinical outcomes.⁴ They recommend 2 strategies to achieve standardized measures for future inclusion in the United States Core Data Set for Interoperability. First, they recommend creation of a public repository for disseminating existing audit log measures and underlying source code as the foundation for understanding and reconciling meaningful differences. Second, they recommend that vendors and investigators use the repository to implement and replicate the measures to build a practice-based foundation for United States Core Data Set for Interoperability standards for EHR audit log measures.

Consistent with Kannampallil and Adler-Milstein’s argument of the importance of EHR audit log measures that capture aspects of clinical work including teamwork and link to patient and clinical outcomes, Rose et al. conducted a multi-site study to determine if novel measures of contextual factors from EHR audit log data can explain variation in clinical process outcomes.⁵ Using the process outcome of emergency department-based team time to deliver tissue plasminogen activator (tPA) to patients with acute ischemic stroke (AIS) (n = 3052), they examined the relationships between audit-log derived measures of treatment team busyness and experience, and door-to-needle time (DNT) for delivery of tPA. Teams with greater prior experience on AIS cases had shorter DNT (minutes) across all sites. However, team busyness was not consistently associated with DNT across study sites. These findings document the novel use of EHR audit log data to measure contextual factors relevant to a clinical process outcome.

The relationship between technology and clinician burnout has gain national attention. The 2019 National Academies consensus study, Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being, highlighted the influence of technology that hinders rather than supports patient care on clinician burnout.¹³ The resulting recommendations included “Optimize the use of health information technologies to support clinicians in providing high-quality patient care.” The highlighted manuscripts in this issue provide guidance to do just that. Zayas-Cabán et al. identified multiple priorities for improving workflow automation including clinician engagement with a variety of tools and Melton and colleagues identified potential solutions to support clinicians to work smarter to provide safe high-value care. Standardization of EHR log audit measures as advocated by Kannampallil and Adler-Milstein will enable evaluation of changes in workflow automation and EHR solutions on care as well as examination of relationships with clinician well-being.

AUTHOR CONTRIBUTIONS

SB and CB conceptualized and drafted the Editorial.

Conflict of interest statement

None declared.