Clinical decision support tools in the EHR are gaining momentum. These exciting and meaningful innovations are challenging us to make room for them to flourish.
New technology is often disruptive before it finds its way to being helpful. In the late 1800s, the telephone created unexpected challenges in medical practice at its inception; it brought a need for new team members to answer calls and required doctors and patients to develop and adjust expectations around phone outreach. The original electronic health record (EHR) design improved digital documentation and billing efficiency but did little to enhance clinical excellence. Rather, it vastly increased clinicians’ task workload and diminished career satisfaction.
Recently, in contrast, I have attended seminars preparing our primary care group for new decision support tools in our EHR. One is an AI-assisted program that identifies patients with non-valvular atrial fibrillation at high risk for stroke who may benefit from having an anticoagulant added to their medical regimen. Another uses similar technology to identify patients who may have familial hyperlipidemia and are currently undertreated. A third alert triggers clinicians to consider a possible diagnosis of hyperaldosteronism in certain patients with resistant hypertension. This is just the tip of the iceberg. These “nudges” – choice prompts designed to alter clinician behavior in a predictable way – are highly valuable for improving medical diagnosis and achieving best practice treatment goals. While the alerts may cause a few extra keystrokes and prompt some unexpected conversations during patient visits, they are improving care by augmenting my doctoring knowledge and skills.
This stands in stark contrast to the multitude of redundant EHR tasks we are accustomed to, which add little value to patient care and contribute to physician burnout. This includes things like excessive visit documentation, drug interaction alerts for medicines patients have been receiving and renewing for years, repetitive password entry requirements, prompts to add diagnoses to problem lists or refine ICD-10 codes. Even some important preventive metrics arguably do not require a physician’s level of training to complete, such as falls risk assessment, orders for mammography, colon cancer screening, and routine vaccination.
Well-designed clinical EHR nudges are a welcome change. Finally, we are able to leverage the extraordinary capacity of digital health data to improve clinical reasoning and diagnosis in the exam room. While awaiting these advances, though, a multitude of below-license tasks have usurped clinicians’ capacity during patient encounters. It is now more pressing than ever to develop workflows to offload these tasks to non-clinician team members to make room for true digitally assisted doctoring. The solution, as it has been for other task overload challenges, is team-based care. Nurses, medical assistants, and population health associates can develop processes to address screening surveys and place test orders for clinician approval. Clinicians can address unexpected replies to questions, which raise concern or hesitancy around testing or vaccination, sparing them from the straightforward responses. These are not new challenges, but advances in decision-support technology have raised their level of urgency. There is only so much time and breadth in an office visit, whether virtual or in-person. Artificial intelligence may someday automate many of these tasks, so we can reduce the cost-heavy need for hiring excessive staff – now a scarce resource.
Digital decision support also implores some rethinking of value-based incentives. To date, there is little evidence that current financial incentive metrics improve health outcomes. Collecting and analyzing data on the influence of clinical decision support nudges on patient outcomes will help define health care value more clearly. This, in turn, may inform the development of performance incentives that are most clinically relevant and impactful in caring for patients.
Nudges have great potential to enhance clinicians’ skills to improve diagnostic accuracy and keep management current and evidence-based. Patients are the center of this effort and stand to gain from more consistent, clinically excellent care. Further, nudges create a need for meaningful conversations and shared decision-making, which, when not squeezed into brief, checkbox-encumbered visits, may challenge primary care clinicians in ways that restore a stronger sense of professional purpose. It is time to think carefully about how to make room for and incentivize their routine use.
Jeffrey H. Millstein is an internal medicine physician.
