The Electronic Health Record Problem | Commonwealth Fund

EHRs have one critical performance requirement: generating clinical revenues. In the fee-for-service world

Source: The Electronic Health Record Problem | Commonwealth Fund

It’s no secret that many physicians are unhappy with their electronic health records (EHRs). They say they spend too much time keying in data and too little making eye contact with patients. They say their electronic records are clunky, poorly designed, hard to navigate, and cluttered with useless detail that colleagues have cut and pasted to meet documentation requirements. Meanwhile, the data they really need are buried almost beyond retrieval.

Not all physicians feel this way. Two-thirds of primary care physicians say there are satisfied with their current EHRs, according to a 2018 survey by The Harris Poll. But the critics have a point. Current EHRs are not well-designed to meet the needs of users. And they don’t do enough to make clinicians smarter and more efficient. This doesn’t mean we would be better off in the paper world of 10 years ago. But it does mean that EHRs need improvement.

As we think about improving them, we need to broaden the discussion of EHRs and their role. We need to reckon with the underlying causes of EHRs’ problems, how to correct them, and how to ensure that their enormous potential benefits are understood and realized.

The Causes

EHRs are a technology. Like most technologies, they can be used in a variety of ways for a variety of purposes. Their human masters decide.

In our current health system, EHRs have one critical performance requirement: generating clinical revenues. In the fee-for-service world, this means supporting providers’ billing and documentation to generate as much revenue as possible for each clinical service. EHRs also must help providers meet regulatory requirements that may have financial or accreditation implications.

This means that current EHRs were not created to support many of the things that physicians, patients, and policymakers value: better care experiences, reduced costs, or improved care quality and population health management. They were not created to make physicians better diagnosticians or more cost-effective prescribers. The reason: our health care system has mostly not rewarded these activities. They have not been mission-critical for providers or, therefore, EHR designers.

For that reason, EHRs have only the most minimal capabilities related to clinical decision support, which has been proven to increase the quality of care, or to the collection of information on duplicate and unnecessary testing, or on the aggregate health of providers’ patient populations.

To put it simply, improving EHRs will require changing the priorities governing their design. That means moving away from fee-for-service payment toward risk-sharing by providers and, ultimately, some form of prospective compensation. Until then, optimizing the usability and value of EHRs will be an uphill struggle.

EHRs’ Undervalued Benefits: Empowering Patients and Advancing Human Health

Because the benefits of EHRs may be less visible than their burdens, some of their contributions are overlooked and undervalued.

One of these benefits is giving patients access to their medical information. Meaningful-use requirements spurred the adoption of patient portals, which, though sometimes clunky, have enabled patients for the first time to routinely see their test and procedure results. Patients can also now download their entire digital record and share it with third parties that can analyze its contents and educate them on their significance. Apple, for example, has agreements with over 100 health systems and practices to perform this function, which is likely to spawn a deluge of consumer-friendly health care applications based on patients’ own information.

Another underrated EHR benefit is that, by capturing billions of patient encounters worldwide, electronic records are generating a vast store of digital health data that are available for novel uses, including research into the causes and cures of disease and the detection and prevention of threats to public health.

Think of these data as the equivalent of a new natural resource, like water or minerals; they sit in the cloud, ready for extraction, refinement, and application. Their value is increasingly understood by technology companies, new startups as well as old stalwarts, that are pouring billions into exploiting them. There are obvious privacy and security issues raised by this development. But never before in human history have we had access to this novel (un)natural resource.

In entering all that data at the point of clinical care, health professionals and patients are creating a public good. But they get little tangible in return — at least in the short run. This maldistribution of benefit and cost lies at the heart of the current EHR controversy.

What Next?

To make health professionals’ work easier, and to exploit the vast potential of EHRs, a number of interventions make sense.

