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Reducing Clinician Burden by Improving ElectronicHealth Record Usability and Support for Clinical WorkflowHL7 Reducing Clinician Burden ProjectGary Dickinson, FHL7 and David Schlossman, MD, PhD Co-FacilitatorsClinical Workflow and Documentation Focus TeamDavid Schlossman, MD, PhD, LeadLisa Masson, MDJames Tcheng, MDLuann Whittenburg, RN, PhDBarry Newman, MDGary Dickinson, FHL7AbstractDespite support from over $35 billion in public funds, most of electronic health records’ (EHRs’) promises to improve healthcare quality, safety, and cost efficiency remain unfulfilled. A large and growing body of data suggests that poor usability and poor integration with clinical workflow are the most important factors preventing EHRs from achieving their design goals. In addition, the burdens imposed on clinicians by these systems are strongly associated with an epidemic of clinician burnout and patient dissatisfaction. As part of the Health Level 7 International (HL7) Reducing Clinician Project, we performed an environmental scan and literature review to enumerate and define EHR-related clinician burdens associated with clinical workflow and documentation. Based on their history and underlying causes, burdens fall into two categories: those related to interactions between clinicians and the regulatory and organizational environment, but implemented via the EHR (extrinsic), and those caused by interactions between clinicians and the EHR technology itself (intrinsic). Here we evaluate the details of several major types of clinician burden and briefly propose potential solutions that are more than just incremental extensions of current methods and EHR products. We conclude it will take disruptive innovation and entirely new frameworks and perspectives for EHRs to help achieve our goals. We highlight ideas from the literature that can form the basis for truly novel EHR designs that better support clinician workflows and thereby enable better patient care.IntroductionHistorical PerspectiveWhen the Health Information Technology for Economic and Clinical Health (HITECH) provisions of the American Recovery and Reinvestment Act (ARRA) of 2009 were passed, the vision was widespread adoption of electronic health records (EHRs) to support national objectives of improving healthcare quality and safety, improving the patient experience, and improving the cost efficiency of the American healthcare system. ADDIN EN.CITE <EndNote><Cite><Author>Hillestad</Author><Year>2005</Year><RecNum>22</RecNum><DisplayText>[1]</DisplayText><record><rec-number>22</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1540492136">22</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hillestad, R.</author><author>Bigelow, J.</author><author>Bower, A.</author><author>Girosi, F.</author><author>Meili, R.</author><author>Scoville, R.</author><author>Taylor, R.</author></authors></contributors><auth-address>RAND, Santa Monica, California, USA. Richard_Hillestad@</auth-address><titles><title>Can electronic medical record systems transform health care? Potential health benefits, savings, and costs</title><secondary-title>Health Aff (Millwood)</secondary-title></titles><periodical><full-title>Health Aff (Millwood)</full-title></periodical><pages>1103-17</pages><volume>24</volume><number>5</number><edition>2005/09/16</edition><keywords><keyword>Aged</keyword><keyword>Cost Control/*economics</keyword><keyword>Delivery of Health Care/economics/*organization &amp; administration</keyword><keyword>Diffusion of Innovation</keyword><keyword>Efficiency, Organizational</keyword><keyword>Health Expenditures/trends</keyword><keyword>Humans</keyword><keyword>*Medical Records Systems, Computerized</keyword><keyword>Middle Aged</keyword><keyword>Quality of Health Care</keyword><keyword>United States</keyword></keywords><dates><year>2005</year><pub-dates><date>Sep-Oct</date></pub-dates></dates><isbn>0278-2715 (Print)&#xD;0278-2715 (Linking)</isbn><accession-num>PMID: 16162551</accession-num><urls><related-urls><url>: 10.1377/hlthaff.24.5.1103</electronic-resource-num></record></Cite></EndNote>[1] A decade later, EHRs are implemented in more than 95% of hospitals and nearly 90% of physician offices, while studies have shown:No significant change in hospital length of stay or inpatient mortalityPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MZWU8L0F1dGhvcj48WWVhcj4yMDEzPC9ZZWFyPjxSZWNO

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ADDIN EN.CITE.DATA [2,3]No improvement in life expectancy, infant mortality, or other population metrics ADDIN EN.CITE <EndNote><Cite><Author>Roser</Author><Year>2017</Year><RecNum>118</RecNum><DisplayText>[4,5]</DisplayText><record><rec-number>118</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1556550046">118</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Roser, M.</author></authors></contributors><titles><title>Link between health spending and life expectancy: US is an outlier</title></titles><volume>2019</volume><number>December 30</number><dates><year>2017</year></dates><urls><related-urls><url> app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1556550190">119</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Thakrar, A. P.</author><author>Forrest A. D.</author><author>Maltenfort, M. G.</author><author>Forrest, C. B.</author></authors></contributors><titles><title>Child Mortality In The US And19 OECD Comparator Nations: A 50-Year Time-Trend Analysis</title><secondary-title>Health Aff (Millwood)</secondary-title></titles><periodical><full-title>Health Aff (Millwood)</full-title></periodical><pages>140-49</pages><volume>37</volume><number>1</number><dates><year>2018</year></dates><accession-num>PMID: 29309221</accession-num><urls></urls><electronic-resource-num>DOI: 10.1377/hlthaff.2017.0767</electronic-resource-num></record></Cite></EndNote>[4,5]Continued rapid rise in annual healthcare expenditures from $2 trillion in 2009 to over $3.5 trillion in 2017 (nearly 18% of GDP) ADDIN EN.CITE <EndNote><Cite ExcludeAuth="1"><Author>Center for Medicare and Medicaid Services</Author><Year>2019</Year><RecNum>83</RecNum><DisplayText>[6]</DisplayText><record><rec-number>83</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1554911870">83</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Center for Medicare and Medicaid Services,</author></authors></contributors><titles><title>CMS National Health Expenditure Data</title></titles><volume>2019</volume><number>December 30</number><dates><year>2019</year></dates><urls><related-urls><url>;[6]Decreased efficiency in healthcare delivery (EHRs add 1-2 hours to the average physician workday)PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaW5za3k8L0F1dGhvcj48WWVhcj4yMDE2PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA [9-11]Modest improvement in care process metrics and guideline adherence only weakly correlated with EHR usePEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DZWJ1bDwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+PFJl

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ZT5=

ADDIN EN.CITE.DATA [12-14]What happened? Why did we encounter so many unanticipated consequences? Why do most of EHRs’ promises remain unfulfilled? What have we learned from the first decade of large scale EHR implementation to solve the problems and improve EHRs?Poor UsabilityA large and growing body of data suggests that poor usability and poor support for and integration into clinical workflow are among the most important factors preventing EHRs from achieving their intended design goals.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CZWxkZW48L0F1dGhvcj48WWVhcj4yMDA5PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA [15,16] Current generation EHRs evolved rapidly from systems designed primarily for billing and administrative purposes, and have yet to be optimized to support the actual work done in patient care delivery. Suboptimal human factors engineering in EHR design creates a challenging user experience leading to decreased clinical productivity, increased error rates, increased user fatigue among providers, and decreased user satisfaction. ADDIN EN.CITE <EndNote><Cite><Author>Belden</Author><Year>2009</Year><RecNum>24</RecNum><DisplayText>[15]</DisplayText><record><rec-number>24</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1540492314">24</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Belden, J. L.</author><author>Grayson, R.</author><author>Barnes, J.</author></authors><tertiary-authors><author>HIMSS</author></tertiary-authors></contributors><titles><title>Defining and Testing EMR Usability: Principles and Proposed Methods of EMR Usability Evaluation and Rating</title></titles><dates><year>2009</year></dates><pub-location>Chicago, IL</pub-location><publisher>HIMSS EHR Usability Task Force</publisher><urls><related-urls><url>;[15] As noted by the Institute of Medicine: ADDIN EN.CITE <EndNote><Cite><Author>Committee on Patient Safety and Health Information Technology</Author><Year>2012</Year><RecNum>88</RecNum><DisplayText>[17]</DisplayText><record><rec-number>88</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555012118">88</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Committee on Patient Safety and Health Information Technology, Institute of Medicine</author></authors></contributors><titles><title>Health IT and Patient Safety: Building Safer Systems for Better Care</title></titles><dates><year>2012</year></dates><pub-location>Washington, D.C.</pub-location><publisher>National Academies Press</publisher><accession-num>PMID: 24600741</accession-num><urls><related-urls><url>: 10.17226/13269</electronic-resource-num></record></Cite></EndNote>[17]Designed and applied inappropriately, health IT can add an additional layer of complexity to the already complex delivery of health care, which can lead to unintended adverse consequences, for example dosing errors, failure to detect fatal illnesses, and delayed treatment due to poor human–computer interactions or loss of data.andAlthough definitive evidence is hard to produce, the committee believes poor user-interface design, poor workflow, and complex data interfaces are threats to patient safety.Healthcare quality and safety are emergent properties which arise from a sociotechnical healthcare system, typically represented by a five-domain model including interactions among people, processes, technology, organizations, and external environment.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Db21taXR0ZWUgb24gUGF0aWVudCBTYWZldHkgYW5kIEhl

