[00:30]
Hello, I’m Dr Sara Horst, and welcome to IBDIQ, part of The IBD Project by Takeda, where we’re coming together to help enhance expertise in IBD care—right from the start.
Thank you for joining me. Today, we will explore optimizing the electronic health record (or EHR). While the electronic medical record (or EMR) traditionally refers to a digital version of a patient’s chart in a single provider’s office, the EHR is designed for broader use—allowing real-time access to patient information and enhancing care coordination across healthcare providers and institutions.1
[01:11]
Let’s take a look at what we’ll cover today. First, we will examine some of the challenges associated with EHR use—especially the burden on healthcare professionals (or HCPs) and staff. Next, we’ll explore some of the tools and strategies to optimize EHR efficiency in inflammatory bowel disease (or IBD) care. And finally, we’ll propose a roadmap for improvement—one that can be tailored to individual practices or institutions.
Let’s begin by exploring the increase in use of the EHR in recent years and some of the challenges associated with it.
Use of telemedicine and the EHR has risen in the past decade, due in part to specific legislation calling for implementation of EHR technology to improve healthcare delivery and experience during the COVID-19 pandemic.2-5 This led to increased use of electronic communication options in healthcare.
[02:08]
Patient portals provide patients with secure access to their health information and enable electronic communication with providers.6 While these tools offer many benefits, they’ve also increased the complexity and volume of messages, adding to the communication workload for healthcare teams.4,7,8
One study reported the increase in patient-initiated messages resulting from the 21st Century Cures Act requiring immediate release of test results and notes.9
Immediate release of results to the patient portal led to an increase in the median number of messages sent by patients within 6 hours of reviewing a test. The results showed a near doubling of messages from 78 messages per day before Cures Act compliance to a median of 146 messages per day after implementation of immediate test release.
[03:00]
A study examining EHR functions during the COVID-19 pandemic between December 2019 and January 2021 found that the volume of average daily messages from patients to clinicians increased to 157% of the volume in pre-pandemic messages.4
Another study found that electronic messages increased immediately after the COVID-19 lockdown in March 2020 and then maintained an elevated rate through the post-COVID period through March 2021, with a 27% increase in the average daily number of inbox items relative to the pre-COVID period.5
Demands imposed on HCPs by the current EHR practices have been linked to physician burnout, loss of satisfaction, and lower quality of life.3,7,10-14
A 2023 study solicited EHR improvement ideas through electronic submissions in a large academic health system partnership involving more than 34,000 employees.15
[04:02]
Data from that study suggest that up to 50% of the perceived need for quality improvement in the use of EHR may be due to lack of understanding of current EHR features.7,15 Thus, a key approach for better use of the EHR is to improve education for providers and staff, helping them understand what EHR tools are available and suggesting how to incorporate them efficiently into their patient care practices.7
When looking at IBD specifically, on average, gastroenterologists spend approximately 45 minutes on EHR tasks for every hour of scheduled patient time.7,16
To gain a better understanding of the current challenges posed by increased EHR use, researchers conducted a survey of EHR practices among 46 physicians and other providers caring for patients with IBD throughout the US.17
When providers of IBD care, including physician and other healthcare team members, were asked about their areas of greatest dissatisfaction, 87% cited the amount of time spent in the EHR, 82% identified working on inbox messages, and 59% specified documentation tasks.17
[05:13]
In light of these concerns, EHR experts have sought practical solutions to alleviate the burden of EHR management.7 Several tools are available in the EHR that could enhance documentation, improve clinical workflows, and reduce the clinician burden in the overall management of patients with IBD.
Shown here is an array of EHR tools available to help increase workflow efficiency within systems such as Epic, which is the most widely adopted EHR system worldwide.7,18 We ‘ll describe a few of these in more detail here, but note that these tools can be categorized in terms of their use for a number of tasks, such as documentation, order management, message basket management, patient education and outcomes, chart review, or data reporting.18
[06:01]
A number of these tools, including SmartPhrases and note templates, can often be implemented directly by the providers.7,18 Other tools—such as SmartSets and Express Lanes—may require support from health information technology (or health IT) teams or additional training and advocacy.