The most important is unrelated to the technology. Clinicians unhappy with EHRs have a huge stake in moving from fee-for-service to value-based payment, so that providers and their EHR vendors start to prioritize the production of health and the reduction of waste in health systems. This will reduce documentation requirements, spur the creation of decision support and information exchange that make clinicians’ lives better, and focus attention on getting value from the information so laboriously recorded by doctors and other health professionals.

A second requirement will be to lower the burden of data entry. Many providers have started using scribes to take notes during visits. While many physicians love scribes, they are expensive. A better long-term solution would be to use natural language processing and artificial intelligence to enable clinicians’ conversations with patients and their subsequent assessment and treatment plan to be recorded in real time. Given the increasing power of these technologies, such applications will soon be available.

Another approach to assisting data entry is to systematically redesign records for ease of use and to prune away unnecessary recording requirements. A recent New England Journal of Medicine commentary provided an excellent example of the benefits of this intervention.

A third requirement for EHR improvement falls to health professionals. When I was a medical student, I spent hundreds of hours learning how to take notes in the paper world. More experienced clinicians reviewed and graded these write-ups. Later, as a young physician, I observed the notes of clinicians I admired, and emulated them. This process of professional education in record-keeping unfolded over years and forever shaped my note-writing habits. If physicians are unhappy with how their colleagues use EHRs, they should start educating young physicians — and their peers — on how to properly keep records in the electronic world. What and how data get recorded are ultimately a professional responsibility.

Lastly, we need to find a way to correct the maldistribution of costs and benefits that now plagues the use of EHRs. By creating vast troves of electronic data and enabling patient empowerment, clinicians and their patients perform a valuable public service that has thus far been unrecognized and unrewarded. Reducing the cost of data entry will help, but as the benefits of EHRs and their data become monetized — as they will — some way to share those gains with clinicians and patients at the frontlines should be considered. This could be accomplished in a variety of ways such as voluntary contributions from businesses that rely on EHR data to an EHR innovation fund and/or directing a share of the taxes paid by these businesses to EHR improvement. But at least until EHRs become much more user friendly, this problem of unfair allocation of benefit and cost needs attention.

We are not going back to the paper world, but EHRs need to work better. As they pursue this goal, clinicians, policymakers, managers, and vendors need to understand and address the root causes of the problem they are trying to solve, and the full array of options for addressing it.


Health indicators in intellectual developmental disorders: The key findings of the POMONA‐ESP project

Source: Health indicators in intellectual developmental disorders: The key findings of the POMONA‐ESP project – Folch – – Journal of Applied Research in Intellectual Disabilities – Wiley Online Library

Annabel Folch, Luis Salvador‐Carulla, Paloma Vicens, Maria José Cortés, Marcia Irazábal, Silvia Muñoz, Lluís Rovira, Carmen Orejuela, Juan A. González, Rafael Martínez‐Leal



The aim of this paper was to summarize the main results of the POMONA‐ESP project, the first study to explore health status in a large representative, randomized and stratified sample of people with intellectual developmental disorders in Spain.


The POMONA‐ESP project collected information about the health of 953 individuals with intellectual developmental disorders.


Diseases such as urinary incontinence, oral problems, epilepsy, constipation or obesity were highly prevalent among the participants; with gender‐differentiated prevalences for certain conditions, and age and intellectual disability level as risk factors for disease. Overmedication was common in the sample, and drugs were often prescribed without any clinical indication or follow‐up. The present authors also found a lack of important relevant information about the participant’s health and a lack of adequate genetic counselling.


Our findings may contribute to a better understanding of health status and needs of people with intellectual developmental disorders and suggest several courses of action to improve their health care.

