Electronic health records (EHRs) were supposed to usher in a golden age of improved care, efficiency, and safety in the USA, increasing patient engagement and even reducing health-care disparities. But these systems have complicated interdisciplinary communication and worsened clinician workloads, contributing to clinician burnout, and opportunities for error, researchers told The Lancet Respiratory Medicine. “Manufacturers told us EHRs would make our lives easier but when we counted the number of tasks and the time required, we found that a frighteningly large fraction of physicians' available time was consumed by EHR tasks”, said Craig M Lilly (University of Massachusetts Medical School, Worcester, MA, USA). “None of the available EHR systems are designed particularly for intensive care unit (ICU) use, so it's not surprising that they would not support critical care workflows very well”, he said. “Many of our providers are doing [EHR] paperwork at home after hours and working really unacceptable numbers of hours.”

The US Government has emphasised the meaningful use of EHR technology to improve quality of care through electronic prescribing, health information sharing, and documenting treatment outcomes. But EHR systems used in the USA were designed primarily with fee-for-service billing in mind rather than to help facilitate efficient workflows in particular clinical settings or to foster effective communication between specialists and the interprofessional team.

Information overload and EHR disorganisation are common resulting laments among clinicians. Medical chart notes were organised in a more formulaic and predictable manner in the paper era, noted Jennifer Thate (Siena College, Albany, NY, USA). With EHRs, there are multiple fields in which a particular piece of information might be entered, complicating quick retrieval. “One of the greatest challenges is that the initial EHR design was not focused on supporting interdisciplinary communication; instead it was focused on information capture and information access”, Thate said. “Now we have a record that has copious amounts of data and information and little evidence as to what information is most salient for important clinical decisions—and where to find this information.”

Nurse notes are predictive of patient outcomes, for example. Yet research has shown that this information is not regularly viewed, Thate noted. “There has been a lot of focus on having certified EHRs that enable us to capture data and share that data”, Thate explained. “We have just kept capturing and collecting data without a lot of thought about how those data support our daily work and how it supports how teams think, communicate, and make decisions. The focus has been more on long-term outcome measures and reimbursement, and incentivising value, which are important, but we're losing real-world value from the record in our daily practice.”

Efforts to build an empirical evidence base for better EHR design has been “pretty limited”, Thate said. “Just as you need evidence-based standards for treating a certain kind of cancer, we need evidence-based standards to guide how we use the EHR for clinical communication.” A recent analysis of 809 physicians' EHR logs found marked variation in descriptions of clinical results, assessment and diagnosis, patients' problem lists, and social histories. The authors concluded that such variation in EHR documentation “impedes effective and safe use of EHRs”. “Understanding how to optimise the EHR to leverage the knowledge captured in clinician's documentation has the potential to improve patient care and reduce adverse events”, Thate said.

In the future, machine learning natural-language processing might help pull relevant information to EHR dashboards as needed, Thate noted. But for the time being, heterogeneity of EHR documentation remains an important issue. Furthermore, deciding what information is relevant requires consensus building among the interprofessional team. A machine learning algorithm, relying on historical data, might not effectively determine what is relevant and result in bias. With EHRs, clinicians don't have to be physically near patients to review their records, Thate added. “We can look at the record from anywhere now”, she said. That's both a positive in terms of convenience but also a negative in terms of clinician disconnectedness, Thate believes. “The chart was a meeting place for us, before—like the water cooler at an office”, she said. “We all wanted to see the chart so we all ended up interfacing there and discussing a patient. But now you can access the patient record on almost any device from any location.”

EHR documentation time demands are another longstanding concern. A 2010 study found that hospital physicians in the USA spent 17% of their shifts on direct patient care and 34% of their time on electronic medical records, for example. Reviewing EHR workloads nearly a decade later, Lilly and colleagues found a “robust direct association” with ICU clinician burnout rates across specialties. “We found that there was an association between the increased amount of [EHR] paperwork by the number of words or pages by specialty, and specialty-specific increased rates of burnout over the intervals when EHRs were implemented”, Lilly said. The association between EHR workload and burnout was more pronounced in disciplines that had adopted streamlined documentation strategies in the pre-EHR era, Lilly noted. EHR notes are longer than those in the pre-EHR era, increasing opportunities for interruptions, the introduction of errors in patient records, and the failure to detect such errors. “They're much more likely to get disorganised”, Lilly said. The time demands of EHR documentation are “not particularly compatible” with clinical workflows, Lilly told The Lancet Respiratory Medicine. “Alarming numbers” of ICU clinicians are working at or near unsustainable workloads that can cause burnout, he believes.

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In theory, well designed EHRs should be able to facilitate interdisciplinary communication and collaboration. Clinicians can annotate one another's notes with questions or additional information, for example. In reality, however, that sort of flexibility fosters organisational inconsistency that can complicate information retrieval and create barriers to effective teamwork. EHR documentation actually leaves clinicians with less time to collaborate with one another, for one thing, Lilly noted. “I think the most important challenges impairing communication between teams in the ICU is that most ICU patients are being followed by numerous medical services, each of which can become solely focused on their specialty or focused organ system (ie, nephrology to the kidney, neurology to the brain), making the bigger picture more difficult to visualise”, said Robert J Anderson (Mayo Clinic, Rochester, MN, USA). “One of the major challenges is to bring all these multi-disciplinary teams together in a real-time fashion by a mechanism that will allow teams to make real-time decisions all together as compared with one team deciding after another team and leading to a ripple-effect.” But it can be difficult to use EHR systems to achieve cross-team consensus because different clinical teams document care in their own way, based on different scales and tools, Anderson said. “The role of the primary service's documentation is to bring all the independent services' input together in one single note or documentation to produce the most comprehensive snapshot of a patient at that time”, Anderson said. But that places the onus on the primary service to abstract consulting services information and recommendations into an EHR, and to include it in an easy-to-read format, he noted. Using standardised tools and metrics across services would streamline that process. “This would allow services all caring for one patient to ‘speak the same language’”, Anderson explained.

Interprofessional communication and collaboration are key to preventing health-care-associated infections, such as central line-associated bloodstream infections (CLABSIs), but little research is available on best practices for how best to communicate through EHRs, Thate noted. Thate and colleagues convened an expert panel of four physicians and six nurses to identify what information should be included in EHRs for central venous catheter management to prevent CLABSIs. The team identified information that must be reliably recorded and easily retrieved to prevent CLABSIs, including the location of the line and length of time the line is in place, the original circumstances for placement, the current circumstances requiring central access, and any issues associated with the existing line, Thate said.

EHR software developers do include clinicians on their teams, Thate acknowledged. “But I think there needs to be a tighter connection between clinicians and the vendors”, she said. “Oftentimes I'll see comments or papers stating that we need physicians to have more input into what's happening with the EHRs. I think that's shortsighted. It has to be interdisciplinary and interprofessional. “There has been an increased interest in developing dashboards or personalised views, but if interdisciplinary teams aren't deciding together what should be viewed, the efficacy of such views will be limited as it relates to interdisciplinary communication or communication among teams of disparate professional groups”, cautioned Thate. “We need evidence-based standards, derived from interprofessional consensus, for information sharing related to key adverse events. This includes interprofessional consensus on what information is needed as well as how and where this information should be shared through the EHR.”

Addressing EHR woes in clinical practice will require closer collaboration between clinicians and software developers to test usability in real-world settings, Lilly and Thate agreed. “Solutions will have to be collaborative and will require both EHR system changes and changes in clinical workflows”, Lilly said.

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