As we now explore EHR optimization, we’ll focus on Epic-specific tools and functionalities.7
However, similar tools and resources are also available in other systems, such as Oracle Health and Meditech.
Most of the concepts described can be adapted to those platforms, with appropriate adjustments to terminology and workflows.
When considering EHR improvements, it’s advisable to consult with designated trainers or experts at your institution.
[06:48]
An important initiative in enhancing EHR use is to look for ways to standardize text components to help with post-visit summaries and other documentation tasks.7
This approach can be applied to the standardization of note templates, patient education materials, the use of patient-reported outcome questionnaires, and so-called dot phrases, known as SmartPhrases within the Epic system.7,19
Dot phrases or SmartPhrases are a resource for streamlining EHR workflow and consist of predefined text shortcuts for inserting data or text.7,19
These shortcuts typically consist of pre-formed content blocks that can be inserted by typing a period, followed by a short descriptive phrase.
Predefined text components such SmartPhrases can streamline charting by inserting standardized text into after-visit summaries, responses to patient questions, and patient education handouts.7
Such phrases can improve documentation efficiency while helping to maintain standardization and accuracy.7 The complexity is often low, allowing clinicians to build these predefined text items and share them with colleagues—without requiring health IT input.
[08:02]
Next, the use of order sets, which are named SmartSets in Epic, makes it possible to group several orders, such as a set of standard laboratory tests, under a single entry.7 The use of order sets may promote consistency in ordering practices and reduce errors. Please note that health IT assistance is typically required in implementing order set options in the EHR.
Additionally, the Express Lane functionality in Epic is a tool that can automatically call up order sets appropriate to the patient as needed, based on clinician prompts, such as a “reason for visit.”7
Overall, the EHR can be configured to help automate several other routine tasks that must be performed on a repetitive basis.20
For example, the development, editing, routing, and sending of appeal letters after an insurance denial are notable time-consuming efforts in the IBD clinic.20 Prior authorizations (or PAs) for biologic medications used to treat IBD are often denied and can require a complex appeals process for patients to gain access to their prescribed medication.
[09:10]
Now, let’s examine a specific workflow improvement using EHR tools to streamline the PA process in an IBD clinic setting.20
As formerly practiced at the study institution, the PA process involved as many as 6 steps for completion after a PA denial was received.20 The appeal letter was composed, then uploaded to the patient’s EHR chart, sent to the prescriber through the EHR messaging for review, edited and returned, then the appeal letter, last visit note, lab report, and imaging results were downloaded. Finally, the appeal letter and supporting documents were faxed to the insurance appeals department.
To evaluate the impact on specialty pharmacist workflow, researchers at the institution launched a quality improvement initiative using standardized appeal and clinical rationale letter templates within the EHR.20
[10:06]
An appeal letter template was built in the EHR by the patient care improvement pharmacist with oversight from the center’s health IT department.20 It included information commonly found in the EHR that could be incorporated in all appeals for inclusion in the letter template, such as the clinic logo and contact information, recent laboratory results, procedure notes, and the most recent clinic visit note.
Similarly, standardized clinical rationale letter content was created for the most common appeal reason seen in the center’s IBD clinic.20 The letters were medication-specific and highlighted the rationale and literature associated with the medication, the indication, and the prescribed dosage. The letters included EHR functionality that allowed the creation of standardized notes that could be customized at the time of use.
[10:58]
Using these innovations, the appeal letter process was reduced to 3 steps: The appeal letter is composed using the appeal letter template and standardized appeal content; the letter is routed to the prescriber for review and routed back to the specialty pharmacist, and finally, the appeal letter and supporting documents are faxed to the insurance appeals department.20
This quality improvement initiative examined 71 patients before implementation and 73 patients after implementation, with 73 appeals being made in each group.20
Before implementation, 29% of appeals were submitted within 3 days of the PA denial, 70% within 7 days, and 88% within 14 days.20
Post-implementation, submission was accelerated, with 89% of appeals submitted within 3 days (an increase from 29%), 97% within 7 days, and 100% within 14 days.20
Despite the difference in turnaround time for appeal, the approval rates were 93% in both groups.20 This implies that the workflow was successfully improved without lowering the quality of the appeals or the likelihood of approval.