Promoting Better Health Beyond Health Care

State-level multi-sector actions for addressing the social, economic, and environmental factors that impact health

May 2018

As part of their Better Health Beyond Health Care initiative, the Center for Health Care Strategies (CHCS) conducted a national analysis on innovative ways to promote health. This report discusses the resulting findings and summarizes information from thirty key informant interviews representing programs in 19 states and a small group convening. It explores ways collaboration and cross-sector partnerships can help promote population health and improve outcomes.
Source: Center for Health Care Strategies (CHCS) 

National experts and state policymakers increasingly recognize that health outcomes are influenced not only by providing access to health care coverage and services, but also by state level policies in non-health sectors, such as agriculture, education, and transportation, among others. The Center for Health Care Strategies (CHCS), with support from the Robert Wood Johnson Foundation, conducted a national exploration of state-level strategies to promote health beyond the traditional health care levers. Through review of published and gray literature, interviews with state officials and relevant subject matter experts, in-depth site visits, and a small group convening, CHCS aimed to answer key questions, including: 1. What are the levers across state agencies that could be used to improve population health, either through specific policy action or by exerting state influence? 2. What are examples of diverse state agencies working together and with other community partners to improve population health? 3. What are the key factors necessary to promote effective cross-sector collaborations? 4. What types of technical assistance and facilitation would increase states’ capacity to pursue and successfully implement these actions? 5. How might state-level assistance be targeted to support and scale similar innovation? Following is a summary of key takeaways from this exploration, organized according to: (1) precursors, or foundational factors that help to prime the environment for state action; (2) catalysts that initiate and advance coordination among diverse state agencies; and (3) success factors for effective implementation and ongoing collaboration.

Mental Health-related Physician Office Visits by Adults Aged 18 and Over: United States, 2012–2014

Source: Products – Data Briefs – Number 311 – June 2018

Key findings

Data from the National Ambulatory Medical Care Survey

  • Among adults aged 18 and over, the rate of mental health-related physician office visits to psychiatrists (693 per 10,000 adults) was higher compared with the rate to primary care physicians overall (397 per 10,000 adults), and for all age groups except 65 and over.
  • For both men and women, the rate of mental health-related office visits to psychiatrists was higher compared with visits to primary care physicians.
  • The percentage of mental health-related office visits to psychiatrists compared with primary care physicians was lower in rural areas, but higher in large metropolitan areas.
  • For all primary expected sources of payment except Medicare, a higher percentage of mental health-related office visits were to psychiatrists rather than to primary care physicians.

In 2016, mental illness affected about 45 million U.S. adults (1). Although mental health-related office visits are often made to psychiatrists (2), primary care physicians can serve as the main source of treatment for patients with mental health issues (3); however, availability of provider type may vary by geographic region (3,4). This report uses data from the 2012–2014 National Ambulatory Medical Care Survey (NAMCS) to examine adult mental health-related physician office visits by specialty and selected patient characteristics.

Know the Science

Source: National Center for Complementary and Integrative Health (NCCIH) – Know the Science

Why is it important to know the science of health? Simply put, because there is a lot of misinformation out there—from anecdotes disguised as evidence to excessive claims made by supplement manufacturers to TV doctors touting the latest “miracle cure.”

On this page you’ll find tools to help you better understand complex scientific topics that relate to health research so that you can be discerning about what you hear and read and make well-informed decisions about your health. Know the Science features a variety of materials including interactive modules, quizzes, and videos to provide engaging, straightforward content. Learn more about how the Know the Science initiative got started.

So, what are you waiting for? Dive in, and get to know the science.

Interactive Modules

Take our module on making sense of health research

Know the Science: 9 Questions To Help You Make Sense of Health Research

Understanding the basics of scientific studies to help you make better health decisions.

Take our module on understanding health news

Know the Science: The Facts About Health News Stories

Find out how to tell if a news story is reliable or has missing, misleading, or conflicting information.