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ADDIN EN.CITE.DATA [9,10,17,19]In addition to problems at the intersection of people and technology, EHRs have also exacerbated healthcare delivery problems at the intersection between people and the external environment. Reimbursement regulations significantly increase the time and effort necessary for clinicians to document care in the medical record. ADDIN EN.CITE <EndNote><Cite><Author>Kuhn</Author><Year>2015</Year><RecNum>1</RecNum><DisplayText>[20]</DisplayText><record><rec-number>1</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1540247178">1</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kuhn, T.</author><author>Basch, P.</author><author>Barr, M.</author><author>Yackel, T.</author><author>Medical Informatics Committee of the American College of Physicians,</author></authors></contributors><titles><title>Clinical documentation in the 21st century: executive summary of a policy position paper from the American College of Physicians</title><secondary-title>Ann Intern Med</secondary-title></titles><periodical><full-title>Ann Intern Med</full-title></periodical><pages>301-3</pages><volume>162</volume><number>4</number><edition>2015/01/13</edition><keywords><keyword>Documentation/*standards</keyword><keyword>Electronic Health Records/*standards</keyword><keyword>Humans</keyword><keyword>Medical History Taking</keyword><keyword>Quality of Health Care</keyword></keywords><dates><year>2015</year><pub-dates><date>Feb 17</date></pub-dates></dates><isbn>1539-3704 (Electronic)&#xD;0003-4819 (Linking)</isbn><accession-num>PMID: 25581028</accession-num><urls><related-urls><url>: 10.7326/M14-2128</electronic-resource-num></record></Cite></EndNote>[20] Large scale poorly coordinated administrative and regulatory reporting programs intended to measure quality improvement and the use of healthcare information technology (health IT) have diverted attention and effort from direct patient care to reimbursement and administrative activities with minimal clinical value. ADDIN EN.CITE <EndNote><Cite><Author>Erickson</Author><Year>2017</Year><RecNum>2</RecNum><DisplayText>[21]</DisplayText><record><rec-number>2</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1540247492">2</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Erickson, S. M.</author><author>Rockwern, B.</author><author>Koltov, M.</author><author>McLean, R. M.</author><author>Medical Practice Quality Committee of the American College of Physicians,</author></authors></contributors><auth-address>From American College of Physicians, Washington, DC.</auth-address><titles><title>Putting Patients First by Reducing Administrative Tasks in Health Care: A Position Paper of the American College of Physicians</title><secondary-title>Ann Intern Med</secondary-title></titles><periodical><full-title>Ann Intern Med</full-title></periodical><pages>659-661</pages><volume>166</volume><number>9</number><edition>2017/03/28</edition><keywords><keyword>Delivery of Health Care/*organization &amp; administration</keyword><keyword>*Health Policy</keyword><keyword>Humans</keyword><keyword>*Practice Management, Medical</keyword><keyword>United States</keyword></keywords><dates><year>2017</year><pub-dates><date>May 2</date></pub-dates></dates><isbn>1539-3704 (Electronic)&#xD;0003-4819 (Linking)</isbn><accession-num>PMID: 28346948</accession-num><urls><related-urls><url>: 10.7326/M16-2697</electronic-resource-num></record></Cite></EndNote>[21] And, there is little evidence such reporting programs have improved the quality of care in any meaningful way (see above).The HL7 Reducing Clinician Burden ProjectViewed from another perspective, widescale implementation of EHRs over the last decade has imposed additional stress, additional physical and cognitive workload, and additional time requirements (“burden”) on healthcare professionals (“clinicians”). whose practice is based on direct observation and treatment of patients. The Reducing Clinician Burden (RCB) Project is an activity of Health Level Seven (HL7) International, a not-for-profit American National Standards Institute (ANSI)-accredited standards development organization, aimed at enumerating and defining specific EHR and health IT burdens, understanding the history and underlying cause of those burdens, and proposing novel, innovative solutions for alleviating the burdens. ADDIN EN.CITE <EndNote><Cite><Author>HL7 International</Author><Year>2019</Year><RecNum>89</RecNum><DisplayText>[22]</DisplayText><record><rec-number>89</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555181921">89</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>HL7 International,</author></authors></contributors><titles><title>Reducing Clinician Burden</title></titles><volume>2019</volume><number>December 31</number><dates><year>2019</year></dates><urls><related-urls><url>;[22] The project also aims to document and share current success stories and best practices in alleviating clinician burden. Using extensive literature review, ADDIN EN.CITE <EndNote><Cite><Author>HL7 International</Author><Year>2019</Year><RecNum>89</RecNum><DisplayText>[22]</DisplayText><record><rec-number>89</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555181921">89</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>HL7 International,</author></authors></contributors><titles><title>Reducing Clinician Burden</title></titles><volume>2019</volume><number>December 31</number><dates><year>2019</year></dates><urls><related-urls><url>;[22] the project has documented EHR-related burdens in multiple domains (see Table 1).Table 1. Types of clinician burden related to the EHRClinical workflow and documentationUser training and proficiencyHuman factors and usabilityDeveloper transparency and responsibilityPatient safetyInteroperabilityClinician-patient interactionLegal aspects and risksClinical decision supportEffect of health IT on nursing practiceAdministrative tasksSupport for public and population healthCare coordination and team managementData integrity and reliabilityThis report presents a literature analysis by the RCB Project clinical workflow and documentation focus team to define clinician burdens in these two domains, understand the underlying causes, and propose new, effective solutions that are more than incremental extensions of current methods and EHR products. We chose to emphasize these areas because they are the most important to front line practicing clinicians and because they encompass many of the other categories (e.g., human factors, patient safety, clinician-patient interaction, clinical decision support, and non-clinical administrative tasks). As discussed above, we found two major categories of workflow burdens, those related to the interactions between clinicians and the regulatory and organizational environment, but implemented via the EHR (extrinsic), and burdens caused by interaction with the EHR technology itself (intrinsic). We conclude that disruptive innovation and entirely new frameworks and perspectives will be needed for EHRs to mitigate, reduce, or alleviate the burdens and enable clinicians to deliver safer, higher quality, more cost-effective healthcare.Clinical WorkflowThe term “clinical workflow” encompasses all clinician physical and mental activities, technologies, tools, environments, teams, and organizations involved in patient care. ADDIN EN.CITE <EndNote><Cite ExcludeAuth="1" ExcludeYear="1"><Author>Agency for Healthcare Research and Quality</Author><RecNum>91</RecNum><DisplayText>[23]</DisplayText><record><rec-number>91</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555426784">91</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Agency for Healthcare Research and Quality,</author></authors></contributors><titles><title>What is Workflow?</title></titles><volume>2019</volume><number>December 31</number><dates></dates><publisher>Agency for Healthcare Research and Quality</publisher><urls><related-urls><url>;[23] As such, clinical workflows are sequences of physical and cognitive actions, occurring over time and through space, which:Are performed by cliniciansConsume, transform, and/or produce informationAre used to assess, maintain, or change the health of a patient. ADDIN EN.CITE <EndNote><Cite><Author>Carter</Author><Year>2018</Year><RecNum>90</RecNum><DisplayText>[24]</DisplayText><record><rec-number>90</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555426463">90</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Carter, J.</author></authors></contributors><titles><title>Workflow &amp; Process Definitions</title></titles><volume>2019</volume><number>December 31</number><dates><year>2018</year></dates><urls><related-urls><url>;[24]Such activities may include but are not limited to 1) direct interaction with patients, 2) finding, organizing, and analyzing data and information from the medical record, 3) researching information from the medical and scientific literature, 4) making diagnoses and clinical decisions, 5) writing orders and making referrals, 6) care coordination and collaboration, 7) population management, 8) clinical documentation, and 9) information sharing with patients and members of the clinical team.Burden Definitions and HistoryExtrinsic BurdensThe large-scale adoption of EHRs has served to reveal and highlight a number of longstanding problems with the healthcare system. Operationalizing certain common processes within the EHR has created unexpected and unintended impediments to workflow. ADDIN EN.CITE <EndNote><Cite><Author>Auerbach</Author><Year>2019</Year><RecNum>143</RecNum><DisplayText>[25]</DisplayText><record><rec-number>143</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1574779027">143</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Auerbach, A. D.</author><author>Khanna, R.</author><author>Adler-Milstein, J.</author></authors></contributors><auth-address>San Francisco Division of Hospital Medicine, University of California, San Francisco, CA, USA. ada@medicine.ucsf.edu.&#xD;San Francisco Center for Digital Health Innovation, University of California, San Francisco, USA. ada@medicine.ucsf.edu.&#xD;San Francisco Division of Hospital Medicine, University of California, San Francisco, CA, USA.&#xD;San Francisco Center for Digital Health Innovation, University of California, San Francisco, USA.&#xD;San Francisco Center for Clinical Informatics &amp; Improvement Research, University of California, San Francisco, USA.</auth-address><titles><title>Letting a Good Crisis Go to Waste</title><secondary-title>J Gen Intern Med</secondary-title></titles><periodical><full-title>J Gen Intern Med</full-title></periodical><edition>2019/11/21</edition><dates><year>2019</year><pub-dates><date>Nov 19</date></pub-dates></dates><isbn>1525-1497 (Electronic)&#xD;0884-8734 (Linking)</isbn><accession-num>PMID: 31745851</accession-num><urls><related-urls><url>: 10.1007/s11606-019-05552-z</electronic-resource-num></record></Cite></EndNote>[25] An effective digital transformation cannot be achieved without addressing these issues, which we enumerate and define here.Clinical documentation requirementsIn 1995, the Health Care Financing Administration (HCFA; predecessor of the Department of Health and Human Services (DHHS) Center for Medicare and Medicaid Services (CMS))developed Evaluation and Management (E&M) guidelines to prevent clinicians from billing at levels not justified by the documentation of their clinical work. The E&M codes, updated in 1997, defined encounter billing levels by “objective, quantifiable, auditable” standards based on information recorded in the medical record. Failure to conform with the E&M guidelines is punishable by fines, imprisonment, and/or decertification from the Medicare Program for billing fraud, so physicians approach E&M-based documentation very seriously. ADDIN EN.CITE <EndNote><Cite><Author>Basch</Author><Year>2018</Year><RecNum>61</RecNum><DisplayText>[26]</DisplayText><record><rec-number>61</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1546632959">61</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Basch, P.</author><author>Smith, J. R. L.</author></authors></contributors><auth-address>MedStar Health, Washington, District of Columbia, United States.&#xD;American Medical Informatics Association, Bethesda, Maryland, United States.</auth-address><titles><title>CMS Payment Policy, E&amp;M Guideline Reform, and the Prospect of Electronic Health Record Optimization</title><secondary-title>Appl Clin Inform</secondary-title></titles><periodical><full-title>Appl Clin Inform</full-title></periodical><pages>914-918</pages><volume>9</volume><number>4</number><edition>2018/12/27</edition><dates><year>2018</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>1869-0327 (Electronic)&#xD;1869-0327 (Linking)</isbn><accession-num>PMID: 30586672</accession-num><urls><related-urls><url>: 10.1055/s-0038-1676337</electronic-resource-num></record></Cite></EndNote>[26] Similar standards were rapidly adopted by the great majority of private payers.Unfortunately, the 1997 CMS E&M guidelines were not based on a scientific examination of what documentation should be included in a clinical note. The guidelines require multiple documentation components with little relevance to the encounter being recorded and little connection to the effort, complexity of medical decision making, or quality of care involved. Even at the time of release, the American Medical Association (AMA) and 38 medical professional societies found the guidelines burdensome, confusing, and flawed, and multiple calls for reform over more than 20 years have yet to be heeded. ADDIN EN.CITE <EndNote><Cite><Author>Basch</Author><Year>2018</Year><RecNum>61</RecNum><DisplayText>[26]</DisplayText><record><rec-number>61</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1546632959">61</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Basch, P.</author><author>Smith, J. R. 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ADDIN EN.CITE.DATA [20,27]Non-clinical documentation requirementsThe rapid adoption of EHRs has also introduced an additional layer of regulatory burdens related to reimbursement justification, quality improvement, and health IT utilization measurement. For example, a recent AMA study with 1000 respondents found that 92% said prior authorization (PA) caused delays in patient care and 61% said PA had a negative effect on clinical outcomes. Physicians reported they spent an average of 14.6 hours per week on activities related to PA, time which could be spent more productively on direct patient care. Similarly, contesting insurance coverage denials that are not medically appropriate consumes significant clinician time and effort in activities which are not clinically useful. ADDIN EN.CITE <EndNote><Cite><Author>Frieden</Author><Year>2018</Year><RecNum>123</RecNum><DisplayText>[28]</DisplayText><record><rec-number>123</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1574279612">123</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Frieden, J.</author></authors></contributors><titles><title>Prior Authorization&apos;s Pain Continues for Providers</title></titles><volume>2019</volume><number>December 31</number><dates><year>2018</year></dates><urls><related-urls><url>;[28]Although such programs are well intentioned, collecting data required for Meaningful Use, Merit based Incentive Payment System (MIPS), as established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), etc. further intrudes on the limited time physicians have with each patient. In addition, these reimbursement programs all focus on process measures with little evidence that such measures have meaningfully improved large-scale health outcomes. ADDIN EN.CITE <EndNote><Cite><Author>Krenn</Author><Year>2017</Year><RecNum>28</RecNum><DisplayText>[29]</DisplayText><record><rec-number>28</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1540591594">28</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Krenn, L.</author><author>Schlossman, D.</author></authors></contributors><auth-address>CoxHealth, 3555 S. National Ave, Suite 401, Springfield, MO 65807( *). Electronic address: Louis.Krenn@.&#xD;MedInfoDoc LLC, 2420 Lacewood Drive, Columbia, MO 65201(dagger). Electronic address: dschloss39@.</auth-address><titles><title>Have Electronic Health Records Improved the Quality of Patient Care?</title><secondary-title>PM R</secondary-title></titles><periodical><full-title>PM R</full-title></periodical><pages>S41-S50</pages><volume>9</volume><number>5S</number><edition>2017/05/22</edition><dates><year>2017</year><pub-dates><date>May</date></pub-dates></dates><isbn>1934-1563 (Electronic)&#xD;1934-1482 (Linking)</isbn><accession-num>PMID: 28527503</accession-num><urls><related-urls><url>: 10.1016/j.pmrj.2017.04.001</electronic-resource-num></record></Cite></EndNote>[29] The mandated use of physician attested ICD-10 codes requires time-intensive selection from large, confusing arrays of choices. ICD-10 codes often require information which may not be available in the early stages of care, creating scenarios where precise and incorrect information is recorded rather than a more general assessment better aligned with the data available at the time. Physician burnoutExtensive clinical and nonclinical documentation regulations, enabled and implemented through the EHR, increase workflow steps and increase demands on physicians’ time, visual recognition processes, working memory, and concentration (together termed cognitive load). This increased cognitive load often results in in delayed decision making, an increased risk of errors, and significant disruption of the physician-patient relationship. The most highly trained members of the care team, the front line physicians and nurses, are too often utilized as data entry clerks, responsible for diagnoses, treatment orders, care coordination, and visit notes, but also for vast amounts of lower level data with much less clinical value. ADDIN EN.CITE <EndNote><Cite><Author>Downing</Author><Year>2018</Year><RecNum>5</RecNum><DisplayText>[30]</DisplayText><record><rec-number>5</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1540247724">5</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Downing, N. L.</author><author>Bates, D. W.</author><author>Longhurst, C. A.</author></authors></contributors><auth-address>Stanford University School of Medicine, Stanford, California (N.L.D.).&#xD;Brigham and Women&apos;s Hospital, Harvard Medical School, and Harvard School of Public Health, Boston, Massachusetts (D.W.B.).&#xD;University of California, San Diego, School of Medicine, San Diego, California (C.A.L.).</auth-address><titles><title>Physician Burnout in the Electronic Health Record Era: Are We Ignoring the Real Cause?</title><secondary-title>Ann Intern Med</secondary-title></titles><periodical><full-title>Ann Intern Med</full-title></periodical><pages>50-51</pages><volume>169</volume><number>1</number><edition>2018/05/26</edition><dates><year>2018</year><pub-dates><date>Jul 3</date></pub-dates></dates><isbn>1539-3704 (Electronic)&#xD;0003-4819 (Linking)</isbn><accession-num>PMID: 29801050</accession-num><urls><related-urls><url>: 10.7326/M18-0139</electronic-resource-num></record></Cite></EndNote>[30] By definition, clinician burnout is a syndrome emerging as a prolonged response to chronic interpersonal stressors on the job and characterized by feelings of emotional exhaustion, cynicism and detachment from work, and a sense of low personal accomplishment. ADDIN EN.CITE <EndNote><Cite><Author>Maslach</Author><Year>2016</Year><RecNum>144</RecNum><DisplayText>[31]</DisplayText><record><rec-number>144</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1575405882">144</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Maslach, Christina</author><author>Leiter, Michael</author></authors></contributors><titles><title>Understanding the Burnout Experience: Recent Research and Its Implications for Psychiatry</title><secondary-title>World Psychiatry</secondary-title></titles><periodical><full-title>World Psychiatry</full-title></periodical><pages>103-111</pages><volume>15</volume><dates><year>2016</year></dates><accession-num>PMID: 27265691</accession-num><urls></urls><electronic-resource-num>DOI: 10.1002/wps.20311</electronic-resource-num></record></Cite></EndNote>[31] About 50% of US physicians report at least one symptom of burnout (twice the rate of the general population), and 70% of US physicians report symptoms of health IT-related stress. ADDIN EN.CITE <EndNote><Cite><Author>Gardner</Author><Year>2019</Year><RecNum>104</RecNum><DisplayText>[10]</DisplayText><record><rec-number>104</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1556207908">104</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Gardner, R. L.</author><author>Cooper, E.</author><author>Haskell, J.</author><author>Harris, D. A.</author><author>Poplau, S.</author><author>Kroth, P. J.</author><author>Linzer, M.</author></authors></contributors><auth-address>Department of Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA.&#xD;Healthcentric Advisors, Providence, Rhode Island, USA.&#xD;Department of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.&#xD;Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA.&#xD;Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA.&#xD;Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA.</auth-address><titles><title>Physician stress and burnout: the impact of health information technology</title><secondary-title>J Am Med Inform Assoc</secondary-title></titles><periodical><full-title>J Am Med Inform Assoc</full-title></periodical><pages>106-114</pages><volume>26</volume><number>2</number><edition>2018/12/06</edition><dates><year>2019</year><pub-dates><date>Feb 1</date></pub-dates></dates><isbn>1527-974X (Electronic)&#xD;1067-5027 (Linking)</isbn><accession-num>PMID: 30517663</accession-num><urls><related-urls><url>: 10.1093/jamia/ocy145</electronic-resource-num></record></Cite></EndNote>[10] The time consumed by the multiple inefficiencies related to regulation-induced documentation burdens disrupts work-life balance and is a major contributor to the current epidemic of physician burnout seen in the US.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Eb3duaW5nPC9BdXRob3I+PFllYXI+MjAxODwvWWVhcj48

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ADDIN EN.CITE.DATA [9-11,30] A number of studies have also shown that the prevalence of physician burnout correlates directly with usage of and frustration with EHRs.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NZWxuaWNrPC9BdXRob3I+PFllYXI+MjAxOTwvWWVhcj48

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ADDIN EN.CITE.DATA [9,10,32]Gaps in regulation of EHR software developmentIncorporating user-centered design (UCD) processes during development is “required” for EHR certification. Yet EHR software developers vary widely in understanding and implementation of UCD processes.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SYXR3YW5pPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48

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ADDIN EN.CITE.DATA [33,34] Currently, no standard measurements of usability are required, and regulations permit non-transparent developer self-attestation making it impossible for purchasers to directly compare products. ADDIN EN.CITE <EndNote><Cite><Author>Ratwani</Author><Year>2019</Year><RecNum>95</RecNum><DisplayText>[35]</DisplayText><record><rec-number>95</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555515024">95</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ratwani, R. M.</author><author>Reider, J.</author><author>Singh, H.</author></authors></contributors><auth-address>National Center for Human Factors in Healthcare, MedStar Health, Georgetown University School of Medicine, Washington, DC.&#xD;Alliance for Better Health, Albany Medical College, Albany, New York.&#xD;Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, Texas.</auth-address><titles><title>A Decade of Health Information Technology Usability Challenges and the Path Forward</title><secondary-title>JAMA</secondary-title></titles><periodical><full-title>JAMA</full-title></periodical><pages>743-744</pages><volume>321</volume><number>8</number><edition>2019/02/05</edition><dates><year>2019</year><pub-dates><date>Feb 4</date></pub-dates></dates><isbn>1538-3598 (Electronic)&#xD;0098-7484 (Linking)</isbn><accession-num>PMID: 30715133</accession-num><urls><related-urls><url>: 10.1001/jama.2019.0161</electronic-resource-num></record></Cite></EndNote>[35] Many clinicians use different EHRs in different contexts. Dealing with different interface designs, icon sets, and workflow steps can create additional usability and safety challenges. Lack of interface level design specifications in the EHR certification process bypasses a potentially useful method for mitigating these problems.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SYXR3YW5pPC9BdXRob3I+PFllYXI+MjAxOTwvWWVhcj48

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ADDIN EN.CITE.DATA [35,36]Usability and safety issues can arise at many points in the health IT software lifecycle including design and development, implementation, customization by organizations, and personalization by users. Uncovering the root cause(s) of issues and solving the problems requires good faith collaboration between developers, organizations, and users. Many health IT contracts between developers and organizations contain “hold harmless clauses” that protect developers from liabilities and intellectual property protections (“gag clauses”) that prevent sharing of screenshots and other material which would help with problem solving. Such contract elements prevent developer accountability and impede root cause analysis of safety problems. ADDIN EN.CITE <EndNote><Cite><Author>Ratwani</Author><Year>2019</Year><RecNum>95</RecNum><DisplayText>[35]</DisplayText><record><rec-number>95</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555515024">95</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ratwani, R. M.</author><author>Reider, J.</author><author>Singh, H.</author></authors></contributors><auth-address>National Center for Human Factors in Healthcare, MedStar Health, Georgetown University School of Medicine, Washington, DC.&#xD;Alliance for Better Health, Albany Medical College, Albany, New York.&#xD;Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, Texas.</auth-address><titles><title>A Decade of Health Information Technology Usability Challenges and the Path Forward</title><secondary-title>JAMA</secondary-title></titles><periodical><full-title>JAMA</full-title></periodical><pages>743-744</pages><volume>321</volume><number>8</number><edition>2019/02/05</edition><dates><year>2019</year><pub-dates><date>Feb 4</date></pub-dates></dates><isbn>1538-3598 (Electronic)&#xD;0098-7484 (Linking)</isbn><accession-num>PMID: 30715133</accession-num><urls><related-urls><url>: 10.1001/jama.2019.0161</electronic-resource-num></record></Cite></EndNote>[35]Organizational Stressors and Moral InjuryThe idea that healthcare should be patient-centered is one of the foundational tenets of the healthcare system. Similarly, from the earliest steps on the pathway to becoming healthcare providers, individual clinicians become deeply committed to a foundational moral principle: The needs of the patient come first. Recently, the daily experience of clinical practice has been increasingly affected by insufficient resources, demands for system performance improvement, production pressures, and changes in reimbursement structures. ADDIN EN.CITE <EndNote><Cite><Author>National Academy of Medicine</Author><Year>2019</Year><RecNum>127</RecNum><DisplayText>[11]</DisplayText><record><rec-number>127</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1574451173">127</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>National Academy of Medicine,</author></authors></contributors><titles><title>Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being</title></titles><dates><year>2019</year></dates><pub-location>Washington, DC</pub-location><publisher>The National Academies Press</publisher><isbn>ISBN: 978-0-309-49547-9</isbn><urls><related-urls><url>: ;[11] Under hazard to personal financial viability, clinicians now face strong pressure to consider the needs of the EHR, the payers (public and private), associated healthcare organizations, and government regulators as relevant and potentially equivalent with the needs of their patients. ADDIN EN.CITE <EndNote><Cite><Author>Dean</Author><Year>2019</Year><RecNum>125</RecNum><DisplayText>[37]</DisplayText><record><rec-number>125</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1574450156">125</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dean, W.</author><author>Talbot, S.</author><author>Dean, A.</author></authors></contributors><titles><title>Reframing Clinician Distress: Moral Injury Not Burnout</title><secondary-title>Federal Practitoner</secondary-title></titles><periodical><full-title>Federal Practitoner</full-title></periodical><pages>400-402</pages><volume>36</volume><number>9</number><dates><year>2019</year></dates><accession-num>PMID: 31571807 </accession-num><urls></urls></record></Cite></EndNote>[37]Exacerbated by inefficiencies related to the EHR, the demands on clinicians have escalated exponentially without any corresponding increase in time with patients or resources. To meet the demands and satisfy intrinsic requirements and standards of providing the best possible care, clinicians devote lunch hours, evenings, and weekends to completing documentation. If most doctors and nurses just signed out and stopped work at the end of their shifts, the healthcare system would collapse. ADDIN EN.CITE <EndNote><Cite><Author>Ofri</Author><Year>2019</Year><RecNum>126</RecNum><DisplayText>[38]</DisplayText><record><rec-number>126</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1574450683">126</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Ofri, D.</author></authors></contributors><titles><title>The Business of Healthcare Depends on Exploiting Doctors and nurses</title></titles><volume>2019</volume><number>December 31</number><dates><year>2019</year></dates><pub-location>The New York Times</pub-location><urls><related-urls><url>;[38] Despite best efforts, clinicians often cannot escape the double bind of knowing what the patient needs and awareness of being unable to meet the need due to circumstances beyond their control, a phenomenon termed “moral injury.” ADDIN EN.CITE <EndNote><Cite><Author>Dean</Author><Year>2019</Year><RecNum>125</RecNum><DisplayText>[37]</DisplayText><record><rec-number>125</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1574450156">125</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dean, W.</author><author>Talbot, S.</author><author>Dean, A.</author></authors></contributors><titles><title>Reframing Clinician Distress: Moral Injury Not Burnout</title><secondary-title>Federal Practitoner</secondary-title></titles><periodical><full-title>Federal Practitoner</full-title></periodical><pages>400-402</pages><volume>36</volume><number>9</number><dates><year>2019</year></dates><accession-num>PMID: 31571807 </accession-num><urls></urls></record></Cite></EndNote>[37]Intrinsic BurdensCurrent EHR design and implementation paradigms were based on the scientific principles and historical precedents available when the products were developed. However, these systems unduly rely on the principle that there is one ideal workflow to carry out and document a given clinical process that is valid and optimal in all contexts. This encourages the suppression of clinical practice variability. Yet variability in clinical practice is nearly inevitable (see below). In failing to adequately account for cognitive psychology and human factors, the EHR products themselves create many impediments to clinical workflow, which we enumerate and define here.EHR systems are electronic filing cabinetsComplex interfaces and navigation render searching for, accessing, and organizing relevant information within EHRs difficult. Lack of consistency from one EHR system to another further impedes clinician access to content. Current generation EHRs adopted the mouse/keyboard interface, analog text-based documentation models, and complex paper-derived data representations available when they were designed, which require clinicians to “navigate deeply nested menus and browse through long pull-down lists that are neither filtered nor contextualized.”PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TdHJlZXQ8L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA [39] Data is entered bit by bit requiring multiple keystrokes, points, clicks, and scrolls and utilizing highly trained clinicians as data entry clerks. One study measured an average of 216 mouse clicks or wheels and 729 keyboard clicks per 20-minute patient visit. ADDIN EN.CITE <EndNote><Cite><Author>Street</Author><Year>2018</Year><RecNum>21</RecNum><DisplayText>[40]</DisplayText><record><rec-number>21</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1540335394">21</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Street, R. L., Jr.</author><author>Liu, L.</author><author>Farber, N. J.</author><author>Chen, Y.</author><author>Calvitti, A.</author><author>Weibel, N.</author><author>Gabuzda, M. T.</author><author>Bell, K.</author><author>Gray, B.</author><author>Rick, S.</author><author>Ashfaq, S.</author><author>Agha, Z.</author></authors></contributors><auth-address>From Department of Communication, Texas A&amp;M University, College Station, TX, USA. r-street@tamu.edu.&#xD;Department of Medicine, Baylor College of Medicine, Houston, TX, USA. r-street@tamu.edu.&#xD;Houston VA Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, USA. r-street@tamu.edu.&#xD;From University of California San Diego, San Diego, CA, USA.&#xD;VA San Diego Healthcare System, San Diego, CA, USA.&#xD;University of California Irvine, Irvine, CA, USA.&#xD;West Health, San Diego, CA, USA.</auth-address><titles><title>Keystrokes, Mouse Clicks, and Gazing at the Computer: How Physician Interaction with the EHR Affects Patient Participation</title><secondary-title>J Gen Intern Med</secondary-title></titles><periodical><full-title>J Gen Intern Med</full-title></periodical><pages>423-428</pages><volume>33</volume><number>4</number><edition>2017/12/01</edition><dates><year>2018</year><pub-dates><date>Apr</date></pub-dates></dates><isbn>1525-1497 (Electronic)&#xD;0884-8734 (Linking)</isbn><accession-num>PMID: 29188544</accession-num><urls><related-urls><url>: 10.1007/s11606-017-4228-2</electronic-resource-num></record></Cite></EndNote>[40] A number of studies also indicate that increased time interacting with the computer is strongly associated with decreased patient satisfaction.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TdHJlZXQ8L0F1dGhvcj48WWVhcj4yMDE4PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA [19,40,41]Low usability interface designInformation in EHRs is often not organized or aligned with the physician’s mental model of care and is not optimized to support clinical decision making. Clicking, scrolling, switching between paths and screens, and counterintuitive data presentations make it challenging to access and process important data. ADDIN EN.CITE <EndNote><Cite><Author>Beasley</Author><Year>2011</Year><RecNum>62</RecNum><DisplayText>[42]</DisplayText><record><rec-number>62</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1546646367">62</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Beasley, J. W.</author><author>Wetterneck, T. B.</author><author>Temte, J.</author><author>Lapin, J. A.</author><author>Smith, P.</author><author>Rivera-Rodriguez, A. J.</author><author>Karsh, B. T.</author></authors></contributors><auth-address>Department of Family Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.</auth-address><titles><title>Information chaos in primary care: implications for physician performance and patient safety</title><secondary-title>J Am Board Fam Med</secondary-title></titles><periodical><full-title>J Am Board Fam Med</full-title></periodical><pages>745-51</pages><volume>24</volume><number>6</number><edition>2011/11/17</edition><keywords><keyword>*Clinical Competence</keyword><keyword>Electronic Health Records</keyword><keyword>Ergonomics</keyword><keyword>Humans</keyword><keyword>*Information Management</keyword><keyword>*Patient Safety</keyword><keyword>*Physicians</keyword><keyword>Practice Management, Medical/*organization &amp; administration</keyword><keyword>Primary Health Care/*organization &amp; administration</keyword><keyword>Workload</keyword></keywords><dates><year>2011</year><pub-dates><date>Nov-Dec</date></pub-dates></dates><isbn>1558-7118 (Electronic)&#xD;1557-2625 (Linking)</isbn><accession-num>PMID: 22086819</accession-num><urls><related-urls><url>: 10.3122/jabfm.2011.06.100255</electronic-resource-num></record></Cite></EndNote>[42] Critical information is often obscured in a plethora of less important text or values.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QYXR0ZXJzb248L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFy

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ADDIN EN.CITE.DATA [43,44] Locating and importing data from outside a clinician’s own health system requires extensive effort by the user, when it works at all, ADDIN EN.CITE <EndNote><Cite><Author>Office of the National Coordinator for Health Information Technology</Author><Year>2018</Year><RecNum>64</RecNum><DisplayText>[45]</DisplayText><record><rec-number>64</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1546986468">64</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author><style face="normal" font="default" size="10">Office of the National Coordinator for Health Information Technology,</style></author></authors></contributors><titles><title>Strategy on Reducing Regulatory and Administrative Burdens Relating to the Use of Health IT and EHRs</title></titles><volume>2019</volume><number>December 31</number><dates><year>2018</year></dates><urls><related-urls><url>;[45] raising concerns that the available information represents only a narrow and incomplete view of the patient. Nearly 60 percent of ambulatory care providers report being dissatisfied with their EHR due to workflow and usability concerns, ADDIN EN.CITE <EndNote><Cite><Author>Patterson</Author><Year>2015</Year><RecNum>8</RecNum><DisplayText>[43]</DisplayText><record><rec-number>8</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1540247733">8</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Patterson, E. S.</author><author>Lowry, S. Z.</author><author>Ramaiah, M.</author><author>Gibbons, M. C.</author><author>Brick, D.</author><author>Calco, R.</author><author>Matton, G.</author><author>Miller, A.</author><author>Makar, E.</author><author>Ferrer, J. A.</author></authors></contributors><auth-address>Ohio State University.&#xD;National Institute of Standards and Technology.&#xD;SAIS Bologna Center ; Johns Hopkins University.&#xD;NYU Langone Medical Center.&#xD;Apex Data Solutions, LLC.&#xD;Vanderbilt University.&#xD;Office of the National Coordinator for Health IT.&#xD;Veterans Health Administration ; UT Health School of Biomedical Informatics.</auth-address><titles><title>Improving Clinical Workflow in Ambulatory Care: Implemented Recommendations in an Innovation Prototype for the Veteran&apos;s Health Administration</title><secondary-title>EGEMS (Wash DC)</secondary-title></titles><periodical><full-title>EGEMS (Wash DC)</full-title></periodical><pages>1149</pages><volume>3</volume><number>2</number><edition>2015/08/21</edition><keywords><keyword>health information technology</keyword><keyword>informatics</keyword><keyword>methods</keyword></keywords><dates><year>2015</year></dates><isbn>2327-9214 (Print)&#xD;2327-9214 (Linking)</isbn><accession-num>PMID: 26290887</accession-num><urls><related-urls><url>: 10.13063/2327-9214.1149</electronic-resource-num></record></Cite></EndNote>[43] and 72 percent of primary care physicians (PCPs) think that improved interface design is necessary to improve inefficiencies and reduce screen time. ADDIN EN.CITE <EndNote><Cite><Author>Stanford Medicine and the Harris Poll</Author><Year>2018</Year><RecNum>30</RecNum><DisplayText>[46]</DisplayText><record><rec-number>30</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1540593043">30</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Stanford Medicine and the Harris Poll,</author></authors></contributors><titles><title>How Doctors Feel About Electronic Health Records: National Physician Poll</title></titles><volume>2019</volume><number>December 31</number><dates><year>2018</year></dates><publisher>Stanford Medicine and The Harris Poll</publisher><urls><related-urls><url>;[46]Document exchange rather than data interoperabilityAnalysis of the new-found emphasis on “interoperability” ADDIN EN.CITE <EndNote><Cite><Author>Office of the National Coordinator for Health Information Technology</Author><Year>2018</Year><RecNum>64</RecNum><DisplayText>[45]</DisplayText><record><rec-number>64</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1546986468">64</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author><style face="normal" font="default" size="10">Office of the National Coordinator for Health Information Technology,</style></author></authors></contributors><titles><title>Strategy on Reducing Regulatory and Administrative Burdens Relating to the Use of Health IT and EHRs</title></titles><volume>2019</volume><number>December 31</number><dates><year>2018</year></dates><urls><related-urls><url>;[45] suggests most interoperability efforts focus on improving document exchange and not discrete data exchange or consistent interoperable semantic meaning. As noted above, a significant volume of currently exchanged document content is of low value to clinical care and augmenting document interchange without documentation reform may increase, rather than address clinician burden. There is a foundational need to identify and specify core clinical data, standards, and vocabularies that enable the national objectives of a healthcare ecosystem that is semantically and syntactically interoperable “without requiring extra user input or ‘special effort’.” ADDIN EN.CITE <EndNote><Cite><Author>Rucker</Author><Year>2018</Year><RecNum>108</RecNum><DisplayText>[47]</DisplayText><record><rec-number>108</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1556315275">108</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Rucker, D.W.</author></authors></contributors><titles><title>Achieving the Interoperability Promise of 21st Century Cures</title></titles><volume>2019</volume><number>December 31</number><dates><year>2018</year></dates><publisher>Health Affairs Blog</publisher><urls><related-urls><url>;[47]EHR systems dictate clinician workflowsSixty percent of PCPs think EHRs need a complete overhaul, and only eight percent say the primary value of their EHR is clinically related. ADDIN EN.CITE <EndNote><Cite ExcludeAuth="1"><Author>Stanford Medicine and the Harris Poll</Author><Year>2018</Year><RecNum>30</RecNum><DisplayText>[46]</DisplayText><record><rec-number>30</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1540593043">30</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Stanford Medicine and the Harris Poll,</author></authors></contributors><titles><title>How Doctors Feel About Electronic Health Records: National Physician Poll</title></titles><volume>2019</volume><number>December 31</number><dates><year>2018</year></dates><publisher>Stanford Medicine and The Harris Poll</publisher><urls><related-urls><url>;[46] Current EHRs have proprietary source codes designed with “one size fits all” workflows, consisting of generic tasks and steps which do not accurately reflect clinicians’ mental models or the way they actually provide care at the bedside and in the clinic.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LYXJzaDwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+PFJl

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ADDIN EN.CITE.DATA [48,49] Including a wide spectrum of clinical specialties, environments, and contexts in a few common pathways produces systems which force physicians to alter their preferred workflow and cognitive style, which are based on years of training and clinical practice, to align with the EHR’s requirements. The mismatch causes physicians to perceive their EHRs as disruptive and inefficient. ADDIN EN.CITE <EndNote><Cite><Author>Karsh</Author><Year>2010</Year><RecNum>9</RecNum><DisplayText>[48]</DisplayText><record><rec-number>9</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1540247736">9</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Karsh, B. T.</author><author>Weinger, M. B.</author><author>Abbott, P. A.</author><author>Wears, R. L.</author></authors></contributors><auth-address>Department of Industrial and Systems Engineering and Systems Engineering Initiative for Patient Safety, University of Wisconsin, Madison, Wisconsin 53706, USA. bkarsh@engr.wisc.edu</auth-address><titles><title>Health information technology: fallacies and sober realities</title><secondary-title>J Am Med Inform Assoc</secondary-title></titles><periodical><full-title>J Am Med Inform Assoc</full-title></periodical><pages>617-23</pages><volume>17</volume><number>6</number><edition>2010/10/22</edition><keywords><keyword>*Attitude to Health</keyword><keyword>*Diffusion of Innovation</keyword><keyword>*Health Policy</keyword><keyword>Humans</keyword><keyword>Medical Informatics/*trends</keyword><keyword>*Technology Assessment, Biomedical</keyword><keyword>United States</keyword></keywords><dates><year>2010</year><pub-dates><date>Nov-Dec</date></pub-dates></dates><isbn>1527-974X (Electronic)&#xD;1067-5027 (Linking)</isbn><accession-num>PMID: 20962121</accession-num><urls><related-urls><url>: 10.1136/jamia.2010.005637</electronic-resource-num></record></Cite></EndNote>[48]Overly simplified algorithmic interface designIn general, current generation EHRs apply a rationalized model of healthcare represented as algorithmic sequences of care delivery choices. In reality, clinical care is iterative and rarely linear. Physicians continuously reformulate goals, revise tasks, and reorder sequences as they acquire new information, interact with individual patients and clinical colleagues, and encountered clinical constraints. ADDIN EN.CITE <EndNote><Cite><Author>Karsh</Author><Year>2010</Year><RecNum>9</RecNum><DisplayText>[48]</DisplayText><record><rec-number>9</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1540247736">9</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Karsh, B. T.</author><author>Weinger, M. B.</author><author>Abbott, P. A.</author><author>Wears, R. L.</author></authors></contributors><auth-address>Department of Industrial and Systems Engineering and Systems Engineering Initiative for Patient Safety, University of Wisconsin, Madison, Wisconsin 53706, USA. bkarsh@engr.wisc.edu</auth-address><titles><title>Health information technology: fallacies and sober realities</title><secondary-title>J Am Med Inform Assoc</secondary-title></titles><periodical><full-title>J Am Med Inform Assoc</full-title></periodical><pages>617-23</pages><volume>17</volume><number>6</number><edition>2010/10/22</edition><keywords><keyword>*Attitude to Health</keyword><keyword>*Diffusion of Innovation</keyword><keyword>*Health Policy</keyword><keyword>Humans</keyword><keyword>Medical Informatics/*trends</keyword><keyword>*Technology Assessment, Biomedical</keyword><keyword>United States</keyword></keywords><dates><year>2010</year><pub-dates><date>Nov-Dec</date></pub-dates></dates><isbn>1527-974X (Electronic)&#xD;1067-5027 (Linking)</isbn><accession-num>PMID: 20962121</accession-num><urls><related-urls><url>: 10.1136/jamia.2010.005637</electronic-resource-num></record></Cite></EndNote>[48] Physician workflows are inherently complex, nonlinear, and dependent on a wide variety of data inputs. Physician workflows differ significantly between specialties, between individual providers, between clinical scenarios, diagnoses, and locations, and even between patients for a single provider. For example, one detailed study of two patient visits by 10 PCPs in 10 different primary care centers observed no single or even common workflow pattern. The order and prevalence of task categories varied through the time course of a visit, with the PCPs collecting data throughout the visit.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ib2xtYW48L0F1dGhvcj48WWVhcj4yMDE2PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA [50] Another study of 55 Emergency Department physicians at four sites using two different EHR products showed wide variability in task durations, ordering, clicks, and accuracy when completing basic EHR functions across EHR products from the same vendor and between products from different vendors. ADDIN EN.CITE <EndNote><Cite><Author>Ratwani</Author><Year>2018</Year><RecNum>46</RecNum><DisplayText>[51]</DisplayText><record><rec-number>46</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1541189508">46</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ratwani, R. M.</author><author>Savage, E.</author><author>Will, A.</author><author>Arnold, R.</author><author>Khairat, S.</author><author>Miller, K.</author><author>Fairbanks, R. J.</author><author>Hodgkins, M.</author><author>Hettinger, A. Z.</author></authors></contributors><auth-address>National Center for Human Factors in Healthcare, MedStar Health, Washington, District of Columbia, USA.&#xD;Department of Emergency Medicine, Georgetown University School of Medicine, Washington, District of Columbia, USA.&#xD;Department of Emergency Medicine, Drexel University School of Medicine, Philadelphia, Pennsylvania, USA.&#xD;Carolina Health Informatics Program, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.&#xD;American Medical Association, Chicago, Illinois, USA.</auth-address><titles><title>A usability and safety analysis of electronic health records: a multi-center study</title><secondary-title>J Am Med Inform Assoc</secondary-title></titles><periodical><full-title>J Am Med Inform Assoc</full-title></periodical><pages>1197-1201</pages><volume>25</volume><number>9</number><edition>2018/07/10</edition><dates><year>2018</year><pub-dates><date>Sep 1</date></pub-dates></dates><isbn>1527-974X (Electronic)&#xD;1067-5027 (Linking)</isbn><accession-num>PMID: 29982549</accession-num><urls><related-urls><url>: 10.1093/jamia/ocy088</electronic-resource-num></record></Cite></EndNote>[51]Clinical workflows are frequently interrupted, for example, by emergencies, phone calls, and/or the need for information not yet available in the electronic record. Time constraints, schedule changes, and revisions in care goals often make it necessary to defer tasks or decisions until more information is available. ADDIN EN.CITE <EndNote><Cite><Author>Karsh</Author><Year>2010</Year><RecNum>9</RecNum><DisplayText>[48]</DisplayText><record><rec-number>9</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1540247736">9</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Karsh, B. T.</author><author>Weinger, M. B.</author><author>Abbott, P. A.</author><author>Wears, R. L.</author></authors></contributors><auth-address>Department of Industrial and Systems Engineering and Systems Engineering Initiative for Patient Safety, University of Wisconsin, Madison, Wisconsin 53706, USA. bkarsh@engr.wisc.edu</auth-address><titles><title>Health information technology: fallacies and sober realities</title><secondary-title>J Am Med Inform Assoc</secondary-title></titles><periodical><full-title>J Am Med Inform Assoc</full-title></periodical><pages>617-23</pages><volume>17</volume><number>6</number><edition>2010/10/22</edition><keywords><keyword>*Attitude to Health</keyword><keyword>*Diffusion of Innovation</keyword><keyword>*Health Policy</keyword><keyword>Humans</keyword><keyword>Medical Informatics/*trends</keyword><keyword>*Technology Assessment, Biomedical</keyword><keyword>United States</keyword></keywords><dates><year>2010</year><pub-dates><date>Nov-Dec</date></pub-dates></dates><isbn>1527-974X (Electronic)&#xD;1067-5027 (Linking)</isbn><accession-num>PMID: 20962121</accession-num><urls><related-urls><url>: 10.1136/jamia.2010.005637</electronic-resource-num></record></Cite></EndNote>[48] Current EHR algorithmic designs are encounter-specific without optimal support for resuming work after an interruption. In addition, documentation and other data entry is frequently completed post-encounter at a different time and place, such as afterhours note completion, documentation of phone calls, review and follow-up on laboratory and radiology data, etc. The clinical time consumed by these nonsynchronous processes is not captured by reimbursement regulations and constitutes another major cause of work-life imbalance and consequent physician burnout.Ineffective nonspecific Clinical Decision Support (CDS) toolsA systematic review of twenty-eight randomized trials of CDS systems showed no survival benefit and minimal impact on morbidity.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Nb2phPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA [52] As the medical and scientific knowledge base expands exponentially, ADDIN EN.CITE <EndNote><Cite><Author>Van Noorden</Author><Year>2014</Year><RecNum>65</RecNum><DisplayText>[53]</DisplayText><record><rec-number>65</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1547070817">65</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Van Noorden, R.</author></authors></contributors><titles><title>Nature News Blog: Global Scientific Output Doubles Every Nine Years</title></titles><volume>2019</volume><number>December 31</number><dates><year>2014</year></dates><urls><related-urls><url>;[53] physicians and care teams need standardized tools to appropriately navigate and assimilate this information as applied to the complex interrelationships found in patient narrative, physical exam, laboratory data, radiographic images, and care delivery. Current CDS interventions too often take the form of pop-up alerts notifying physicians of warnings such as drug-drug interactions (DDI), drug allergy interactions (DAI), dose ranges etc. Other CDS formats include order sets and either direct links to medical literature or links to guidelines, calculators, or knowledge summaries. Unfortunately, many DDI and DAI tools are interruptive and fail to integrate key pieces of data found throughout the medical record, resulting in large numbers of low value alerts, which lead to “alert fatigue.” The proportion of DDI alerts overridden ranges from 50% to 90% in various studies, with over 60% of the overrides found to be clinically appropriate.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CcnlhbnQ8L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA [54] Linked literature and knowledge summaries frequently display far more information than needed at the current point in workflow, requiring a long search to find the piece needed to complete the immediate clinical task. ADDIN EN.CITE <EndNote><Cite><Author>Caban</Author><Year>2015</Year><RecNum>67</RecNum><DisplayText>[55]</DisplayText><record><rec-number>67</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1547073625">67</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Caban, J</author><author>Gotz, D.</author></authors></contributors><titles><title>Visual Analytics in Healthcare--Opportunities and Research Challenges</title><secondary-title>J Am Med Inform Assoc</secondary-title></titles><periodical><full-title>J Am Med Inform Assoc</full-title></periodical><pages>s260-262</pages><volume>22</volume><number>2</number><dates><year>2015</year></dates><accession-num>PMID: 25814539</accession-num><urls></urls><electronic-resource-num>DOI: 10.1093/jamia/ocv006</electronic-resource-num></record></Cite></EndNote>[55] Lack of context-specific information preprocessingClinicians commonly work under precise and stringent time constraints in demanding environments. Excessive choices create uncertainty and distraction leading to errors. Existing EHR systems are not currently designed to identify what clinical process is underway or parse what data/information is needed at any particular point in workflow. As a result, EHR designers tend to display too many choices, interface links, and other elements to ensure all possible use cases are covered. This creates a system in which “users” become distracted when interrupted and EHR use becomes disorganized and confusing.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Nb3JpdGE8L0F1dGhvcj48WWVhcj4yMDE2PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA [56,57] Better mechanisms are needed to retrieve and display information in a context- and/or clinician-determined manner. ADDIN EN.CITE <EndNote><Cite><Author>Office of the National Coordinator for Health Information Technology</Author><Year>2018</Year><RecNum>64</RecNum><DisplayText>[45]</DisplayText><record><rec-number>64</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1546986468">64</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author><style face="normal" font="default" size="10">Office of the National Coordinator for Health Information Technology,</style></author></authors></contributors><titles><title>Strategy on Reducing Regulatory and Administrative Burdens Relating to the Use of Health IT and EHRs</title></titles><volume>2019</volume><number>December 31</number><dates><year>2018</year></dates><urls><related-urls><url>;[45]Insufficient support for critical nursing functionsIn various settings, nurses spend anywhere from 22% to 33% of patient care time in medication related activities.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LZW9oYW5lPC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48

