Electronic health records (EHRs) first replaced paper medical records in the 1960s, and the technology has since progressed from punch cards, magnetic tape, and floppy discs to today’s cloud computing.1 The format of taking a patient’s medical history has also changed, from problem-oriented medical records to the more modern subjective, objective, assessment, and plan (SOAP) note.2 Despite this progress, the full potential of EHRs remains elusive for clinicians, consumers, health systems, and the health care system as a whole.
As the EHR market continues to consolidate, cloud adoption increases, and additional 21st Century Cures Act requirements go into effect later this year, health care organizations should be considering the future of EHRs. To better understand how EHRs should evolve to meet changing needs, the Deloitte Center for Health Solutions conducted a survey of 38 US-based College of Healthcare Information Management Executive (CHIME) members in the spring of 2022 and interviewed 13 EHR experts from 10 organizations including health care provider organizations, EHR companies, startup companies, and government agencies in the summer of 2022. The survey was designed to learn how EHRs can strive to:
Our research found that many users want their EHRs to do more. Nineteen percent of the CHIME survey respondents were dissatisfied or very dissatisfied with their organization’s EHR system, with another 11% neither satisfied nor dissatisfied. Even respondents who were satisfied (70%) stated that aspects of their current EHR system wouldn’t be able to meet future needs. Interviewees noted that allowing clinicians to chart the way they want has always faced tension with the need for EHRs to satisfy other requirements (e.g., billing and regulatory reporting).
As we think about how EHRs should evolve out of necessity, it helps to understand what health care might look like in the next decade. Deloitte’s vision for the Future of HealthTM predicts that key drivers such as consumerism, data-sharing, and data interoperability will transform the health care industry by 2030. Consumers will seek out convenience and will be more focused on prevention and well-being. More advanced technologies will enable new capabilities. Are today’s EHRs prepared to help health systems meet this new future?
“I think they [EHR vendors] have to change, or they will become extinct”
-Chief medical information officer, startup company
Health care organizations have realized the initial benefits of digitizing records, but health care leaders should prepare for the next generation of EHRs. Many of our interviewees felt that change is already underway, particularly with the opportunities that cloud native EHRs and a platform ecosystem approach can provide. Health systems should think more holistically about EHRs within the context of their current digital technology investments and identify what capabilities could improve the experience for consumers and clinicians. They also should develop a plan to test new capabilities and workflows, potentially with health care and technology partners.
The 21st Century Cures Act3,4,5,6 advances biomedical innovation, allows for innovation and flexibility for product regulation, and among other provisions, aims to improve interoperability of electronic health information (EHI). A key provision prevents information blocking, defined as interfering with access, exchange, or use of EHI. Certification criteria for health IT developers also include using HL7 FHIR APIs. While some certification and information blocking requirements from the 21st Century Cures Act went into effect as early as 2020, there continue to be additional requirements in 2022 and 2023:
Interviewees noted that health care consumers want both convenient access to health care and good relationships with their physicians. But if they had to choose one, they would choose convenience. To help address this, more than half of the survey respondents are interested in adopting tools that would improve the consumer experience by reducing the time and burden of accessing care. In fact, 61% of the respondents plan to invest in patient communication tools, such as telehealth and messaging capabilities, with their health care team over the next three to five years (figure 1). Online appointment scheduling and virtual registration are other consumer-specific capabilities that organizations are looking to invest in during this timeframe.
To address some of these pain points, Geisinger Health System is streamlining its patient registration process using biometrics.7 Patient wait times are shorter because the patients are checked in faster and no longer required to share their date of birth, social security number, or medical record number at each appointment. This solution can also reduce the burden on front-office staff and reduce patient misidentification and fraud.8 Nearly 80% of patients who were offered facial biometrics chose to enroll in the program, demonstrating its appeal to consumers, likely due in part to consumers’ comfort level with similar technology on their smartphones.9
Unsurprisingly, interviewees noted that EHRs and patient portals are not intuitive enough, and improvements are needed for both clinicians and consumers. Clinicians in particular find documentation burdensome.10 While interviewees agreed that keyboard shortcuts and macros can help alleviate some of the data entry issues, broader changes should be made. Finding information is not always easy, and even if the capability is there, figuring out how to use it (e.g., sharing data and making it actionable) can be difficult.
Leveraging user experience design is important, but interviewees also touched on using human-centered design (HCD) and equity-centered design in the development of future EHRs (see sidebar, “Visualizing patient asthma history using HCD processes,” for more information.). That means designing EHRs with an understanding that not all end users are the same—even if they fit under the same persona category. It’s also important to recognize why different users are using the system (including researchers and administrators pulling reports for payers, regulators, public health agencies, etc.), invite a diverse set of users into the discussion from the beginning of the process, and provide more education and training on the EHR and some aspects of human- and equity-centered design.
The Children’s Hospital of Philadelphia (CHOP) developed an interactive visualization of patient asthma history using HCD processes.11 Embedded in the EHR and using Fast Healthcare Interoperability Resources (FHIR), the tool was used in a pediatric emergency department. CHOP found that using the asthma timeline application resulted in a reduction in time on task, number of screens, and cognitive load as well as high user satisfaction.
In ensuring that EHRs serve future health care needs, it also falls on developers to think about how to “build humanity into our systems.”12 There are a few examples of this including, empathetic chatbots that respond with “I’m sorry that this has happened to you” instead of “Thank you for your feedback.”13 Another solution is allowing patients to record their names to be stored in the EHR to help clinicians pronounce their patients’ names properly, thus helping health care professionals practice culturally humble care and rebuild patient trust.14 Ensuring patient portals are available in different languages to improve equitable access to patient health information is another potential solution.
