EHR Design Transformation: From Records and Transactions to Plans and Artificial Intelligence

John Glaser, former CIO of Partner’s Health Care and former CEO of Siemens Health Services, spoke at an HSI seminar on September 24, 2020 titled, “Transformation of the Electronic Health Record”. He placed the health industry within the context of all others by framing the discussion as a change in the dominant design of the enterprise system. “The core enterprise systems for an industry have a common design, which reflects common business models and the core processes of the industry organization.” When the business model changes, when a what a business does and how they do it changes, the dominant design of the IT system must also change to support that new model.

The Changing Business Model of Healthcare

Glaser highlighted four significant forces changing the healthcare model. First, there is a movement away from reactive care - patients seeing doctors once something is already wrong - to the proactive management of health. In the latter scenario, clinicians would concern themselves with the social determinants of health, for example, making sure a patient can purchase and take the medication, rather than just writing a prescription.
 
Second, there is a move away from fee-for-service and toward value-based payments. Rather than rewarding volume, clinicians will be rewarded for quality, safety and efficiency. A VBP system may very well have helped hospitals and healthcare providers during the pandemic. People stayed away in droves from medical appointments that were not absolutely necessary, precipitating a fiscal crisis for many health clinics and institutions. If they had been given instead a set payment per person to keep their patients healthy, the revenue stream would have been more reliable.
 
The third movement is away from fragmented niche care and toward a continuum of care. Patients end up at an array of settings during a particular health crisis or condition: doctors’ offices, hospital beds, rehab care, home care. A thoughtfully integrated continuum of care would ensure that patients are in the right setting for their stage in the care process.
 
The last is a movement away from solely clinician centricity to one of patient centricity. One of the benefits of this change is that patients are responsible for managing their health and being active participants.  
 
None of these changes is new. These ideas have been put in practice to some extent and in some places. Glaser believes that the pandemic may accelerate the rate of change in some cases. Along with the acceptance and support toward VBP, telemedicine and video visits have been widely adopted more quickly than perhaps they would have been without the pandemic. Not all of those gains will vanish once life returns to something more like 2019.  
 
From a Record to a Plan
The emphasis has been converting from a paper-based record system to an electronic health record system. Making this transformation was often expensive and painful for healthcare providers, but the advantages outweighed the difficulties. However, an electronic record does not mean that care is better or safer or really more efficient. Glaser posits that what is needed is a patient plan, rather than a patient record.
 
A patient plan would keep the person healthy rather than focus on being reactive. There also has to be intelligence for the clinicians to be alerted if the plan is not working or the patient has strayed. There has to be a mechanism to bring the patient back on track. Patients with more than one condition would have multiple plans. In addition to the medical plan, there would be a social plan to manage habits and lifestyle changes and making sure a patient’s social needs are being met. Finally, all of these have to be rolled up into a master plan, which has the intelligence to make sure the components do not conflict and that they make sense together. Right now, there may be fragmented plans for a patient, but there is no holistic view.
 
This shift requires that the EHR have plan-centric capability. It needs to be able to tailor, monitor, alert, analyze and compare plans. The right healthcare providers have to take responsibility for the varied parts, and all of them should be able to have a view of the whole.
 
From Transaction-oriented to Intelligence-oriented
For decades the emphasis has been on computerizing transactions: ordering, referring, documenting, retrieving results. There is value to making transactions easier and more transparent, even though it is difficult to do in a healthcare setting. The shift in this case is placing an emphasis on applying artificial intelligence to transactions, processes and patient plans. And to do this judiciously to advance efficiency, effectiveness and safety of care.
 
Similar to business model changes discussed easier, some of these AI capabilities already exist. The idea is to make them focused and central and embed them within the EHR. This transformation requires that the EHR have several intelligence-oriented skills. For example, AI can guide clinical diagnosis and decision making. It can be used to analyze patient data to discover new treatment, safety issues or unusual patterns. In a patient-centric system where patients have more responsibility for their health, AI can provide information and decision support to patients, families and caregivers.
 
The AI-enabled EHR does not replace the clinician, but advises, recommends and supports. Clinicians may accept or reject suggestions, but in either case they will be able to tell the reasoning behind their recommendations and decided course of care.
 
The Transition
Change is hard, expensive and time intensive. Healthcare providers likely well remember the difficulties inherent in making the change from paper records to EHRs. The switching costs are very high in a variety of resources.
 
Glaser believes that the transition will come not as a full replacement, but that several types of AI capabilities will wrap around the EHR. The new functions will address population health management, health information exchange, patient health management, big data analytics, and decision and workflow support. Both the what and the how of the healthcare business model is changing. The enterprise system will develop to support those new offerings and methods. Glaser said in summary, “the dominant design of health care enterprise systems will be comprised of platforms that support the delivery of intelligence and plans, and will surround the EHR.”