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ADDIN EN.CITE.DATA [60,61] The lack of context specificity and standardization in EHR care transition tools challenges the nurse to efficiently spot trends in data over time, effectively summarize data for communication across organizations or service lines, and accommodate variation in nursing knowledge and experience. ADDIN EN.CITE <EndNote><Cite><Author>Staggers</Author><Year>2012</Year><RecNum>113</RecNum><DisplayText>[62,63]</DisplayText><record><rec-number>113</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1556316520">113</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Staggers, N.</author><author>Clark, L.</author><author>Blaz, J. W.</author><author>Kapsandoy, S.</author></authors></contributors><titles><title>Nurses&apos; information management and use of electronic tools during acute care handoffs</title><secondary-title>West J Nurs Res</secondary-title></titles><periodical><full-title>West J Nurs Res</full-title></periodical><pages>153-73</pages><volume>34</volume><number>2</number><dates><year>2012</year></dates><accession-num>PMID: 21540355</accession-num><urls></urls><electronic-resource-num>DOI: 10.1177/0193945911407089</electronic-resource-num></record></Cite><Cite><Author>Staggers</Author><Year>2011</Year><RecNum>114</RecNum><record><rec-number>114</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1556316823">114</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Staggers, N.</author><author>Clark, L.</author><author>Blaz, J. W.</author><author>Kapsandoy, S.</author></authors></contributors><titles><title>Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses’ handoffs on medical and surgical units: insights from interviews and observations</title><secondary-title>Health Inform J</secondary-title></titles><periodical><full-title>Health Inform J</full-title></periodical><pages>209-23</pages><volume>17</volume><number>3</number><dates><year>2011</year></dates><accession-num>PMID: 21937463</accession-num><urls></urls><electronic-resource-num>DOI: 10.1177/1460458211405809</electronic-resource-num></record></Cite></EndNote>[62,63] Nursing documentation is crucial in the clinical process, for communicating with other care team members, for establishing comprehensive care plans, and for recognizing trends in patients’ needs and clinical condition. Yet a recent study found that nearly a fifth of patient files contained inaccurate medication dose documentation, nearly a third showed one or more care orders was fulfilled late, and in nearly half, nursing patient documentation was partially missing. ADDIN EN.CITE <EndNote><Cite><Author>Drach-Zahavy</Author><Year>2015</Year><RecNum>115</RecNum><DisplayText>[64]</DisplayText><record><rec-number>115</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1556317192">115</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Drach-Zahavy, A.</author><author>Hadid, N.</author></authors></contributors><titles><title>Nursing handovers as resilient points of care: linking handover strategies to treatment errors in the patient care in the following shift</title><secondary-title>J Adv Nurs</secondary-title></titles><periodical><full-title>J Adv Nurs</full-title></periodical><pages>1135-45</pages><volume><style face="normal" font="default" size="10">71</style></volume><number>5</number><dates><year>2015</year></dates><accession-num>PMID: 25641374</accession-num><urls></urls><electronic-resource-num>DOI: 10.1111/jan.12615</electronic-resource-num></record></Cite></EndNote>[64] Another study identified perioperative documentation, including perioperative nursing notes, as a source of communication failures among providers. ADDIN EN.CITE <EndNote><Cite><Author>Braaf</Author><Year>2011</Year><RecNum>117</RecNum><DisplayText>[65]</DisplayText><record><rec-number>117</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1556317669">117</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Braaf, S.</author><author>Manias, E.</author><author>Riley, R.</author></authors></contributors><auth-address>Department of Nursing, Melbourne School of Health Sciences, The University of Melbourne, Australia. scbraaf@pgrad.unimelb.edu.au</auth-address><titles><title>The role of documents and documentation in communication failure across the perioperative pathway. A literature review</title><secondary-title>Int J Nurs Stud</secondary-title></titles><periodical><full-title>Int J Nurs Stud</full-title></periodical><pages>1024-38</pages><volume>48</volume><number>8</number><edition>2011/06/15</edition><keywords><keyword>*Communication</keyword><keyword>*Documentation</keyword><keyword>Humans</keyword><keyword>*Perioperative Care</keyword></keywords><dates><year>2011</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>1873-491X (Electronic)&#xD;0020-7489 (Linking)</isbn><accession-num>PMID: 21669433</accession-num><urls><related-urls><url>: 10.1016/j.ijnurstu.2011.05.009</electronic-resource-num></record></Cite></EndNote>[65]Ideas and New Perspectives for Reducing BurdenExtrinsic BurdensSerious underlying problems with the economic and social framework of the healthcare system and the culture of medicine interact with and are amplified by the limitations of the EHR. Healthcare leaders, administrators, policy makers, and regulators must commit to comprehensively updating practices and standards so clinician workflows, mental models, and care plans are accurately represented in EHRs and CDS tools which more effectively support clinical workflow. ADDIN EN.CITE <EndNote><Cite><Author>Auerbach</Author><Year>2019</Year><RecNum>143</RecNum><DisplayText>[25]</DisplayText><record><rec-number>143</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1574779027">143</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Auerbach, A. D.</author><author>Khanna, R.</author><author>Adler-Milstein, J.</author></authors></contributors><auth-address>San Francisco Division of Hospital Medicine, University of California, San Francisco, CA, USA. ada@medicine.ucsf.edu.&#xD;San Francisco Center for Digital Health Innovation, University of California, San Francisco, USA. ada@medicine.ucsf.edu.&#xD;San Francisco Division of Hospital Medicine, University of California, San Francisco, CA, USA.&#xD;San Francisco Center for Digital Health Innovation, University of California, San Francisco, USA.&#xD;San Francisco Center for Clinical Informatics &amp; Improvement Research, University of California, San Francisco, USA.</auth-address><titles><title>Letting a Good Crisis Go to Waste</title><secondary-title>J Gen Intern Med</secondary-title></titles><periodical><full-title>J Gen Intern Med</full-title></periodical><edition>2019/11/21</edition><dates><year>2019</year><pub-dates><date>Nov 19</date></pub-dates></dates><isbn>1525-1497 (Electronic)&#xD;0884-8734 (Linking)</isbn><accession-num>PMID: 31745851</accession-num><urls><related-urls><url>: 10.1007/s11606-019-05552-z</electronic-resource-num></record></Cite></EndNote>[25]Reform clinical documentation regulationsTwo recent studies show that physicians in the US spend nearly two hours on EHR documentation and clerical work for every hour of face time with patients.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaW5za3k8L0F1dGhvcj48WWVhcj4yMDE2PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA [7,8] Comprehensive regulatory reform is indispensable to reducing the impact of reimbursement regulations and policies on physician workflows. Healthcare systems in other industrialized countries are often cited for the ability to provide higher quality, more cost-effective care compared to the US. Interestingly, clinical documentation in countries demonstrating higher quality, cost-effective care largely omits the reimbursement and regulatory information that bloats American clinical notes, resulting in documentation which is, on average, four times shorter than that in the US. ADDIN EN.CITE <EndNote><Cite><Author>Downing</Author><Year>2018</Year><RecNum>5</RecNum><DisplayText>[30]</DisplayText><record><rec-number>5</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1540247724">5</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Downing, N. L.</author><author>Bates, D. W.</author><author>Longhurst, C. A.</author></authors></contributors><auth-address>Stanford University School of Medicine, Stanford, California (N.L.D.).&#xD;Brigham and Women&apos;s Hospital, Harvard Medical School, and Harvard School of Public Health, Boston, Massachusetts (D.W.B.).&#xD;University of California, San Diego, School of Medicine, San Diego, California (C.A.L.).</auth-address><titles><title>Physician Burnout in the Electronic Health Record Era: Are We Ignoring the Real Cause?</title><secondary-title>Ann Intern Med</secondary-title></titles><periodical><full-title>Ann Intern Med</full-title></periodical><pages>50-51</pages><volume>169</volume><number>1</number><edition>2018/05/26</edition><dates><year>2018</year><pub-dates><date>Jul 3</date></pub-dates></dates><isbn>1539-3704 (Electronic)&#xD;0003-4819 (Linking)</isbn><accession-num>PMID: 29801050</accession-num><urls><related-urls><url>: 10.7326/M18-0139</electronic-resource-num></record></Cite></EndNote>[30] According to the American College of Physicians, “The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication.” ADDIN EN.CITE <EndNote><Cite><Author>Kuhn</Author><Year>2015</Year><RecNum>1</RecNum><DisplayText>[20]</DisplayText><record><rec-number>1</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1540247178">1</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kuhn, T.</author><author>Basch, P.</author><author>Barr, M.</author><author>Yackel, T.</author><author>Medical Informatics Committee of the American College of Physicians,</author></authors></contributors><titles><title>Clinical documentation in the 21st century: executive summary of a policy position paper from the American College of Physicians</title><secondary-title>Ann Intern Med</secondary-title></titles><periodical><full-title>Ann Intern Med</full-title></periodical><pages>301-3</pages><volume>162</volume><number>4</number><edition>2015/01/13</edition><keywords><keyword>Documentation/*standards</keyword><keyword>Electronic Health Records/*standards</keyword><keyword>Humans</keyword><keyword>Medical History Taking</keyword><keyword>Quality of Health Care</keyword></keywords><dates><year>2015</year><pub-dates><date>Feb 17</date></pub-dates></dates><isbn>1539-3704 (Electronic)&#xD;0003-4819 (Linking)</isbn><accession-num>PMID: 25581028</accession-num><urls><related-urls><url>: 10.7326/M14-2128</electronic-resource-num></record></Cite></EndNote>[20] Selecting which data to present at a particular point in care and organizing it such that the clinical thinking is easily consumed and understood by the rest of the care team is a complex, variable, context-dependent process. Many sections of a patient’s medical history (specialty specific problem list, allergies, past medical history, family and social history, review of systems) change very slowly and are already present in the EHR. The patient’s medical history should not be redundantly included, either in whole or in part, in every note. Only certain values or trends in a laboratory panel or sections of a radiology report are typically pertinent in the context of the current encounter. Entering the entire panel or report is distracting and confusing to the reader. The encounter note author should be allowed to enter a discrete value or trend summary compressed and filtered to be meaningful. Physicians understand the meaning of “normal physical exam” and “normal laboratory panel,” and should be allowed to document by variance from the norm when appropriate. Including extraneous documentation of normal findings and associated metadata may often obscure more pertinent information and decrease the quality of care.The CMS 2021 changes proposed for the Common Procedural Terminology (CPT) E&M guidelines represent a regulatory simplification that could potentially help eliminate some burdens. ADDIN EN.CITE <EndNote><Cite><Author>Basch</Author><Year>2018</Year><RecNum>61</RecNum><DisplayText>[26]</DisplayText><record><rec-number>61</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1546632959">61</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Basch, P.</author><author>Smith, J. R. L.</author></authors></contributors><auth-address>MedStar Health, Washington, District of Columbia, United States.&#xD;American Medical Informatics Association, Bethesda, Maryland, United States.</auth-address><titles><title>CMS Payment Policy, E&amp;M Guideline Reform, and the Prospect of Electronic Health Record Optimization</title><secondary-title>Appl Clin Inform</secondary-title></titles><periodical><full-title>Appl Clin Inform</full-title></periodical><pages>914-918</pages><volume>9</volume><number>4</number><edition>2018/12/27</edition><dates><year>2018</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>1869-0327 (Electronic)&#xD;1869-0327 (Linking)</isbn><accession-num>PMID: 30586672</accession-num><urls><related-urls><url>: 10.1055/s-0038-1676337</electronic-resource-num></record></Cite></EndNote>[26] In that system codes are based on medical decision making (MDM) or time, and specific elements of the history and physical exam do not contribute to coding. 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ADDIN EN.CITE.DATA [26,66] While new CMS definitions may aim to make the determination of MDM more rational, significant uncertainties remain. The definition of time as “total physician/qualified health professional (QHP) time on the date of service” does not clarify how working after office hours to complete EHR documentation/note entries and review ancillary data (e.g., laboratory, radiology) will factor into the time determination. ADDIN EN.CITE <EndNote><Cite><Author>Aubry</Author><Year>2019</Year><RecNum>129</RecNum><DisplayText>[66]</DisplayText><record><rec-number>129</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1574541607">129</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Aubry, Barbara</author></authors></contributors><titles><title>CMS and AMA: 2021 proposewd changes to E/M outpatient srevices</title></titles><volume>2019</volume><number>December 31</number><dates><year>2019</year></dates><urls><related-urls><url>;[66]Within the next few years, defining the content and quality in clinical notes must be returned from payers and regulators to practicing physicians, clinical specialty societies, and medical educators, who have the most training and knowledge to make these determinations. The outcome stakeholders must focus on developing evidence-based, context-specific, specialty-specific models and templates which guide and support clinicians in streamlining core documentation to contain only the essential data needed for high quality healthcare and team communication.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Eb3duaW5nPC9BdXRob3I+PFllYXI+MjAxODwvWWVhcj48

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ADDIN EN.CITE.DATA [30,35]Reform non-clinical documentation regulationsMonitoring and improving care quality, assuring physicians meet appropriate standards of care, confirming care documented as provided is commensurate with charges, and collecting structured, computable clinical data as the basis of a learning healthcare system are achievable goals. However, if we are to achieve needed improvements in the healthcare system, physicians must be free to focus on the patient and on clinical care, not on administrative, regulatory, and financial processes much less relevant to clinical care. The new goals must be to simplify, harmonize, and automate all nonclinical documentation and administrative responsibilities. In supporting clinical care delivery, EHRs should submit all information needed for routine preauthorizations and insurance company determinations without clinician intervention. Regulatory incentives for payers to create a dedicated language or interface portals to handle authorization transaction sets should be implemented. The HL7 Da Vinci Project is already working to develop such transaction sets based on the HL7 FHIR standard.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5ITDcgSW50ZXJuYXRpb25hbDwvQXV0aG9yPjxZZWFyPm4u

