take advantage of EHR capabilities (e.g., the Sprint team model).Tailor the size and makeup of clinician development teams, taking into account the clinical resources available.
Deliver EHR development projects soon after clinicians ask for them.
Establish an EHR governance process that gives the clinical organization nimbleness in responding to health emergencies and crisis scenarios.
Make analytics data available to clinicians—presented in a way that is intuitive at the point of care.
Shift nonessential EHR data entry to ancillary staff. In the near term, consider increasing the number of medical assistants to act as “digital scribes” (though this option is expensive). In the long term, seek automated solutions to eliminate manual EHR documentation.
Reevaluate your organization’s interpretation of privacy rules.
Create opportunities for patients to digitally maintain their records (providing family history, medical history, medications, health monitoring data, etc.).
Junk the fax machine (if you still have one) and embrace electronic communications.
Start accepting electronic payments, if you don’t already.
For Payers
EHRs reflect the current fee‐for‐service payment paradigm. Commit to value‐based care and provide adequate support to clinicians under this model, including greater reimbursement for preventive care services and the use of digital health to engage patients.
Create common standards for billing and quality reporting across payers.
Streamline preauthorization procedures.
Make claims data more accessible to physicians to enable a longitudinal view of their patients.
For Regulators
Affirm commitment to value‐based care and move away from requiring literal documentation of patient‐doctor interactions.
Create more flexibility around who needs to enter data into the EHR, as many tasks do not require the expertise of a highly trained clinician.
Clarify information‐blocking rules to encourage open APIs and eliminate perverse incentives to hoard information.
For Technologists
Clarify definitions of interoperability—in collaboration with other stakeholder groups—and adopt common technical standards to support them.
Develop systems and product updates in partnership with your end users—less than half of U.S. physicians believe EHR developers are responsive to their feedback.
Embrace open APIs and nurture a community of developers to enable an app‐based ecosystem that puts the patient in control.
Develop and market an ecosystem of third‐party apps that put patients in control of their own health data.
Focus on eliminating the manual entry of data into the EHR by recruiting AI, natural language processing, and other emerging technologies.
Develop AI to increase the intelligence of clinical information systems, enabling them toSynthesize relevant information in the EHR before each patient encounter and present the physician with a pithy summary.Combine patient complaint information with EHR databases and the latest medical literature to support medical decision‐making.Deliver current and contextualized information to each member of a patient care team (i.e., enable intelligent “care traffic control”).
Detached and Disconnected from Patients
Much of the health care system is defined by one‐way transactions: patients are diagnosed and receive treatment, but there’s often little communication with the patients and their families about their preferences, their family history, or their financial circumstances. This can lead to ill‐advised decisions about what treatments to provide.
Low Value
The health outcomes in the United States are not what they should be, particularly given the level of spending. In 2016, the United States devoted $3.3 trillion to health care, which was 17.9 percent of the country’s gross domestic product [24]. Other developed economies spend less—a lot less. Among the members of the Organization for Economic Cooperation and Development—a group of developed countries—the second‐highest level of spending in 2016, as a share of GDP, was 12.4 percent (Switzerland) [25]. The U.S. figure was also twice as high as the average of other comparable countries [26]. Yet U.S. health outcomes are typically no better—and often worse—than those found in other developed countries.
Misguided Incentives
Much of the U.S. health care system is based on a reimbursement model that rewards volume of care rather than outcomes of care. As a result, there’s little incentive for physicians or hospitals to focus on whether specific treatments are successful, or on the costs of post‐acute care.
Opaque Pricing
Few people outside the health care industry have a comprehensive understanding of the interplay between health care delivery and the fees charged and the payments made. “Imagine if you paid for an airplane ticket and then got separate and inscrutable bills from the airline, the pilot, the copilot, and the flight attendants,” writes Elisabeth Rosenthal, a Harvard‐trained physician and former New York Times reporter. “That’s how the healthcare market works” [27].
To further illustrate this point, consider a story from Alex Azar, the current U.S. secretary of health and human services. In a March 2018 speech, he recounted his own battle with opaque pricing in a hospital:
A few years ago, my doctor back in Indiana wanted me to do a routine echocardio stress test. I figured this could occur within the scope of his practice, which was connected to a major medical center. Instead, I was sent a few floors down, where I was told to start handing over all sorts of information to a receptionist. Soon enough, I have a plastic wristband slapped on me, and, to my surprise, what I thought would be a simple test in the room next door had resulted in my being admitted to the hospital.
Now, I had a high‐deductible plan, so I would be paying for this test out of pocket. As someone who works in healthcare, I knew that the sticker price on the test had just jumped dramatically by my receiving it within a hospital—something that might never occur to most healthcare consumers. So I asked how much the test was going to cost, and was told that information wasn’t available. Fortunately, I didn’t just fall off the turnip truck, so I persisted, and, eventually the manager of the clinic appeared and gave me the answer. The list price was $5,500.
I knew that wasn’t the right answer either. The key piece of information was what my insurer would pay as a negotiated rate, or what I’d pay with cash. That information didn’t come easily, but eventually, I was told it would be $3,500.
I happened to know of a website where you could search typical prices for such procedures, so I looked up what it would have been if I’d received it outside of the hospital, in a doctor’s office. The answer was $550.
Now, there I was, the former deputy secretary of Health and Human Services, and that is the kind of effort it took to find out how much I would owe for a procedure. What if I had been a grandmother? Or a 20‐something with a high‐deductible plan [28]?
The opaque pricing Azar describes is a source of exasperation for countless individuals, but it also points to the inefficiencies in the system and