[12:15]
Let’s consider another useful resource available in the EHR: the tracking of patient-reported outcomes (or PROs).
PROs can be obtained through the use of customizable questionnaires and surveys, sent via the EHR, which enables proactive monitoring of patient progress, early identification of potential issues, and tailoring of treatment plans for optimal outcomes.21
In IBD care, electronic PROs can alert the treatment teams about the changes in patient clinical status through inbox notifications, without direct patient-to-provider messaging.7 This approach is associated with substantial patient satisfaction, can reduce provider workflow, and can increase patient-centered care.7,22
[13:03]
There are many other enhancement possibilities within the EHR, and our time today allowed us to highlight only a few that are most applicable to creating efficiencies within your IBD care practice.7,18 In addition to the specific tools we’ve discussed, EHR systems may offer a variety of support options.
These options include community forums such as Epic UserWeb, an online repository of user support resources and user-to-user assistance; Potential resources also include centralized builds such as the Epic Foundation System, through which institutions can customize the basic platform based on specific institutional needs. National committee options such as Epic’s Specialty Steering Boards, enable representative experts to provide guidance in configuring the EHR system to meet the needs of an individual specialty.7,23-25
[14:03]
Tools such as Qorus, SmartSet, and other resources are available within Epic or other EHR systems and can be accessed with help from the institution or practice’s health IT team.7
How are enhancements implemented within the EHR at an individual practice or institution? Advocates of optimizing EHR use have outlined a potential EHR roadmap or optimization plan to help standardize and optimize EHR workflows.7 The key concept is the use of an IBD clinician champion in coordination with health IT experts to educate clinical staff and implement quality improvement initiatives.
The first step is a survey initiative to ask IBD clinicians about how EHRs are used at their practice or institution and to assess patterns of use.7
Next comes the education step.7 Health IT experts partner with a selected IBD clinician champion to review the EHR tools currently available at their site. That champion then helps educate fellow clinicians on the optimization tools in place and how to use them.
[15:17]
Educating to help providers and staff understand the current EHR tools available should include advocating for health IT changes, an important role for clinician champions within organizations.7
The next step is action—addressing gaps in EHR use and tackling implementation challenges.7 Here, the IBD clinician champion would lead institution-level quality improvement initiatives.
In a broader perspective, further collaboration should be considered.7 For example, meetings could be held between EHR system developers and clinical leaders from national IBD committees, specialty steering boards, and other organizations, such as improveCareNow or IBD Qorus, to discuss quality improvement initiatives and approaches tailored to specific EHR types.
Currently, more collaboration is needed between clinician leaders of national IBD committees and EHR system developers to implement readily available and standardized EHR tools for care of patients with IBD.
[16:27]
Ultimately, these initiatives could help standardize EHR optimization approaches in IBD care.7
Now, let’s summarize the key points from our discussion. We began by exploring the rising use of EHR and the increasing burden it places on clinicians, especially those managing complex conditions like IBD.3,4,7,9,16 We also reviewed survey findings that pointed to widespread dissatisfaction and identified key areas where EHR use could be improved.17
Next, we examined tools—many of which are already available—that may support efficiency, though awareness and implementation remain limited.7 Finally, we shared a roadmap to guide EHR improvements at both the individual and institutional level, with the potential to drive broader alignment and coordination across systems.7
[17:26]
By leveraging important enhancement tools—such as the ones we've reviewed today—the EHR can be optimized to its fullest potential as a component in delivering exceptional IBD care. Our aim is to safeguard the benefits it may offer patients and healthcare systems, while reducing the strain on providers and staff.
Thank you for your interest and for spending some time with IBDIQ today to help adapt to the evolving care needs of all patients with IBD.
