Pew Issues Comments on ONC’s HIT Burden Reduction Strategy

In new comments to the Office of the National Coordinator for Health IT (ONC), the Pew Charitable Trusts stated that two key EHR (electronic health record) challenges—system usability and ineffective exchange of health data—can also introduce patient safety problems and hinder the coordination of care.

In late November, the Department of Health and Human Services (HHS) issued a federal draft strategy designed to help reduce administrative and regulatory burden on clinicians caused by technology such as EHRs. The draft strategy, which is 74 pages, was developed by the health IT arm of the federal government—the ONC—in partnership with the Centers for Medicare & Medicaid Services (CMS), and was required in the 21st Century Cures Act.

Based on the input received by ONC and CMS, the draft strategy outlined three overarching goals designed to reduce clinician burden:

1. Reduce the effort and time required to record health information in EHRs for clinicians;

2. Reduce the effort and time required to meet regulatory reporting requirements for clinicians, hospitals, and health care organizations; and

3. Improve the functionality and intuitiveness (ease of use) of EHRs.

Stakeholders were encouraged to comment on the document up until January 28. Pew—a research and policy organization with a number of initiatives focused on improving the quality and safety of patient care—noted in its comments that ONC, through several policies under development, can take steps to address the core EHR challenges of poor system usability and the lack of quality health data exchange.

According to Pew’s Ben Moscovitch, project director, health IT, “usability challenges can arise from the implementation, customization, layout, use, and maintenance of the EHR system. These same factors can also contribute to medical errors—such as patients receiving the wrong dose of a drug.”

Pew agrees with ONC that principles such as considering workflows in healthcare facilities and engaging with end users—such a physicians and nurses—throughout the development and implementation of IT systems can help developers and facilities understand how clinicians use EHRs and when workarounds are initiated to address design deficiencies. And, testing EHRs throughout their lifecycle, by using rigorous test cases can help detect issues that frustrate clinicians, while also detecting those that contribute to patient safety problems, according to Pew.

Meanwhile, the comments noted that two provisions in the Cures Act afford ONC the opportunity to improve reduce clinician burden and improve safety via enhanced usability: the development of a reporting program on EHR functions and the establishment of new voluntary criteria for technology used in the care of children. In both of these situations, ONC should focus on the safety and usability of EHRs, Pew’s letter stated.

What’s more, the comments noted that ONC’s draft strategy highlights how application programming interfaces (APIs)—software tools that enable data extraction from EHRs—can enhance the sharing of patient information. “Forthcoming ONC regulations should ensure that EHRs make data available via APIs in an effective and efficient way—which would reduce burdens on clinicians while also equipping health,” Moscovitch said.

He further expressed optimism on APIs—particularly those that leverage the Fast Healthcare Interoperability Resources (FHIR) standard—which enable health technologies to extract only the information needed. “For example, FHIR-based APIs can enable clinicians to access patients’ medication lists without having to also receive every blood pressure reading or laboratory result in individuals’ records. As a result, these APIs can reduce clinician burden when using EHRs, but only if the interfaces are effectively implemented,” he said.

As such, as ONC develops regulations for EHRs to include APIs that allow access to and extraction of “all data elements” in patients’ records “without special effort,” a provision referred to as “open APIs,” the agency should take several steps to ensure that these interfaces enable the effective exchange of information:

1. These APIs should support the exchange of more data from EHRs than currently enabled—beyond Common Clinical Data Set (CCDS), which, according to Pew, contains some information, such as medication lists, but lacks other needed data—including clinical notes.
2. ONC should ensure that these APIs support access to individual data elements without requiring clinicians to receive the entire patient record. Use of the FHIR standard can enable this type of access, Pew believes.
3. ONC should ensure that data are exchanged even when not documented in a widely used terminology, such the Logical Observation Identifiers Names and Codes or Systematized Nomenclature of Medicine–Clinical Terms standards.