Approaching EHRs with human- and equity-centered design approaches could lead to a host of improved outcomes. A few of the improvements include, reduced time spent documenting, a better understanding of the patient’s medical history, a stronger patient/clinician relationship, less clinician burnout, more engaged health care consumers, and less stress in sometimes difficult health care interactions.
Interviewees also noted that a focus on prevention and wellness will be essential moving forward. As John Glaser writes, “the electronic health record must transition from an emphasis on a person’s medical record to an emphasis on a person’s plan for health.”15 Rather than recording what a patient is encountering, the EHR should help the clinician plan a course of action to improve the patient’s health or keep them healthy. This could include a library of care plans, personalized algorithms, care team support, interoperability, decision support, and analytics, and support the transition to value-based care. A person with well-managed diabetes, for example, would have a different care plan than that of a person with diabetes who needs more support. Survey respondents seemed keen on this idea as two-thirds of respondents are looking to enhance clinical decision support and advanced diagnostics for their clinicians in the next three to five years. In addition, 50% of respondents plan to invest in advanced analytics and machine learning that suggest a course of treatment and automate some of the steps.
“Optimally, a care plan is a living document, as opposed to a static note.”
-Chief medical information officer, community health care provider
As participatory health—in which patients and health professionals collaborate, share decision-making, and function as equal partners in health care16—increases, consumers will need access to their health information and the ability to add to it and edit it as needed. Consumers want convenience and a better technology experience, but in the end, the goal for all is better health outcomes. Giving consumers more access and control over their health data, which as one interviewee noted is predominately generated by patients even within health care settings, can allow consumers to better collaborate with their care team, prioritize their health goals, and improve quality of life.
Our research uncovered health care organizations’ plans to incorporate more artificial intelligence (AI) into EHRs and their intentions to move EHRs to the cloud. Seventy-one percent of respondents were interested in adopting AI/ML in the next three to five years (figure 2) and close to half of survey respondents are planning to move or are already moving their EHRs to the cloud (figure 3). The survey respondents noted that the benefits of moving to the cloud include redundancy and fallback, and ensuring scalability, security, and the ability to access an ecosystem of capabilities to enhance EHRs. Interestingly, despite citing the lack of “intelligent automation, insight-driven processes, and workflow” as the top EHR constraint to moving to the Future of Health, less than one-third of respondents view a cloud-based EHR system’s main benefit as increasing analytics capabilities.
The move toward more AI and cloud adoption can address many EHR needs for clinicians and consumers. From using natural language processing to help improve the usability of EHRs, to allowing for more types of data (e.g., wearables, Internet of Things, drivers of health, environmental, retail) to be included and overlayed with traditional EHR data, these technologies can help store more data, generate new insights to keep consumers well, and improve access to health care information.
Ochsner Health System and Kaiser Permanente (KP) have designed digital health programs using wearables.21 The organizations have integrated the data directly into their EHRs and engaged the care teams in using the data but noted “wearables were only one aspect of an integrated care delivery process” that also included other services such as coaching and preventive care.
Ochsner Health created a program focused on hypertension using a home blood pressure monitor while KP’s program used a home glucometer for diabetes. Seventy-one percent of Ochsner Health’s patients enrolled in this digital program achieved target blood pressure control, compared to 31% under the usual course of treatment. Likewise, KP’s program saw benefits in doubling clinician capacity to manage diabetic patients. With these successes, the digital health program developers believe wearables could one day aid disease diagnosis, help clinicians understand response to treatment, and support patient-specific precision care.
With the move to cloud-based systems, the increased use of AI, and the call for consumer-centric health care, many interviewees believe that a turning point in health care and health care IT systems is coming soon. Like enterprise resource planning systems, EHRs that move into the cloud and become cloud native will likely be able to fully capitalize on the benefits of cloud. While not all current EHR functionality may work quite as well during the initial move to the cloud, the overall improvements over the long run can be significant (figure 4 and figure 5). Furthermore, interoperability is getting closer with API standards and FHIR standards in place. This creates a possibility for developing a new kind of EHR: A platform ecosystem that is more than a technology platform, it’s also a business model.
The technology platform could create an infrastructure to collect, secure, and exchange data and insights. On top of this platform, organizations could create specialized products and services that consumers, clinicians, and administrators would interface with directly. Like an app on a mobile device, consumers could have easy access to their appointment scheduling app or their diabetes management app. Traditional EHR vendors could play in both the app and platform markets. Specialized solutions will likely stand out in this environment, compared to companies that try to do everything. Platform developers, app developers, health systems, and consumers can then come together as an ecosystem of participants on a digital platform to cocreate goods and services, and provide opportunities for wider reach, access to new capabilities, and increased revenue.
“The EHR of the future is really a platform, not a billion lines of code, where if you change one thing and everything changes.”
-Chief medical information officer, community health care provider
Will the future of EHRs include ambient listening systems? Holograms? Hospitals at home? Many interviewees felt that change is afoot, with the possibility of a new generation of EHRs arising soon. In preparation for this, health systems should:
Future EHR solutions should be designed to cater to the needs of all users—especially the needs of consumers and clinicians. These solutions also should leverage the latest technology such as cloud native, platform ecosystems to improve consumers’ health and wellness.
Amid uncertainty and change, health care stakeholders are looking for new ways to transform the journey of care. By focusing on the differentiated needs of plans and providers, our US health care practice helps clients transform uncertainty into possibility, and rapid change into lasting progress.
The Deloitte Center for Health Solutions, under the guidance of Executive Director Jay Bhatt, delves deeper into your top-of-mind issues and provides fresh thinking around complex challenges. Timely, relevant research and thought-provoking analyses deliver insight to help you see solutions through a new lens.