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ADDIN EN.CITE.DATA [67,68] Within the next few years, EHRs, as a condition of certification, should record, aggregate, and submit other required non-clinical data, (e.g., quality improvement data, federal EHR usage data, public health syndromic surveillance data, etc.) without clinician intervention, although other staff members might help with this process. If medicolegal issues arise about whether standards of care have been met or charges are justified, the audit trail should be capable of tracking what data was reviewed, how much time was spent in each section of the EHR, and any other information necessary to answer those questions.Close the gaps in regulation of EHR software developmentUCD processes must be applied more rigorously, consistently, and transparently. EHR developers should be required to document the details of their UCD methods and to demonstrate that team members with human factors/usability expertise are involved in product development. ADDIN EN.CITE <EndNote><Cite><Author>Savage</Author><Year>2017</Year><RecNum>99</RecNum><DisplayText>[36]</DisplayText><record><rec-number>99</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555604920">99</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Savage, E. L.</author><author>Fairbanks, R. J.</author><author>Ratwani, R. M.</author></authors></contributors><auth-address>National Center for Human Factors in Healthcare, MedStar Health, Washington, DC, USA.</auth-address><titles><title>Are informed policies in place to promote safe and usable EHRs? A cross-industry comparison</title><secondary-title>J Am Med Inform Assoc</secondary-title></titles><periodical><full-title>J Am Med Inform Assoc</full-title></periodical><pages>769-775</pages><volume>24</volume><number>4</number><edition>2017/03/25</edition><keywords><keyword>Electronic Health Records/legislation &amp; jurisprudence</keyword><keyword>*Ergonomics</keyword><keyword>*Government Agencies</keyword><keyword>*Government Regulation</keyword><keyword>Humans</keyword><keyword>Medical Records Systems, Computerized/*legislation &amp; jurisprudence/organization &amp;</keyword><keyword>administration</keyword><keyword>*Patient Safety</keyword><keyword>*Public Policy</keyword><keyword>Qualitative Research</keyword><keyword>United States</keyword><keyword>United States Food and Drug Administration</keyword><keyword>User-Computer Interface</keyword><keyword>electronic health records</keyword><keyword>human factors engineering</keyword><keyword>policy</keyword></keywords><dates><year>2017</year><pub-dates><date>Jul 1</date></pub-dates></dates><isbn>1527-974X (Electronic)&#xD;1067-5027 (Linking)</isbn><accession-num>PMID: 28339697</accession-num><urls><related-urls><url>: 10.1093/jamia/ocw185</electronic-resource-num></record></Cite></EndNote>[36] Consensus reproducible measures of health IT usability and safety should be developed, based on plausible use case testing scenarios applied in both formative (during software development) and summative (implemented products at healthcare organizations) contexts. ADDIN EN.CITE <EndNote><Cite><Author>Ratwani</Author><Year>2019</Year><RecNum>95</RecNum><DisplayText>[35]</DisplayText><record><rec-number>95</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555515024">95</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ratwani, R. M.</author><author>Reider, J.</author><author>Singh, H.</author></authors></contributors><auth-address>National Center for Human Factors in Healthcare, MedStar Health, Georgetown University School of Medicine, Washington, DC.&#xD;Alliance for Better Health, Albany Medical College, Albany, New York.&#xD;Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, Texas.</auth-address><titles><title>A Decade of Health Information Technology Usability Challenges and the Path Forward</title><secondary-title>JAMA</secondary-title></titles><periodical><full-title>JAMA</full-title></periodical><pages>743-744</pages><volume>321</volume><number>8</number><edition>2019/02/05</edition><dates><year>2019</year><pub-dates><date>Feb 4</date></pub-dates></dates><isbn>1538-3598 (Electronic)&#xD;0098-7484 (Linking)</isbn><accession-num>PMID: 30715133</accession-num><urls><related-urls><url>: 10.1001/jama.2019.0161</electronic-resource-num></record></Cite></EndNote>[35] EHR system functional standards have been used successfully in the past to specify system behavior. Similarly, functional requirements and standards for usability, implemented through certification programs or other national health IT strategies, could contribute to improving EHR usability. ADDIN EN.CITE <EndNote><Cite><Author>Meehan</Author><Year>2016</Year><RecNum>131</RecNum><DisplayText>[69]</DisplayText><record><rec-number>131</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1574618140">131</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Meehan, R. A.</author><author>Mon, D. T.</author><author>Kelly, K. M.</author><author>Rocca, M.</author><author>Dickinson, G.</author><author>Ritter, J.</author><author>Johnson, C. M.</author></authors></contributors><auth-address>Kent State University, Kent, OH, USA. Electronic address: Rmeehan3@kent.edu.&#xD;RTI International, Chicago, IL, USA.&#xD;UCLA Health, Los Angeles, CA, USA.&#xD;Dipl. Inform. Med., Food and Drug Administration, Silver Spring, MD, USA.&#xD;CentriHealth, Los Angeles, CA, USA.&#xD;Your Data Steward, Monroeville, PA, USA.&#xD;Duke University, Durham, NC, USA.</auth-address><titles><title>Increasing EHR system usability through standards: Conformance criteria in the HL7 EHR-system functional model</title><secondary-title>J Biomed Inform</secondary-title></titles><periodical><full-title>J Biomed Inform</full-title></periodical><pages>169-173</pages><volume>63</volume><edition>2016/10/25</edition><keywords><keyword>Computer Systems</keyword><keyword>*Electronic Health Records</keyword><keyword>*Health Level Seven</keyword><keyword>Humans</keyword><keyword>Medical Informatics</keyword><keyword>*Health information technology</keyword><keyword>*Standards</keyword><keyword>*Usability</keyword></keywords><dates><year>2016</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>1532-0480 (Electronic)&#xD;1532-0464 (Linking)</isbn><accession-num>PMID: 27523469</accession-num><urls><related-urls><url>: 10.1016/j.jbi.2016.08.015</electronic-resource-num></record></Cite></EndNote>[69] Work on such an “EHR usability functional profile” is already in progress at HL7. ADDIN EN.CITE <EndNote><Cite><Author>HL7 International</Author><Year>n. d.</Year><RecNum>132</RecNum><DisplayText>[70]</DisplayText><record><rec-number>132</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1574619169">132</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>HL7 International,</author></authors></contributors><titles><title>Usability</title></titles><volume>2019</volume><number>December 31</number><dates><year>n. d.</year></dates><urls><related-urls><url>;[70]Results from scenario-based testing would encourage market competition based on observed quality in real practice settings and drive the rounds of iterative improvement that form the heart of UCD, although the extremely high cost of changing EHR products will still create persistent barriers to this process. Consensus specialty-specific standard scenario libraries agreed on by clinicians, developers, researchers, regulators and healthcare organizations could form the basis for consistent usability certification testing and monitoring progress in this area. ADDIN EN.CITE <EndNote><Cite><Author>Ratwani</Author><Year>2019</Year><RecNum>95</RecNum><DisplayText>[35]</DisplayText><record><rec-number>95</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555515024">95</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ratwani, R. M.</author><author>Reider, J.</author><author>Singh, H.</author></authors></contributors><auth-address>National Center for Human Factors in Healthcare, MedStar Health, Georgetown University School of Medicine, Washington, DC.&#xD;Alliance for Better Health, Albany Medical College, Albany, New York.&#xD;Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, Texas.</auth-address><titles><title>A Decade of Health Information Technology Usability Challenges and the Path Forward</title><secondary-title>JAMA</secondary-title></titles><periodical><full-title>JAMA</full-title></periodical><pages>743-744</pages><volume>321</volume><number>8</number><edition>2019/02/05</edition><dates><year>2019</year><pub-dates><date>Feb 4</date></pub-dates></dates><isbn>1538-3598 (Electronic)&#xD;0098-7484 (Linking)</isbn><accession-num>PMID: 30715133</accession-num><urls><related-urls><url>: 10.1001/jama.2019.0161</electronic-resource-num></record></Cite></EndNote>[35] Finally, support mechanisms which enable experienced physicians and nurses to participate in usability testing by allowing job flexibility and replacing income lost due to time consumed in such testing are sorely needed.An effective approach to preventing problems related to clinicians’ use of multiple EHR systems in different contexts would be the development of interface-level design specifications supported by evidence-based principles of human-computer interface (HCI) design. ADDIN EN.CITE <EndNote><Cite><Author>Ratwani</Author><Year>2019</Year><RecNum>95</RecNum><DisplayText>[35]</DisplayText><record><rec-number>95</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555515024">95</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ratwani, R. M.</author><author>Reider, J.</author><author>Singh, H.</author></authors></contributors><auth-address>National Center for Human Factors in Healthcare, MedStar Health, Georgetown University School of Medicine, Washington, DC.&#xD;Alliance for Better Health, Albany Medical College, Albany, New York.&#xD;Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, Texas.</auth-address><titles><title>A Decade of Health Information Technology Usability Challenges and the Path Forward</title><secondary-title>JAMA</secondary-title></titles><periodical><full-title>JAMA</full-title></periodical><pages>743-744</pages><volume>321</volume><number>8</number><edition>2019/02/05</edition><dates><year>2019</year><pub-dates><date>Feb 4</date></pub-dates></dates><isbn>1538-3598 (Electronic)&#xD;0098-7484 (Linking)</isbn><accession-num>PMID: 30715133</accession-num><urls><related-urls><url>: 10.1001/jama.2019.0161</electronic-resource-num></record></Cite></EndNote>[35] Utilizing such platform conventions to enable a familiar “look and feel” in different contexts has been very successful for improving safety in both the automotive and aviation industries. 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ADDIN EN.CITE.DATA [35,36] The ONC discussed this in its 2018 draft strategy on reducing clinician burden and would be well positioned to lead the effort. ADDIN EN.CITE <EndNote><Cite><Author>Office of the National Coordinator for Health Information Technology</Author><Year>2018</Year><RecNum>64</RecNum><DisplayText>[45]</DisplayText><record><rec-number>64</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1546986468">64</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author><style face="normal" font="default" size="10">Office of the National Coordinator for Health Information Technology,</style></author></authors></contributors><titles><title>Strategy on Reducing Regulatory and Administrative Burdens Relating to the Use of Health IT and EHRs</title></titles><volume>2019</volume><number>December 31</number><dates><year>2018</year></dates><urls><related-urls><url>;[45]Many health IT contracts between developers and organizations contain “hold harmless” clauses ADDIN EN.CITE <EndNote><Cite><Author>Koppel</Author><Year>2009</Year><RecNum>96</RecNum><DisplayText>[71]</DisplayText><record><rec-number>96</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555535477">96</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Koppel, R.</author><author>Kreda, D.</author></authors></contributors><auth-address>Department of Sociology and Center for Clinical Epidemiology and Biostatistics, School of Medicine, University of Pennsylvania, Philadelphia, USA. rkoppel@sas.upenn.edu</auth-address><titles><title>Health care information technology vendors&apos; &quot;hold harmless&quot; clause: implications for patients and clinicians</title><secondary-title>JAMA</secondary-title></titles><periodical><full-title>JAMA</full-title></periodical><pages>1276-8</pages><volume>301</volume><number>12</number><edition>2009/03/26</edition><keywords><keyword>Commerce/legislation &amp; jurisprudence</keyword><keyword>Ethics, Professional</keyword><keyword>Forecasting</keyword><keyword>Health Personnel/legislation &amp; jurisprudence</keyword><keyword>Humans</keyword><keyword>*Liability, Legal</keyword><keyword>*Medical Informatics/ethics/legislation &amp; jurisprudence/trends</keyword><keyword>United States</keyword></keywords><dates><year>2009</year><pub-dates><date>Mar 25</date></pub-dates></dates><isbn>1538-3598 (Electronic)&#xD;0098-7484 (Linking)</isbn><accession-num>PMID: 19318655</accession-num><urls><related-urls><url>: 10.1001/jama.2009.398</electronic-resource-num></record></Cite></EndNote>[71] that protect developers from liabilities and intellectual property protections (“gag clauses”) that prevent sharing of screenshots and other material which would help with problem solving. Such contract elements prevent developer accountability and impede the root cause analysis of safety problems. They should be prohibited. Policy makers, for example, the Office of the National Coordinator, should also support creation of a national usability and safety database where clinicians can freely report, illustrate, and share usability and safety issues and compare experiences ADDIN EN.CITE <EndNote><Cite><Author>Ratwani</Author><Year>2019</Year><RecNum>95</RecNum><DisplayText>[35]</DisplayText><record><rec-number>95</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555515024">95</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ratwani, R. M.</author><author>Reider, J.</author><author>Singh, H.</author></authors></contributors><auth-address>National Center for Human Factors in Healthcare, MedStar Health, Georgetown University School of Medicine, Washington, DC.&#xD;Alliance for Better Health, Albany Medical College, Albany, New York.&#xD;Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, Texas.</auth-address><titles><title>A Decade of Health Information Technology Usability Challenges and the Path Forward</title><secondary-title>JAMA</secondary-title></titles><periodical><full-title>JAMA</full-title></periodical><pages>743-744</pages><volume>321</volume><number>8</number><edition>2019/02/05</edition><dates><year>2019</year><pub-dates><date>Feb 4</date></pub-dates></dates><isbn>1538-3598 (Electronic)&#xD;0098-7484 (Linking)</isbn><accession-num>PMID: 30715133</accession-num><urls><related-urls><url>: 10.1001/jama.2019.0161</electronic-resource-num></record></Cite></EndNote>[35] and where reports can be investigated as appropriate, similar to programs in place at the National Transportation Safety Board or the US Food and Drug Administration. Such a database would emphasize that improving health IT quality and safety is a shared responsibility, ADDIN EN.CITE <EndNote><Cite><Author>Sittig</Author><Year>2018</Year><RecNum>18</RecNum><DisplayText>[72]</DisplayText><record><rec-number>18</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1540334935">18</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Sittig, D. F.</author><author>Belmont, E.</author><author>Singh, H.</author></authors></contributors><auth-address>University of Texas - Memorial Hermann Center for Healthcare Quality &amp; Safety, School of Biomedical Informatics, University of Texas Health Science Center at Houston, TX, United States. Electronic address: dean.f.sittig@uth.tmc.edu.&#xD;MaineHealth, Portland, ME, United States.&#xD;Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, United States.</auth-address><titles><title>Improving the safety of health information technology requires shared responsibility: It is time we all step up</title><secondary-title>Healthc (Amst)</secondary-title></titles><periodical><full-title>Healthc (Amst)</full-title></periodical><pages>7-12</pages><volume>6</volume><number>1</number><edition>2017/07/19</edition><dates><year>2018</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>2213-0772 (Electronic)&#xD;2213-0764 (Linking)</isbn><accession-num>PMID: 28716376</accession-num><urls><related-urls><url>: 10.1016/j.hjdsi.2017.06.004</electronic-resource-num></record></Cite></EndNote>[72] and it could be accomplished while still addressing developer concerns about intellectual property. ADDIN EN.CITE <EndNote><Cite><Author>Ratwani</Author><Year>2019</Year><RecNum>95</RecNum><DisplayText>[35]</DisplayText><record><rec-number>95</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555515024">95</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ratwani, R. M.</author><author>Reider, J.</author><author>Singh, H.</author></authors></contributors><auth-address>National Center for Human Factors in Healthcare, MedStar Health, Georgetown University School of Medicine, Washington, DC.&#xD;Alliance for Better Health, Albany Medical College, Albany, New York.&#xD;Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, Texas.</auth-address><titles><title>A Decade of Health Information Technology Usability Challenges and the Path Forward</title><secondary-title>JAMA</secondary-title></titles><periodical><full-title>JAMA</full-title></periodical><pages>743-744</pages><volume>321</volume><number>8</number><edition>2019/02/05</edition><dates><year>2019</year><pub-dates><date>Feb 4</date></pub-dates></dates><isbn>1538-3598 (Electronic)&#xD;0098-7484 (Linking)</isbn><accession-num>PMID: 30715133</accession-num><urls><related-urls><url>: 10.1001/jama.2019.0161</electronic-resource-num></record></Cite></EndNote>[35]Address the root causes of organizational stress and moral injuryHealthcare organizations have so far taken two major approaches to the problems of clinician distress and burnout. 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ADDIN EN.CITE.DATA [73] The second is to implement physician wellness and resiliency programs focusing on mindfulness, meditation, exercise, sleep hygiene, and other well established stress management techniques from the psychology literature. ADDIN EN.CITE <EndNote><Cite><Author>Dean</Author><Year>2019</Year><RecNum>125</RecNum><DisplayText>[37,74]</DisplayText><record><rec-number>125</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1574450156">125</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dean, W.</author><author>Talbot, S.</author><author>Dean, A.</author></authors></contributors><titles><title>Reframing Clinician Distress: Moral Injury Not Burnout</title><secondary-title>Federal Practitoner</secondary-title></titles><periodical><full-title>Federal Practitoner</full-title></periodical><pages>400-402</pages><volume>36</volume><number>9</number><dates><year>2019</year></dates><accession-num>PMID: 31571807 </accession-num><urls></urls></record></Cite><Cite><Author>American Hospital Association</Author><Year>2019</Year><RecNum>134</RecNum><record><rec-number>134</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1574620555">134</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>American Hospital Association,</author></authors></contributors><titles><title>Well Being Playbook: A Guide for Hospital and Health System Leaders</title></titles><volume>2019</volume><number>December 31</number><dates><year>2019</year></dates><urls><related-urls><url>;[37,74] Although these interventions have significant value and provide some short term relief, they are not long term solutions because they do not address the root cause of clinician stress and burnout. The very term “burnout” suggests that the problem originates in the clinician, who somehow lacks the personal resources or resiliency to bear up against the pressures of the work environment. In fact, most healthcare organizations do not fully practice their stated values, and the reality of practice misaligns with clinicians’ deeply held commitment to putting the patient first. ADDIN EN.CITE <EndNote><Cite><Author>American Hospital Association</Author><Year>2019</Year><RecNum>134</RecNum><DisplayText>[37,74]</DisplayText><record><rec-number>134</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1574620555">134</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>American Hospital Association,</author></authors></contributors><titles><title>Well Being Playbook: A Guide for Hospital and Health System Leaders</title></titles><volume>2019</volume><number>December 31</number><dates><year>2019</year></dates><urls><related-urls><url> app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1574450156">125</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dean, W.</author><author>Talbot, S.</author><author>Dean, A.</author></authors></contributors><titles><title>Reframing Clinician Distress: Moral Injury Not Burnout</title><secondary-title>Federal Practitoner</secondary-title></titles><periodical><full-title>Federal Practitoner</full-title></periodical><pages>400-402</pages><volume>36</volume><number>9</number><dates><year>2019</year></dates><accession-num>PMID: 31571807 </accession-num><urls></urls></record></Cite></EndNote>[37,74] Dean and coworkers have therefore suggested that the term burnout should be reframed as moral injury, which “describes the challenge of simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control.” ADDIN EN.CITE <EndNote><Cite><Author>Dean</Author><Year>2019</Year><RecNum>125</RecNum><DisplayText>[37]</DisplayText><record><rec-number>125</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1574450156">125</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dean, W.</author><author>Talbot, S.</author><author>Dean, A.</author></authors></contributors><titles><title>Reframing Clinician Distress: Moral Injury Not Burnout</title><secondary-title>Federal Practitoner</secondary-title></titles><periodical><full-title>Federal Practitoner</full-title></periodical><pages>400-402</pages><volume>36</volume><number>9</number><dates><year>2019</year></dates><accession-num>PMID: 31571807 </accession-num><urls></urls></record></Cite></EndNote>[37]On average, patients are sicker these days, with increasing number and severity of chronic conditions. No amount of EHR tweaking or yoga will solve the problems of declined preauthorization for vital treatments, inadequate time to discuss complex diagnoses, treatments, and patient emotions, and responding to a computer system that relentlessly favors metrics and data entry over communication. ADDIN EN.CITE <EndNote><Cite><Author>Dean</Author><Year>2019</Year><RecNum>125</RecNum><DisplayText>[37]</DisplayText><record><rec-number>125</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1574450156">125</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dean, W.</author><author>Talbot, S.</author><author>Dean, A.</author></authors></contributors><titles><title>Reframing Clinician Distress: Moral Injury Not Burnout</title><secondary-title>Federal Practitoner</secondary-title></titles><periodical><full-title>Federal Practitoner</full-title></periodical><pages>400-402</pages><volume>36</volume><number>9</number><dates><year>2019</year></dates><accession-num>PMID: 31571807 </accession-num><urls></urls></record></Cite></EndNote>[37] The economic framework of the healthcare system constantly pressures clinicians to consider the payer, the EHR, the hospital, and the healthcare system along with the patient and punishes them when their productivity metrics don’t confirm that they are indeed considering all those priorities. Is that really the road to patient-centered care? The root cause of individual distress is found in a broken healthcare system, not in the deficiencies of individuals. ADDIN EN.CITE <EndNote><Cite><Author>Dean</Author><Year>2019</Year><RecNum>125</RecNum><DisplayText>[37]</DisplayText><record><rec-number>125</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1574450156">125</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dean, W.</author><author>Talbot, S.</author><author>Dean, A.</author></authors></contributors><titles><title>Reframing Clinician Distress: Moral Injury Not Burnout</title><secondary-title>Federal Practitoner</secondary-title></titles><periodical><full-title>Federal Practitoner</full-title></periodical><pages>400-402</pages><volume>36</volume><number>9</number><dates><year>2019</year></dates><accession-num>PMID: 31571807 </accession-num><urls></urls></record></Cite></EndNote>[37]Since 1975, the number of healthcare administrators has increased more than 1,500 percent, ADDIN EN.CITE <EndNote><Cite><Author>Tabarrok</Author><Year>2019</Year><RecNum>145</RecNum><DisplayText>[75]</DisplayText><record><rec-number>145</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1577810048">145</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Tabarrok, A.</author></authors></contributors><titles><title>Are Health Administrators To Blame?</title></titles><volume>2019</volume><number>December 31</number><dates><year>2019</year></dates><urls><related-urls><url>;[75] and there are now about 10 administrators for every physician. ADDIN EN.CITE <EndNote><Cite><Author>Kocher</Author><Year>2013, September 23</Year><RecNum>136</RecNum><DisplayText>[76]</DisplayText><record><rec-number>136</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1574628970">136</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Kocher, Robert</author></authors></contributors><titles><title>The Downside of Health Care Job Growth</title></titles><volume>2019</volume><number>December 31</number><dates><year>2013, September 23</year></dates><urls><related-urls><url>;[76] The productivity metrics governing physician evaluations are written by industrial efficiency engineers who have never taken care of a patient. It is critical for clinicians and healthcare administrators to communicate more honestly and transparently about balancing the priorities of healing versus profit, about acknowledging the value of the time clinicians and patients spend together, and about creating a system that values empathy and compassion and truly supports its clinicians’ commitment to always make their patients’ best interest the highest priority. ADDIN EN.CITE <EndNote><Cite><Author>Dean</Author><Year>2019</Year><RecNum>125</RecNum><DisplayText>[37]</DisplayText><record><rec-number>125</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1574450156">125</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dean, W.</author><author>Talbot, S.</author><author>Dean, A.</author></authors></contributors><titles><title>Reframing Clinician Distress: Moral Injury Not Burnout</title><secondary-title>Federal Practitoner</secondary-title></titles><periodical><full-title>Federal Practitoner</full-title></periodical><pages>400-402</pages><volume>36</volume><number>9</number><dates><year>2019</year></dates><accession-num>PMID: 31571807 </accession-num><urls></urls></record></Cite></EndNote>[37] As with clinical documentation, the process of redesigning workflow, improving the efficiency of EHRs, determining the time needed for clinical processes, and establishing evidence-based, specialty-specific productivity metrics should include extensive input from practicing clinicians, medical specialty societies, and medical educators. Clinician stakeholders must also put aside competition and reestablish mutual support, mentorship and activism in advocating for fundamental changes that will be both expensive and difficult to implement. ADDIN EN.CITE <EndNote><Cite><Author>Dean</Author><Year>2019</Year><RecNum>125</RecNum><DisplayText>[37]</DisplayText><record><rec-number>125</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1574450156">125</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dean, W.</author><author>Talbot, S.</author><author>Dean, A.</author></authors></contributors><titles><title>Reframing Clinician Distress: Moral Injury Not Burnout</title><secondary-title>Federal Practitoner</secondary-title></titles><periodical><full-title>Federal Practitoner</full-title></periodical><pages>400-402</pages><volume>36</volume><number>9</number><dates><year>2019</year></dates><accession-num>PMID: 31571807 </accession-num><urls></urls></record></Cite></EndNote>[37] Intrinsic BurdensEHRs rely too heavily on simply representing paper-based standards and on forcing clinicians to conform to a rigid, idealized image of workflow that often bears little resemblance to actual clinical practice. It will take disruptive innovation to progress beyond these limitations and create systems that accommodate the inevitable variability in patient care and more effectively support clinical workflow.Rethink user-centered designIndividual patients are remarkably variable on multiple levels. Studies of Medicare beneficiaries with multiple chronic conditions found over 2 million combinations of 70 disease categories in 32 million Medicare beneficiaries.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Tb3JhY2U8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFyPjxS

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ADDIN EN.CITE.DATA [81] Even though the well-designed project incorporated every known UCD best practice, the results showed no usability improvement at all. The perceived workload and overall satisfaction were the same for both designs, and navigation patterns in either design were highly variable across participants, as were participants’ choices of which system they would prefer to use.UCD practices work well for optimizing commercial and industrial IT designs because the processes being supported are relatively constant and well understood; the options at each step are somewhat constrained, thus the number of decisions is manageable. Clinical processes must accommodate a wide range of data types in support of an enormous range of users performing varying, highly individualized sequences of high complexity tasks, caring for highly individual patients, often with incomplete data. ADDIN EN.CITE <EndNote><Cite><Author>Carter</Author><Year>2016</Year><RecNum>48</RecNum><DisplayText>[82]</DisplayText><record><rec-number>48</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1541273952">48</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Carter, J.</author></authors></contributors><titles><title>Fixing EHR Usability Requires More Than Doubling-Down on Usability Testing and UCD</title></titles><volume>2019</volume><number>December 31</number><dates><year>2016</year></dates><urls><related-urls><url>;[82] Applying usability research methods to EHR design assumes there is a standard or optimal way of thinking about each clinical process at a very granular level, yet no such standard exists. In fact, most clinical processes are context-dependent and have never been thoroughly mapped or understood, ADDIN EN.CITE <EndNote><Cite><Author>Carter</Author><Year>2017</Year><RecNum>49</RecNum><DisplayText>[83]</DisplayText><record><rec-number>49</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1541274232">49</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Carter, J.</author></authors></contributors><titles><title>EHR Design: Unintended Consequences and Irreconcilable Differences</title></titles><volume>2019</volume><number>December 31</number><dates><year>2017</year></dates><urls><related-urls><url>;[83] and physicians approach them with highly variable mental models and cognitive styles. It seems unlikely that any amount of usability research can derive a single consensus “one size fits all” interface model acceptable to a large proportion of physicians, even in a single specialty. On the other hand, a new approach to UCD, deployed across multiple specialties at a more granular and localized level, could be quite valuable to identify the information physicians need for optimal function within new, flexible, context-aware frameworks.A more location- and context-specific application of UCD was demonstrated by Bishop et al. ADDIN EN.CITE <EndNote><Cite><Author>Bishop</Author><Year>2015</Year><RecNum>14</RecNum><DisplayText>[84]</DisplayText><record><rec-number>14</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1540247752">14</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Bishop, R. O.</author><author>Patrick, J.</author><author>Besiso, A.</author></authors></contributors><auth-address>Department of Emergency Medicine, Nepean Hospital, Penrith, NSW, Australia.&#xD;Innovative Clinical Information Management Systems Pty Ltd, Sydney, NSW, Australia. Electronic address: jonpat@.au.&#xD;Innovative Clinical Information Management Systems Pty Ltd, Sydney, NSW, Australia.</auth-address><titles><title>Efficiency achievements from a user-developed real-time modifiable clinical information system</title><secondary-title>Ann Emerg Med</secondary-title></titles><periodical><full-title>Ann Emerg Med</full-title></periodical><pages>133-42 e5</pages><volume>65</volume><number>2</number><edition>2014/07/07</edition><keywords><keyword>Computer Systems</keyword><keyword>*Efficiency, Organizational</keyword><keyword>*Electronic Health Records</keyword><keyword>Emergency Service, Hospital/*organization &amp; administration</keyword><keyword>Humans</keyword><keyword>Information Management</keyword><keyword>*Management Information Systems</keyword><keyword>Medical Informatics/methods</keyword><keyword>Organizational Case Studies</keyword><keyword>Retrospective Studies</keyword><keyword>*Software</keyword><keyword>Workflow</keyword></keywords><dates><year>2015</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>1097-6760 (Electronic)&#xD;0196-0644 (Linking)</isbn><accession-num>PMID: 24997563</accession-num><urls><related-urls><url>: 10.1016/j.annemergmed.2014.05.032</electronic-resource-num></record></Cite></EndNote>[84] who used a library of interface functions invoked using a drag and drop interface builder. Using this design tool, a small team of clinicians and one or two engineers was able to totally control the design, appearance, and operation of every aspect of a model clinical information system for the Emergency Department (ED) at a single hospital. The design outputs were rapidly (overnight) and automatically compiled into an operational clinical information system executed in a Web browser. Through iterative testing and revision (UCD) the team converged on a system optimized for its particular workflows, data flows, and screen layouts from the ground up. ADDIN EN.CITE <EndNote><Cite><Author>Bishop</Author><Year>2015</Year><RecNum>14</RecNum><DisplayText>[84]</DisplayText><record><rec-number>14</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1540247752">14</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Bishop, R. O.</author><author>Patrick, J.</author><author>Besiso, A.</author></authors></contributors><auth-address>Department of Emergency Medicine, Nepean Hospital, Penrith, NSW, Australia.&#xD;Innovative Clinical Information Management Systems Pty Ltd, Sydney, NSW, Australia. Electronic address: jonpat@.au.&#xD;Innovative Clinical Information Management Systems Pty Ltd, Sydney, NSW, Australia.</auth-address><titles><title>Efficiency achievements from a user-developed real-time modifiable clinical information system</title><secondary-title>Ann Emerg Med</secondary-title></titles><periodical><full-title>Ann Emerg Med</full-title></periodical><pages>133-42 e5</pages><volume>65</volume><number>2</number><edition>2014/07/07</edition><keywords><keyword>Computer Systems</keyword><keyword>*Efficiency, Organizational</keyword><keyword>*Electronic Health Records</keyword><keyword>Emergency Service, Hospital/*organization &amp; administration</keyword><keyword>Humans</keyword><keyword>Information Management</keyword><keyword>*Management Information Systems</keyword><keyword>Medical Informatics/methods</keyword><keyword>Organizational Case Studies</keyword><keyword>Retrospective Studies</keyword><keyword>*Software</keyword><keyword>Workflow</keyword></keywords><dates><year>2015</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>1097-6760 (Electronic)&#xD;0196-0644 (Linking)</isbn><accession-num>PMID: 24997563</accession-num><urls><related-urls><url>: 10.1016/j.annemergmed.2014.05.032</electronic-resource-num></record></Cite></EndNote>[84] Such a process could iterate rapidly because the software enabled near real-time generation of a run-time system. Primary control by a user-led design team would increase the ability to identify and incorporate context-specific information flows and displays and rapidly implement improvements in response to new clinical challenges. Research to increase the granularity of UCD methods and enable developers to use clinician-led design teams should receive strong support. It is important to note that developing more individualized interfaces and workflows can still be compatible with the presence of safety “guardrails” within systems and with the ability of developers to innovate.Rethink the EHR interface design paradigmCurrent EHR human-computer interfaces (HCI) continue to adopt visually complex representations derived from prior paper-based records. 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ADDIN EN.CITE.DATA [39] Data is entered one bit at a time requiring multiple keystrokes, points, clicks, and scrolls. An important lesson of the last 10 years is that physician-patient interactions and physician physical and cognitive workflow processes are not orderly or linear enough to be well accommodated by current algorithmic methods and client server architectures, and the mismatch causes many adverse consequences. ADDIN EN.CITE <EndNote><Cite><Author>Karsh</Author><Year>2010</Year><RecNum>9</RecNum><DisplayText>[48]</DisplayText><record><rec-number>9</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1540247736">9</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Karsh, B. T.</author><author>Weinger, M. B.</author><author>Abbott, P. A.</author><author>Wears, R. L.</author></authors></contributors><auth-address>Department of Industrial and Systems Engineering and Systems Engineering Initiative for Patient Safety, University of Wisconsin, Madison, Wisconsin 53706, USA. bkarsh@engr.wisc.edu</auth-address><titles><title>Health information technology: fallacies and sober realities</title><secondary-title>J Am Med Inform Assoc</secondary-title></titles><periodical><full-title>J Am Med Inform Assoc</full-title></periodical><pages>617-23</pages><volume>17</volume><number>6</number><edition>2010/10/22</edition><keywords><keyword>*Attitude to Health</keyword><keyword>*Diffusion of Innovation</keyword><keyword>*Health Policy</keyword><keyword>Humans</keyword><keyword>Medical Informatics/*trends</keyword><keyword>*Technology Assessment, Biomedical</keyword><keyword>United States</keyword></keywords><dates><year>2010</year><pub-dates><date>Nov-Dec</date></pub-dates></dates><isbn>1527-974X (Electronic)&#xD;1067-5027 (Linking)</isbn><accession-num>PMID: 20962121</accession-num><urls><related-urls><url>: 10.1136/jamia.2010.005637</electronic-resource-num></record></Cite></EndNote>[48]Requiring physicians to allot ever increasing amounts of time for EHR training in an attempts to modify their thought processes and workflows to predetermined systems will not improve quality of care or decrease burnout. Rather, designers should be required to produce more flexible, modular systems that may be adapted to individual mental models and cognitive styles. Disruptive innovation and real progress will require EHRs to evolve from data-centric transactional systems (electronic filing cabinets) to process-centric workflow systems, designed from the ground up to be flexible and context-aware and to provide “just in time” delivery of exactly the data and functionality the physician needs at the current point in workflow. EHRs are tools, and should adapt to their users, not the other way around.Systems must also accommodate the inevitable variability involved in clinical practice and be adjustable to fit new clinician needs on the fly. Instead of requiring physicians to fetch each piece of information from different drawers of the filing cabinet one by one, EHRs must assist in aggregating, organizing, and presenting relevant context-specific information to the clinician. Other members of the care continuum (e.g., trained medical assistants and especially patients) should be more actively included in the documentation and data entry process, freeing clinicians to keep their full attention focused on clinical care and communication. Team based care must be based on workflow-integrated data capture supported by multiple members of the care team, each working at the “top of his license.” Much of the data captured should be structured based on defined terminologies and data standards which enable semantic interoperability, data persistence, and access to data via application programming interfaces (APIs).PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TYW5ib3JuPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48

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ADDIN EN.CITE.DATA [85,86] The current trend of utilizing scribes for data entry is another example of this approach, although the use of scribes increases costs, may inhibit physician-patient interactions, and may add a layer of privacy and security concerns.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HZWxsZXJ0PC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48