MLTSS for People for Intellectual and Developmental Disabilities: Strategies for Success

Managed Long-term Services and Supports (MLTSS) 
MLTSS for People for Intellectual and Developmental Disabilities: Strategies for Success 
The National Association of States United for Aging and Disabilities (NASUAD), along with the National Association of State Directors of Developmental Disabilities Services (NASDDDS) and Ari Ne’eman of are the authors of this important report MLTSS for People for Intellectual and Developmental Disabilities: Strategies for Success. 
Because there are unique challenges in implementing a managed long-term services and supports (MLTSS) program for people with intellectual and developmental disabilities (I/DD), the report provides context on the intersection of program design and participant advocacy and outlines successful strategies for both states and health plans. Promising practices from the few MLTSS programs delivering I/DD services are highlighted throughout.  Check it out if your state is engaged in MLTSS or is thinking about/planning for the transition.  

Opportunities for Improving Programs and Services for Children with Disabilities 

Health Services 
Opportunities for Improving Programs and Services for Children with Disabilities 
While a variety of services and programs exist to support the needs of children with disabilities and their families, a focus on achieving specific near- and long-term goals that help prepare for adulthood and coordination of care within and across service sectors are integral to encouraging healthy growth and development, says a new 
report from the National Academies of Sciences, Engineering, and Medicine.  The committee that conducted the study and wrote the report examined federal, state, and local programs and services in a range of areas, such as health care, special education, transition to adulthood, vocational rehabilitation, and social needs care.

Responsive Practice | Institute on Disability/UCED

“Responsive Practice builds on knowledge that providers already have and identifies opportunities to maximize wellness for individuals with disabilities,” explains Kimberly Phillips, DPH Principal Investigator and co-author of the training.” 

Source: Responsive Practice | Institute on Disability/UCED

Responsive Practice 
Responsive Practice: Providing Health Care & Screenings to Individuals with Disabilities
The New Hampshire Disability and Public Health (DPH) project’s Responsive Practice training is now available online, on-demand, and is free for a limited time. Responsive Practice enhances health care providers’ ability to deliver disability-competent care that is accessible to people with intellectual, mobility, and other disabilities.

Health conditions, functional status and health care utilization in adults with cerebral palsy

Family Practice, 2018, 1–10

Robert J Fortuna1,*, Ashley Holub2, Margaret A Turk3, Jon Meccarello4 and Philip W Davidson4

1 Departments of Internal Medicine and Pediatrics and
2 Department of Public Health Sciences, University of Rochester, Rochester, NY, USA,
3 Department of Pediatrics and Physical Medicine and Rehabilitation, State University of New York Upstate Medical University, Syracuse, NY, USA and
4 Department of Pediatrics, Neurodevelopmental and Behavioral Pediatrics, University of Rochester, Rochester, NY, USA

*Correspondence to Robert J. Fortuna, Departments of Internal Medicine and Pediatrics, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA; E-mail:


Aim. Health conditions in children with cerebral palsy (CP) are well described, yet health is less defined with advancing age. We examined health conditions, functional status and health care utilization in adults with CP across age groups.

Methods. We collected cross-sectional data on health conditions, functional status and utilization from the medical records of adults with CP across a large university-affiliated primary care network using the Rochester Health Status Survey IV (RHSS-IV), a 58-item validated survey. Data from the National Health and Nutrition Examination Survey and National Health Interview Survey provided prevalence estimates for the general population as comparison.

Results. Compared to the general population, adults with CP had higher rates of seizure disorder, obesity and asthma across all ages. Adults with CP under 30 years of age had higher rates of hypertension (16.7 versus 5.6%; P = 0.04), urinary incontinence (41.7 versus 10.5%; P < 0.001) and depression (16.7 versus 6.9%; P = 0.07). Conversely, there were lower rates of alcohol misuse, tobacco/nicotine and sexually transmitted illnesses. Independence with all activities of daily living decreased from 37.5% at 18–29 years of age to 22.5% in those 60 and over. Seizure disorders, urinary incontinence and gastroesophageal reflux disease were all independently associated with lower functional status. As expected, health care utilization increased with advancing age.

Conclusions: Adults with CP should be monitored for conditions occurring at higher prevalence in CP, as well as common conditions occurring with advancing age. Age-related functional decline should be anticipated, especially with coexisting seizure disorders and urinary incontinence.

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