Optimization of Electronic Health Record Usability Through a Department-Led Quality Improvement Process

Abstract

BACKGROUND Electronic health records (EHR) have become commonplace in medicine. A disconnect between developers and users while creating the interface often fails to create a product that captures clinical workflow and issues become apparent with implementation. Optimization allows collaboration of clinicians and informaticists after implementation, but documentation of success has only been at the institutional level.METHODS A 4-month, department-wide EHR optimization was conducted with information technology (IT). Optimizations were developed from an intensive quality improvement process involving all levels of clinicians and clinical staff. The optimizations were then categorized as accommodations (department adjusted workflow to EHR), creations (IT developed new workflows within EHR), discoveries (department found workflows within EHR), and modifications (IT changed workflows within EHR). Departmental productivity, defined as number of visits, charges, and payments, was standardized to ratios prior to COVID-19 and evaluated by Taylor's change point analysis. Significant improvements were defined as shifts (change points), trends (5 or more consecutive values above/below the mean), and values outside 95% CIs. RESULTSThe 124 optimizations were categorized as 43 accommodations, 13 creations, 54 discoveries, and 14 modifications. Productivity ratios of monthly charges (0.74 to 1.28) and payments (0.83 to 1.58) significantly improved with the optimization efforts. Monthly visit ratios increased (0.65 to 0.98) but did not change significantly.CONCLUSION Departmental collaboration with organizational IT for EHR optimization focused on detailed analysis of how workflows can impact productivity. Discovery optimization predominance indicates many solutions to EHR usability problems were already in the system. A large proportion of accommodation optimizations reinforced the need for better developer-user collaboration before implementation.

Friend or Foe? Helping Health Care Leadership Reimagine a Healthy EHR Relationship

“…5 It is a tired cliché for clinicians to despondently remark that EHRs are for billing and not patient care.Considering these challenges, the work by Franks et al is crucial, showing a light at the end of the tunnel and offering hospitals a map to find it. 6 With only 4 one-hour meetings, the authors describe a process by which 8 interdisciplinary teams generated over 120 recommendations that were able to be actioned over the project timeline. 6 Critically, as the authors themselves note, nearly 80% of their optimization recommendations did not require IT investment and 35% involved purely non-technical workarounds.…”

“…6 With only 4 one-hour meetings, the authors describe a process by which 8 interdisciplinary teams generated over 120 recommendations that were able to be actioned over the project timeline. 6 Critically, as the authors themselves note, nearly 80% of their optimization recommendations did not require IT investment and 35% involved purely non-technical workarounds. 6 Put differently, over 65% of optimizations could be delivered by modifying…”

“…6 Most shockingly, almost one-half (44%) of optimizations required no technical investment at all but rather education about existing technology. 6 Finally, as Frank and colleagues underscored, these optimizations were designed and rolled out solely at a departmental level, without broader organizational buy-in or workflow interruption. 6 While we are optimistic about these findings, there are several caveats.…”

“…6 Finally, as Frank and colleagues underscored, these optimizations were designed and rolled out solely at a departmental level, without broader organizational buy-in or workflow interruption. 6 While we are optimistic about these findings, there are several caveats. First, the authors' optimization work was influenced by the COVID-19 pandemic, potentially minimizing the impact of their interventions.…”

“…As Franks et al observe, many of the optimizations devised over the course of the study could have been designed before implementation had there been better collaboration between EHR designers and clinical users. 6 A critical need exists for a workforce fluent in both clinical medicine and technology, capable of understanding clinical needs and effectively communicating them to IT staff. The closest current roles are the so-called EHR "superusers."…”