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ADDIN EN.CITE.DATA [87,88]Utilize application programming interfaces (APIs)API technology certification criteria were introduced as part of ONC’s 2015 Health IT Certification Criteria, ADDIN EN.CITE <EndNote><Cite><Author>Office of the National Coordinator for Health Information Technology</Author><Year>2015</Year><RecNum>98</RecNum><DisplayText>[89]</DisplayText><record><rec-number>98</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555601748">98</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Office of the National Coordinator for Health Information Technology,</author></authors></contributors><titles><title>Certification of Health IT 2015 Edition</title></titles><volume>2019</volume><number>December 31</number><dates><year>2015</year></dates><urls><related-urls><url>;[89] but this technology has so far been viewed as a method to facilitate consumer access to healthcare data and provider ability to access, integrate, and report required regulatory data such as electronic clinical quality measures (eCQMs). EHR developers should be required to provide robust general-purpose APIs (and associated development platforms) allowing the use of innovative, pluggable, interchangeable apps created by physicians, healthcare organizations, and many other sources and not dependent on particular EHR products or versions. ADDIN EN.CITE <EndNote><Cite><Author>Evans</Author><Year>2016</Year><RecNum>55</RecNum><DisplayText>[90]</DisplayText><record><rec-number>55</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1541729598">55</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Evans, R. S.</author></authors></contributors><auth-address>R. Scott Evans, MS, PhD, FACMI, Department of Medical Informatics, LDS Hospital, 8th Ave &amp; C Street, Salt Lake City, Utah 84143, USA, Tel: +1 801 408-3029, Fax: +1 801 408-5802, E-mail: rscott.evans@.</auth-address><titles><title>Electronic Health Records: Then, Now, and in the Future</title><secondary-title>Yearb Med Inform</secondary-title></titles><periodical><full-title>Yearb Med Inform</full-title></periodical><pages>S48-61</pages><volume>Suppl 1</volume><edition>2016/05/21</edition><keywords><keyword>Computer Systems/history/trends</keyword><keyword>Decision Support Systems, Clinical/history</keyword><keyword>Electronic Health Records/*history/standards/*trends</keyword><keyword>Forecasting</keyword><keyword>History, 20th Century</keyword><keyword>History, 21st Century</keyword><keyword>Humans</keyword><keyword>*Electronic Health Record</keyword><keyword>*medical chart</keyword><keyword>*medical record</keyword></keywords><dates><year>2016</year><pub-dates><date>May 20</date></pub-dates></dates><isbn>2364-0502 (Electronic)&#xD;0943-4747 (Linking)</isbn><accession-num>PMID: 27199197</accession-num><urls><related-urls><url>: 10.15265/IYS-2016-s006</electronic-resource-num></record></Cite></EndNote>[90] Based on developer resistance so far, this will only be accomplished by strong regulatory incentives. Industry standard APIs could be based on the Substitutable Medical Apps And Reusable Technology (SMART) on Fast Healthcare Interoperability Resources (FHIR) platformPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NYW5kZWw8L0F1dGhvcj48WWVhcj4yMDE2PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA [68] enabling the development of an “apps-based information economy,” ADDIN EN.CITE <EndNote><Cite><Author>Mandl</Author><Year>2015</Year><RecNum>57</RecNum><DisplayText>[91]</DisplayText><record><rec-number>57</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1541729712">57</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Mandl, K. D.</author><author>Mandel, J. C.</author><author>Kohane, I. S.</author></authors></contributors><auth-address>Computational Health Informatics Program, Boston Children&apos;s Hospital, Boston, MA 02115, USA ; Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA ; Department of Biomedical Informatics, Harvard Medical School, Boston, MA 02115, USA.&#xD;Computational Health Informatics Program, Boston Children&apos;s Hospital, Boston, MA 02115, USA ; Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA.&#xD;Department of Biomedical Informatics, Harvard Medical School, Boston, MA 02115, USA.</auth-address><titles><title>Driving Innovation in Health Systems through an Apps-Based Information Economy</title><secondary-title>Cell Syst</secondary-title></titles><periodical><full-title>Cell Syst</full-title></periodical><pages>8-13</pages><volume>1</volume><number>1</number><edition>2015/09/05</edition><dates><year>2015</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>2405-4712 (Print)&#xD;2405-4712 (Linking)</isbn><accession-num>PMID: 26339683</accession-num><urls><related-urls><url>: 10.1016/j.cels.2015.05.001</electronic-resource-num></record></Cite></EndNote>[91] where interested professionals from many disciplines, including physicians, can develop programs which fill gaps in current EHR functionality and provide a more tailored end user experience. Work on this approach has already been started as The HL7 Argonaut Project. ADDIN EN.CITE <EndNote><Cite ExcludeAuth="1"><Author>HL7 International</Author><Year>2018</Year><RecNum>70</RecNum><DisplayText>[92]</DisplayText><record><rec-number>70</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1547231926">70</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>HL7 International,</author></authors></contributors><titles><title>Welcome to the Argonaut Project</title></titles><volume>2019</volume><number>December 31</number><dates><year>2018</year></dates><urls><related-urls><url>;[92] Such work should receive much more vigorous financial and regulatory support.Implement interface level design specificationsAs noted above, many clinicians already use multiple health IT systems, and dealing with multiple differing interface designs, icon sets, and workflow steps can conceivably create additional safety and usability challenges. ADDIN EN.CITE <EndNote><Cite><Author>Savage</Author><Year>2017</Year><RecNum>99</RecNum><DisplayText>[36]</DisplayText><record><rec-number>99</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555604920">99</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Savage, E. L.</author><author>Fairbanks, R. J.</author><author>Ratwani, R. M.</author></authors></contributors><auth-address>National Center for Human Factors in Healthcare, MedStar Health, Washington, DC, USA.</auth-address><titles><title>Are informed policies in place to promote safe and usable EHRs? A cross-industry comparison</title><secondary-title>J Am Med Inform Assoc</secondary-title></titles><periodical><full-title>J Am Med Inform Assoc</full-title></periodical><pages>769-775</pages><volume>24</volume><number>4</number><edition>2017/03/25</edition><keywords><keyword>Electronic Health Records/legislation &amp; jurisprudence</keyword><keyword>*Ergonomics</keyword><keyword>*Government Agencies</keyword><keyword>*Government Regulation</keyword><keyword>Humans</keyword><keyword>Medical Records Systems, Computerized/*legislation &amp; jurisprudence/organization &amp;</keyword><keyword>administration</keyword><keyword>*Patient Safety</keyword><keyword>*Public Policy</keyword><keyword>Qualitative Research</keyword><keyword>United States</keyword><keyword>United States Food and Drug Administration</keyword><keyword>User-Computer Interface</keyword><keyword>electronic health records</keyword><keyword>human factors engineering</keyword><keyword>policy</keyword></keywords><dates><year>2017</year><pub-dates><date>Jul 1</date></pub-dates></dates><isbn>1527-974X (Electronic)&#xD;1067-5027 (Linking)</isbn><accession-num>PMID: 28339697</accession-num><urls><related-urls><url>: 10.1093/jamia/ocw185</electronic-resource-num></record></Cite></EndNote>[36] An effective approach to mitigating such problems would be the development of interface-level design specifications supported by evidence-based principles of human-computer interface (HCI) design.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SYXR3YW5pPC9BdXRob3I+PFllYXI+MjAxOTwvWWVhcj48

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ADDIN EN.CITE.DATA [35,36] Utilizing such platform conventions to enable a familiar “look and feel” in different contexts has been very successful for improving safety in both the automotive and aviation industries. EHR developers have consistently argued that such standards would stifle innovation, but examples from other industries do not support this claim. Again, it is a shared responsibility of developers, clinicians, user experience (UX) experts, researchers, and regulators to collaborate in developing standards to improve EHR usability and safety. ADDIN EN.CITE <EndNote><Cite><Author>Ratwani</Author><Year>2019</Year><RecNum>95</RecNum><DisplayText>[35]</DisplayText><record><rec-number>95</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555515024">95</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ratwani, R. M.</author><author>Reider, J.</author><author>Singh, H.</author></authors></contributors><auth-address>National Center for Human Factors in Healthcare, MedStar Health, Georgetown University School of Medicine, Washington, DC.&#xD;Alliance for Better Health, Albany Medical College, Albany, New York.&#xD;Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, Texas.</auth-address><titles><title>A Decade of Health Information Technology Usability Challenges and the Path Forward</title><secondary-title>JAMA</secondary-title></titles><periodical><full-title>JAMA</full-title></periodical><pages>743-744</pages><volume>321</volume><number>8</number><edition>2019/02/05</edition><dates><year>2019</year><pub-dates><date>Feb 4</date></pub-dates></dates><isbn>1538-3598 (Electronic)&#xD;0098-7484 (Linking)</isbn><accession-num>PMID: 30715133</accession-num><urls><related-urls><url>: 10.1001/jama.2019.0161</electronic-resource-num></record></Cite></EndNote>[35] The ONC discussed this in its 2018 draft strategy on reducing clinician burden ADDIN EN.CITE <EndNote><Cite><Author>Office of the National Coordinator for Health Information Technology</Author><Year>2018</Year><RecNum>64</RecNum><DisplayText>[45]</DisplayText><record><rec-number>64</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1546986468">64</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author><style face="normal" font="default" size="10">Office of the National Coordinator for Health Information Technology,</style></author></authors></contributors><titles><title>Strategy on Reducing Regulatory and Administrative Burdens Relating to the Use of Health IT and EHRs</title></titles><volume>2019</volume><number>December 31</number><dates><year>2018</year></dates><urls><related-urls><url>;[45] and would be well positioned to lead the effort.Develop innovative models for CDS toolsEffective CDS must provide the right information to the right person in the right CDS intervention format through the right channel at the right point in workflow, ADDIN EN.CITE <EndNote><Cite><Author>Osheroff</Author><Year>2012</Year><RecNum>140</RecNum><DisplayText>[93]</DisplayText><record><rec-number>140</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1574699340">140</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Osheroff, Jerome A.</author><author>Teich, Jonathan M.</author><author>Levick, Donald</author><author>Velasco, Ferdinand T.</author><author>Sittig, Dean F.</author><author>Rogers, Kendall M.</author><author>Jenders, Robrt A.</author></authors></contributors><titles><title>Improving Outcomes with Clinical Decision Support: An Implementer&apos;s Guide</title></titles><dates><year>2012</year></dates><pub-location>Chicago, IL</pub-location><publisher>CRC Press</publisher><isbn>ISBN: 9780984457731</isbn><urls></urls></record></Cite></EndNote>[93] by developing improved human computer interfaces that support rather than interrupt workflow. Using artificial intelligence to properly incorporate data already in the EHR into trigger algorithms and redefining the severity level where alerts are interruptive would decrease the number of low value alerts. CDS tools must show the clinical user the underlying data and rationale leading to a recommendation, at a user-selectable level of detail, and allow the user to immediately act on the information. CDS systems should make it easy for users to provide feedback on the accuracy and clinical utility of alerts to be used in iterative rounds of system optimization. Finally, CDS should not have to be created as a one-off in every new implementation. Regulators (such as the ONC) should support the creation of internet accessible CDS repositories of validated, curated CDS knowledge modules and basic operational components (triggers, notifications, etc.) available as standard sets and templates. ADDIN EN.CITE <EndNote><Cite><Author>Tcheng</Author><Year>2017</Year><RecNum>121</RecNum><DisplayText>[94]</DisplayText><record><rec-number>121</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1569595006">121</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Tcheng, J. E.</author><author>Bakken, S.</author><author>Bates, D.W.</author><author>Bonner III, H.</author><author>Gandhi, T.K.</author><author>Josephs, M.</author><author>Kawamoto, K.</author></authors></contributors><titles><title>Optimizing Strategies for Clinical Decision Support: Summary of a Meeting Series</title></titles><dates><year>2017</year></dates><pub-location>Washington, DC</pub-location><publisher>National Academy of Medicine</publisher><isbn>ISBN: 9781947103092 </isbn><urls></urls></record></Cite></EndNote>[94]Uncouple the data model from the interfaceCurrently, patient representations (the body of information representing a patient’s medical history and current medical status) exist mainly within siloed EHRs. Interoperability is suboptimal, and representing a patient from the perspective of one EHR will invariably be limited. 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ADDIN EN.CITE.DATA [95] Such models would be stored in a “patient cloud,” and EHRs would access and synchronize with them using a standard interface, termed a “clinical portal.” The availability of the canonical model in a patient cloud external to EHRs could allow clinical judgment and clinical actions to be based on complete, up-to-date patient centered information, regardless of site or time of service. This is the definition and purpose of full interoperability. Patients would assume full control over the privacy and sharing of their data, and knowledge about healthcare would be provided to help them interpret the data in the models. Such functions would be provided by new and improved “patient portals” different from the clinical portals and from current EHR-tethered patient portals. Patient data maintained in its own independent system could be obtained via a single query to a single record custodian and a single patient account, rather than the complexity of a broadcast query to multiple health information networks and potentially thousands of devices. Defining and standardizing a reference architecture for CPDMs and demonstrating a reference implementation would be a major contribution to accelerating progress towards this solution and should be strongly supported.Allow users to customize data representationsAnother approach to achieving the flexibility needed to support highly variable clinician workflows is the development of widget based EHR interfaces. A “widget” is defined as a single draggable window containing exactly the data selected by a particular physician. A widget could contain a lab panel, text from a note or report, a graph of lab results, or a radiographic image, and custom widgets could be created by dropping individual chunks of information onto a blank widget. A physician could populate one or more screens, in real time, with exactly the widgets needed at a particular point in workflow and save them for reuse and sharing with others.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TZW5hdGhpcmFqYWg8L0F1dGhvcj48WWVhcj4yMDE0PC9Z

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ADDIN EN.CITE.DATA [96] Screens composed of information elements selected or created by the user increase the chance that all relevant items are on screen and exclude distractions, decreasing keyhole effect and reducing the need for screen transitions. Externalizing some of the information the user has to consider utilizes distributed cognition to reduce cognitive load. Spatially arranging the elements to construct a representation which better fits the user’s mental model and/or the external features of the task (e.g., problem priorities, diagnostic categories) facilitates clinical thinking and decision making.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TZW5hdGhpcmFqYWg8L0F1dGhvcj48WWVhcj4yMDE0PC9Z

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ADDIN EN.CITE.DATA [96] Widget based interfaces and workflow managers implemented locally and interacting with data stored as CPDMs in the cloud could form the basis for appropriately flexible EHRs ADDIN EN.CITE <EndNote><Cite><Author>Carter</Author><Year>2015</Year><RecNum>52</RecNum><DisplayText>[97]</DisplayText><record><rec-number>52</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1541707855">52</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Carter, J.</author></authors></contributors><titles><title>Liberating the EHR User Interface, Part II: Workflows and Widgets</title></titles><volume>2019</volume><number>December 31</number><dates><year>2015</year></dates><urls><related-urls><url>;[97] which can adapt to end users on the fly and evolve new functionalities much more quickly than current products.Incorporate machine learning and artificial intelligenceThe most promising long-term approach to improving clinical workflow, but also the most technically challenging, is the application of natural language processing (NLP), machine learning (ML), and artificial intelligence (AI) methods. Current NLP systems already exceed the performance of human transcriptionists, but speech capture alone does not solve the problems, because the clinician still has to select excerpts from unstructured text and synthesize them with other clinical data to achieve logical structure and narrative interpretability. Entering data with mouse and keyboard remains inherently slow, frustrating and “clunky.” PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ub3BvbDwvQXV0aG9yPjxZZWFyPjIwMTk8L1llYXI+PFJl

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ADDIN EN.CITE.DATA [98-100] What clinicians need is an AI enabled voice command interface which can parse the topics covered in the encounter. Such context aware AI could then become IA (an intelligent assistant), designed to collect, sort, and present clinical information related to those topics from multiple sources (previous notes, laboratory results, radiology reports, pharmacy records, etc.), organized to support clinical thinking and decision making.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MaW48L0F1dGhvcj48WWVhcj4yMDE4PC9ZZWFyPjxSZWNO

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ADDIN EN.CITE.DATA [99,100] The postulated IA would also semantically search relevant scientific literature to present real-time evidence-based recommendations such as differential diagnoses, suggested evaluations, risk calculations and clinical guidelines. ADDIN EN.CITE <EndNote><Cite><Author>Mehta</Author><Year>2018</Year><RecNum>56</RecNum><DisplayText>[100]</DisplayText><record><rec-number>56</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1541729652">56</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Mehta, N.</author><author>Devarakonda, M. V.</author></authors></contributors><auth-address>Education Informatics and Technology, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio. Electronic address: mehtan@.&#xD;Department of Biomedical Informatics, Arizona State University, College of Health Solutions, Scottsdale, Ariz.</auth-address><titles><title>Machine learning, natural language programming, and electronic health records: The next step in the artificial intelligence journey?</title><secondary-title>J Allergy Clin Immunol</secondary-title></titles><periodical><full-title>J Allergy Clin Immunol</full-title></periodical><pages>2019-2021 e1</pages><volume>141</volume><number>6</number><edition>2018/03/09</edition><keywords><keyword>Machine learning</keyword><keyword>artificial intelligence</keyword><keyword>electronic health records</keyword><keyword>medical computer science</keyword><keyword>natural language processing</keyword></keywords><dates><year>2018</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>1097-6825 (Electronic)&#xD;0091-6749 (Linking)</isbn><accession-num>PMID: 29518424</accession-num><urls><related-urls><url>: 10.1016/j.jaci.2018.02.025</electronic-resource-num></record></Cite></EndNote>[100] The extra workflow support could help free physicians’ active listening and engagement capabilities and help restore patients’ sense of empathy and connection. ADDIN EN.CITE <EndNote><Cite><Author>Topol</Author><Year>2019</Year><RecNum>87</RecNum><DisplayText>[98]</DisplayText><record><rec-number>87</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555002612">87</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Topol, E.</author></authors></contributors><titles><title>Deep Medicine: How Artificial Intelligence Can Make Medicine Human Again</title></titles><section>37-38</section><dates><year>2019</year></dates><pub-location>New York, NY</pub-location><publisher>Basic Books</publisher><isbn>ISBN: 9781541644632</isbn><urls></urls></record></Cite></EndNote>[98]The deep neural networks employed in ML contain many hidden layers and are proficient at recognizing patterns not discernible to humans. They are also narrow, require well-formed data, and are prone to error in contexts that do not precisely fit their training data sets. ADDIN EN.CITE <EndNote><Cite><Author>Topol</Author><Year>2019</Year><RecNum>87</RecNum><DisplayText>[98]</DisplayText><record><rec-number>87</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555002612">87</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Topol, E.</author></authors></contributors><titles><title>Deep Medicine: How Artificial Intelligence Can Make Medicine Human Again</title></titles><section>37-38</section><dates><year>2019</year></dates><pub-location>New York, NY</pub-location><publisher>Basic Books</publisher><isbn>ISBN: 9781541644632</isbn><urls></urls></record></Cite></EndNote>[98] Neither the networks nor their designers can explain how the system arrives at its predictions in a manner comprehensible to a human being, creating the aptly named “black box” problem. ADDIN EN.CITE <EndNote><Cite><Author>Knight</Author><Year>2017</Year><RecNum>71</RecNum><DisplayText>[101]</DisplayText><record><rec-number>71</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1547245763">71</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Knight, W.</author></authors></contributors><titles><title>MIT Technology Review: The Dark Secret at the Heart of AI</title></titles><volume>2019</volume><number>December 31</number><dates><year>2017</year></dates><urls><related-urls><url>;[101] In the healthcare domain, the consequences of AI-related errors could be life threatening. Most physicians, and also most patients, would be appropriately uncomfortable making medical decisions based solely on the recommendations of even the most sophisticated ML system. It is therefore vital to design AI enhanced systems as partners to human practitioners and enable them to present information and recommendations in a non-disruptive way that decreases cognitive load and enhances clinician reasoning. Work on such intelligent assistants, termed “autoscribe AI” has already been initiated at Stanford University Medical Center in collaboration with Google. ADDIN EN.CITE <EndNote><Cite><Author>Lin</Author><Year>2018</Year><RecNum>59</RecNum><DisplayText>[99]</DisplayText><record><rec-number>59</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1543357360">59</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lin, S. Y.</author><author>Shanafelt, T. D.</author><author>Asch, S. M.</author></authors></contributors><auth-address>Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA. Electronic address: stevenlin@stanford.edu.&#xD;WellMD Center, Stanford University School of Medicine, Stanford, CA.&#xD;Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA; VA Center for Innovation to Implementation, Palo Alto, CA.</auth-address><titles><title>Reimagining Clinical Documentation With Artificial Intelligence</title><secondary-title>Mayo Clin Proc</secondary-title></titles><periodical><full-title>Mayo Clin Proc</full-title></periodical><pages>563-565</pages><volume>93</volume><number>5</number><edition>2018/04/11</edition><dates><year>2018</year><pub-dates><date>May</date></pub-dates></dates><isbn>1942-5546 (Electronic)&#xD;0025-6196 (Linking)</isbn><accession-num>PMID: 29631808</accession-num><urls><related-urls><url>: 10.1016/j.mayocp.2018.02.016</electronic-resource-num></record></Cite></EndNote>[99] Work on algorithms to support clinician workflow and automate documentation is also in progress at Microsoft, Amazon, Nuance, Google, and multiple startups. ADDIN EN.CITE <EndNote><Cite><Author>Topol</Author><Year>2019</Year><RecNum>87</RecNum><DisplayText>[98]</DisplayText><record><rec-number>87</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555002612">87</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Topol, E.</author></authors></contributors><titles><title>Deep Medicine: How Artificial Intelligence Can Make Medicine Human Again</title></titles><section>37-38</section><dates><year>2019</year></dates><pub-location>New York, NY</pub-location><publisher>Basic Books</publisher><isbn>ISBN: 9781541644632</isbn><urls></urls></record></Cite></EndNote>[98]Interestingly, these concepts are not new. In 1970 William Schwartz wrote in the New England Journal of Medicine: ADDIN EN.CITE <EndNote><Cite><Author>Schwartz</Author><Year>1970</Year><RecNum>101</RecNum><DisplayText>[102]</DisplayText><record><rec-number>101</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555614639">101</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Schwartz, W. B.</author></authors></contributors><titles><title>Medicine and the computer. The promise and problems of change</title><secondary-title>N Engl J Med</secondary-title></titles><periodical><full-title>N Engl J Med</full-title></periodical><pages>1257-64</pages><volume>283</volume><number>23</number><edition>1970/12/03</edition><keywords><keyword>Automation</keyword><keyword>*Computers</keyword><keyword>Costs and Cost Analysis</keyword><keyword>Curriculum</keyword><keyword>Decision Making</keyword><keyword>Diagnosis, Computer-Assisted</keyword><keyword>Education, Medical</keyword><keyword>Health Workforce/statistics &amp; numerical data</keyword><keyword>Malpractice</keyword><keyword>*Medicine</keyword><keyword>Patients</keyword><keyword>Physician-Patient Relations</keyword><keyword>Physicians</keyword><keyword>*Quality of Health Care</keyword><keyword>Students, Medical</keyword></keywords><dates><year>1970</year><pub-dates><date>Dec 3</date></pub-dates></dates><isbn>0028-4793 (Print)&#xD;0028-4793 (Linking)</isbn><accession-num>PMID: 4920342</accession-num><urls><related-urls><url>: 10.1056/NEJM197012032832305</electronic-resource-num></record></Cite></EndNote>[102]Indeed, it seems probable that in the not too distant future the physician and the computer will engage in frequent dialogue, the computer continuously taking note of history, physical findings, laboratory data, and the like, alerting the physician to the most probable diagnoses, and suggesting the appropriate, safest course of action.That we are just now, nearly 50 years later, achieving the computational power to seriously pursue this goal shows how difficult the problem is. However, computational power alone is not enough. Even if the system can synthesize unstructured language and multiple disparate clinical data types into a succinct note, nonverbal interactions will be missed and knowing that the encounter is being recorded and archived will likely affect clinician and patient behavior and interactions. ADDIN EN.CITE <EndNote><Cite><Author>Topol</Author><Year>2019</Year><RecNum>87</RecNum><DisplayText>[98]</DisplayText><record><rec-number>87</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555002612">87</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Topol, E.</author></authors></contributors><titles><title>Deep Medicine: How Artificial Intelligence Can Make Medicine Human Again</title></titles><section>37-38</section><dates><year>2019</year></dates><pub-location>New York, NY</pub-location><publisher>Basic Books</publisher><isbn>ISBN: 9781541644632</isbn><urls></urls></record></Cite></EndNote>[98] Despite the enormous resources and work necessary to make progress, strong research support directed at incorporating AI into medical practice is justified by the potential gains.Conclusions and Lessons LearnedTechnology alone is not enoughBedside clinical medicine is an intensely human endeavor, and many of its most important components are uniquely human and nonquantifiable. In the foreseeable future, it is unlikely machines will be able to provide empathy, compassion, and emotional support, to reason under conditions of uncertainty and incomplete data, to integrate and resolve conflicting values and priorities, to use insight and imagination to create completely new and worthwhile concepts, or to inspire the trust and confidence necessary to heal individual humans or lead human teams. Information technology solutions cannot, by themselves, improve the quality of care, especially as they are currently employed to pressure clinicians, enforce narrowly defined productivity goals, and maximize profits. ADDIN EN.CITE <EndNote><Cite><Author>Dean</Author><Year>2019</Year><RecNum>125</RecNum><DisplayText>[37,98]</DisplayText><record><rec-number>125</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1574450156">125</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dean, W.</author><author>Talbot, S.</author><author>Dean, A.</author></authors></contributors><titles><title>Reframing Clinician Distress: Moral Injury Not Burnout</title><secondary-title>Federal Practitoner</secondary-title></titles><periodical><full-title>Federal Practitoner</full-title></periodical><pages>400-402</pages><volume>36</volume><number>9</number><dates><year>2019</year></dates><accession-num>PMID: 31571807 </accession-num><urls></urls></record></Cite><Cite><Author>Topol</Author><Year>2019</Year><RecNum>87</RecNum><record><rec-number>87</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555002612">87</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Topol, E.</author></authors></contributors><titles><title>Deep Medicine: How Artificial Intelligence Can Make Medicine Human Again</title></titles><section>37-38</section><dates><year>2019</year></dates><pub-location>New York, NY</pub-location><publisher>Basic Books</publisher><isbn>ISBN: 9781541644632</isbn><urls></urls></record></Cite></EndNote>[37,98] The goal of health IT is not to create an ever-accelerating healthcare assembly line, but to utilize machines’ special strengths (such as finding patterns in big data sets, summarizing huge volumes of research literature, never becoming fatigued or distracted) to accomplish some of the routine, quantitative elements of care more efficiently and free clinicians to focus their attention and concentration on the transrational components of care which only humans can provide and on supporting and bonding with their patients. ADDIN EN.CITE <EndNote><Cite><Author>Topol</Author><Year>2019</Year><RecNum>87</RecNum><DisplayText>[98]</DisplayText><record><rec-number>87</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555002612">87</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Topol, E.</author></authors></contributors><titles><title>Deep Medicine: How Artificial Intelligence Can Make Medicine Human Again</title></titles><section>37-38</section><dates><year>2019</year></dates><pub-location>New York, NY</pub-location><publisher>Basic Books</publisher><isbn>ISBN: 9781541644632</isbn><urls></urls></record></Cite></EndNote>[98]Information technology must partner with, not dictate to cliniciansBased on limited but reasonably convincing data that the broad implementation of health IT would improve healthcare quality and cost efficiencyPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IaWxsZXN0YWQ8L0F1dGhvcj48WWVhcj4yMDA1PC9ZZWFy

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ADDIN EN.CITE.DATA [1,103], policymakers and regulators instituted substantial positive and negative incentives that drove the rapid adoption of these systems. Development was focused on meeting the requirements of EHR certification rather than clinical functionality or usability, and the commercial products were based on the systems and paradigms available at the time they were designed. The policies were well intended and aimed at valid social and scientific goals, but were fraught with many unexpected and unintended consequences, as evidenced by our experiences over the last ten years.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LZWxsZXJtYW5uPC9BdXRob3I+PFllYXI+MjAxMzwvWWVh

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ADDIN EN.CITE.DATA [16,104] In our haste to implement EHRs and meet the regulatory requirements, systems were not optimized to support real bedside clinical workflows and did not adequately incorporate the large existing body of knowledge about human factors and human safety engineering. As a result, we failed to achieve the right balance between clinicians, patients, and machines, and we created a path leading to widespread clinician burnout and patient dissatisfaction. ADDIN EN.CITE <EndNote><Cite><Author>Topol</Author><Year>2019</Year><RecNum>87</RecNum><DisplayText>[98]</DisplayText><record><rec-number>87</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555002612">87</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Topol, E.</author></authors></contributors><titles><title>Deep Medicine: How Artificial Intelligence Can Make Medicine Human Again</title></titles><section>37-38</section><dates><year>2019</year></dates><pub-location>New York, NY</pub-location><publisher>Basic Books</publisher><isbn>ISBN: 9781541644632</isbn><urls></urls></record></Cite></EndNote>[98] The rise of EHRs also amplified the distortions caused by the inherent conflict between our for-profit healthcare system and our stated ideal of patient-centered healthcare for the common good.For health IT to achieve its goals, it must be re-envisioned and redesigned to achieve a full partnership where clinicians can comfortably utilize machines’ speed, accuracy and predictive power (all demonstrably better than that of humans) to increase the time available for explanation, thinking, decision making, and better patient understanding of and participation in the decisions ultimately made. ADDIN EN.CITE <EndNote><Cite><Author>Verghese</Author><Year>2018</Year><RecNum>72</RecNum><DisplayText>[105]</DisplayText><record><rec-number>72</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1547246100">72</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Verghese, A.</author><author>Shah, N. H.</author><author>Harrington, R. A.</author></authors></contributors><auth-address>Department of Medicine, Stanford University School of Medicine, Stanford, California.</auth-address><titles><title>What This Computer Needs Is a Physician: Humanism and Artificial Intelligence</title><secondary-title>JAMA</secondary-title></titles><periodical><full-title>JAMA</full-title></periodical><pages>19-20</pages><volume>319</volume><number>1</number><edition>2017/12/21</edition><keywords><keyword>*Artificial Intelligence</keyword><keyword>Electronic Health Records</keyword><keyword>*Humanism</keyword><keyword>Humans</keyword><keyword>Physician-Patient Relations</keyword><keyword>*Physicians</keyword></keywords><dates><year>2018</year><pub-dates><date>Jan 2</date></pub-dates></dates><isbn>1538-3598 (Electronic)&#xD;0098-7484 (Linking)</isbn><accession-num>PMID: 29261830</accession-num><urls><related-urls><url>: 10.1001/jama.2017.19198</electronic-resource-num></record></Cite></EndNote>[105] To paraphrase Verghese and colleagues, “Only a combination of well-informed, empathetic physicians and sophisticated predictive tools that free them from clinical workflow burdens and help them focus on patients and reason more accurately will enable the high quality, patient-centered, cost-effective healthcare system clinicians desire and society needs.” ADDIN EN.CITE <EndNote><Cite><Author>Verghese</Author><Year>2018</Year><RecNum>72</RecNum><DisplayText>[105]</DisplayText><record><rec-number>72</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1547246100">72</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Verghese, A.</author><author>Shah, N. H.</author><author>Harrington, R. A.</author></authors></contributors><auth-address>Department of Medicine, Stanford University School of Medicine, Stanford, California.</auth-address><titles><title>What This Computer Needs Is a Physician: Humanism and Artificial Intelligence</title><secondary-title>JAMA</secondary-title></titles><periodical><full-title>JAMA</full-title></periodical><pages>19-20</pages><volume>319</volume><number>1</number><edition>2017/12/21</edition><keywords><keyword>*Artificial Intelligence</keyword><keyword>Electronic Health Records</keyword><keyword>*Humanism</keyword><keyword>Humans</keyword><keyword>Physician-Patient Relations</keyword><keyword>*Physicians</keyword></keywords><dates><year>2018</year><pub-dates><date>Jan 2</date></pub-dates></dates><isbn>1538-3598 (Electronic)&#xD;0098-7484 (Linking)</isbn><accession-num>PMID: 29261830</accession-num><urls><related-urls><url>: 10.1001/jama.2017.19198</electronic-resource-num></record></Cite></EndNote>[105]Overcoming the barriers to innovation is everyone’s responsibilityAlleviating clinical workflow burdens will be extraordinarily challenging. Problems with technical complexity, high development costs, patient privacy, legal ramifications of system-related errors, unavoidable “black box” problems ADDIN EN.CITE <EndNote><Cite><Author>Knight</Author><Year>2017</Year><RecNum>71</RecNum><DisplayText>[101]</DisplayText><record><rec-number>71</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1547245763">71</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Knight, W.</author></authors></contributors><titles><title>MIT Technology Review: The Dark Secret at the Heart of AI</title></titles><volume>2019</volume><number>December 31</number><dates><year>2017</year></dates><urls><related-urls><url>;[101] associated with AI and deep ML, and many other issues must be solved. Clinicians, policy makers, and regulators must also open more honest and transparent lines of communication about the economic framework of the healthcare system. ADDIN EN.CITE <EndNote><Cite><Author>Dean</Author><Year>2019</Year><RecNum>125</RecNum><DisplayText>[37]</DisplayText><record><rec-number>125</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1574450156">125</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dean, W.</author><author>Talbot, S.</author><author>Dean, A.</author></authors></contributors><titles><title>Reframing Clinician Distress: Moral Injury Not Burnout</title><secondary-title>Federal Practitoner</secondary-title></titles><periodical><full-title>Federal Practitoner</full-title></periodical><pages>400-402</pages><volume>36</volume><number>9</number><dates><year>2019</year></dates><accession-num>PMID: 31571807 </accession-num><urls></urls></record></Cite></EndNote>[37] The same economic distortions that cause the US to spend twice as much per capita on healthcare as other industrialized countries also impede our efforts to improve the functioning of health IT and to improve the daily experiences of patients and clinicians. One thing is absolutely clear. Incremental tweaks based on the current paradigm may be of some help, but will not suffice to achieve the long-term goal. Building the healthcare system of the future will require huge investment in clinical and academic health informatics research and comprehensive regulatory reform which frees physicians and EHR developers from current constraints and provides powerful incentives for them to explore new frameworks and more novel, creative solutions, some of which are reviewed above.Many stakeholders may argue that the concepts expressed here are too radical, too aspirational, too expensive, too revisionist, too risky in abandoning sunk costs, and too disruptive to traditional medical frameworks. Yet progress based on our current efforts has been glacially slow, and it seems highly unlikely that we will achieve a better quality, more patient-centered, safer, more cost-effective healthcare system without radical reform and a new vision. The lesson of the last decade in health IT is that only disruptive innovation will get us where we need to go. It is the shared responsibility of clinicians, health IT professionals, EHR developers, researchers, user experience professionals, healthcare administrators, and regulators to overcome inertia, stand up to vested interests, and do whatever it takes to put the patient back at the center of the healthcare system. ADDIN EN.CITE <EndNote><Cite><Author>Topol</Author><Year>2019</Year><RecNum>87</RecNum><DisplayText>[98]</DisplayText><record><rec-number>87</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555002612">87</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Topol, E.</author></authors></contributors><titles><title>Deep Medicine: How Artificial Intelligence Can Make Medicine Human Again</title></titles><section>37-38</section><dates><year>2019</year></dates><pub-location>New York, NY</pub-location><publisher>Basic Books</publisher><isbn>ISBN: 9781541644632</isbn><urls></urls></record></Cite></EndNote>[98]On September 12, 1962 in a speech at Rice University, President John F. Kennedy said: ADDIN EN.CITE <EndNote><Cite><Author>National Aeronautics and Space Administration</Author><Year>n. d.</Year><RecNum>102</RecNum><DisplayText>[106]</DisplayText><record><rec-number>102</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555702935">102</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>National Aeronautics and Space Administration,</author></authors></contributors><titles><title>John F. Kennedy Moon Speech - Rice Stadium</title></titles><volume>2019</volume><number>December 31</number><dates><year>n. d.</year></dates><urls><related-urls><url>;[106]We choose to go to the moon. We choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one we intend to win.On July 20, 1969 Neil Armstrong said, “That’s one small step for [a] man, one giant leap for mankind.” ADDIN EN.CITE <EndNote><Cite><Author>National Aeronautics and Space Administration</Author><Year>n. d.</Year><RecNum>103</RecNum><DisplayText>[107]</DisplayText><record><rec-number>103</rec-number><foreign-keys><key app="EN" db-id="fzfpteex22vsrkeaz5fvf2xw5pxrpas59zr2" timestamp="1555703276">103</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>National Aeronautics and Space Administration,</author></authors></contributors><titles><title>Apollo 11</title></titles><volume>2019</volume><number>December 31</number><dates><year>n. d.</year></dates><urls><related-urls><url>;[107] We will likely never again see the level of resources and national commitment that went into the Apollo Program. However, as annual US healthcare costs approach 20% of GDP, nearly twice the level of most other industrialized nations, it seems reasonable to ask whether putting our healthcare system on a new and better path isn’t every bit as important as beating the Russians to the moon.References ADDIN EN.REFLIST 1.Hillestad R, Bigelow J, Bower A, et al. Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health Aff (Millwood). 2005;24(5):1103-1117.PMID: 16162551.DOI: 10.1377/hlthaff.24.5.11032.Lee J, Kuo YF, Goodwin JS. The effect of electronic medical record adoption on outcomes in US hospitals. BMC Health Serv Res. 2013;13:39.PMID: 23375071.DOI: 10.1186/1472-6963-13-393.Yanamadala S, Morrison D, Curtin C, et al. Electronic Health Records and Quality of Care: An Observational Study Modeling Impact on Mortality, Readmissions, and Complications. 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