EHRs in a Mobile First World

As an aside, before I started this post I was going over my personal task list. I was attempting to add symbols for the various ways in which I can complete tasks (phone, email, etc). This goes back to my days of following GTD. Anyway, what I quickly discovered as I sat at the airport was that none of the tasks I needed to complete could really be done on my smartphone. Well, I could probably complete several of them but it would be incredibly inefficient compared to doing them on my computer. It quickly occurred to me that anything I could do on mobile was already done, and the only tasks left were on hold until I got time on my computer. Most of the on-hold tasks were longer content pieces.

The title of this post refers to a post by Fred Wilson from 8 years ago about building products first for mobile, then for larger form factors. There are lots of success stories of products that launched and only supported mobile (Waze and Instagram to name a couple). For consumer health products, the paradigm of mobile-first development holds true today. Look no further than then the myriad of health and wellness apps in the iOS App Store. To gain adoption and engaged users, mobile is essential. This post isn’t about mobile consumer healthcare apps.

On the enterprise side of healthcare, the dominant software in use today is the EHR. It’s used by all different types of users across clinical, financial, and even operations. Specifically for clinical users, EHRs eat up significant amounts of time each day. By and large, the major EHR vendors (Epic, Cerner, and Athena) are not mobile-first. This means that clinical users are forced to find and spend much of their time each day on a desktop screen. For a very mobile workforce, this is an incredibly inefficient use of time.

There are examples of newer, iPad-first or iPad-only EHRs. My wife and several of her colleagues use a specialty-specific iPad-only EHR from Modernizing Medicine. A scribe charts her encounters and then my wife is left, usually at the end of the week, with 100-150 notes to close out. She does this at home on her iPad but could just as easily close them out on a computer. The reason her EHR is mobile-first, for her at least, is because she has a scribe that charts her encounter while she sees the patient. The caveat to this is she still uses a laptop at home in the evenings to quickly close out notes and do referrals.

Unbundling the EHR

Considering EHRs are inefficient when it comes to eating up clinician time (a very valuable resource), clinicians are a mobile workforce, and nearly 100% of clinicians have smartphones, it’s worth thinking about how to reimagine clinical documentation to be mobile-first. This isn’t to say EHRs don’t help with organizational efficiency but I’m thinking about clinician efficiency. The major EHR vendors listed above are not going to be replaced anytime soon and, if I was an investor, I wouldn’t invest in a new enterprise EHR. That leaves the option of chipping away at specific sets of functionality currently in the EHR. I have come to refer to this as unbundling the EHR.

EHRs in a mobile-first world are only possible by unpacking the functionality of the EHR into discrete workflows/functions that can be completed efficiently on a smartphone. This isn’t replacing the EHR but is a way to make using an EHR more efficient. It’s mobile-enabling the EHR, or more accurately clinical workflow, in a stepwise fashion with a goal to leverage mobile to minimize desktop time and use. The data remains within the EHR (at least for the immediate term) but the ways in which clinicians interface with EHR data are broken up into discrete, mobile-enabled functions. Proving ROI with this approach is not hard if solutions either improve throughput/capacity for clinicians or show benefits like closing out notes in a more timely way and being able to bill faster or more accurately. And marketing these solutions as helping healthcare organizations better leverage the massive investment they have made in EHRs will resonate. Essentially, the goal is to leverage mobile to more efficiently use an EHR and only leave certain functions to non-mobile devices.

In order to succeed the specific functionality enabled on mobile needs to be able to pull the relevant context, usually based on the patient. By definition, these types of solutions are dependent on EHR data and must be able to integrate with the EHR. This is becoming easier as EHRs open up data via FHIR but data integration remains the biggest hurdle to unpacking the EHR and starting to break up the EHR user experience. This is another example of EHR customers needing to push their EHR vendors harder to accelerate initiatives to ease access to EHR data.

Mobile-first EHR Tools

There are already successful examples of unbundling the EHR to leverage mobile. Many of these, even ones that have scaled to hundreds of hospitals, are still only scratching the surface of unbundling the EHR.

• Clinical Communications. Communication is a major part of delivering care to patients. It also happens to be something that EHRs don’t do very well. Companies like Voalte and TigerConnect have built products to connect clinicians. And now these companies are expanding the value to users with new workflows and data integration. I’ve never seen this statistic but I wonder how much time nurses and doctors spend in clinical communication apps vs EHRs.

• Clinical Documentation Improvement (CDI). This is a new mobile-enabled functionality to be unbundled from the EHR. Artifact Health is a good example. Artifact built a mobile application that brings relevant patient context related to CDI into a mobile interface where clinicians can answer simple questions. The answers to those questions are then returned back to the EHR and/or billing. Instead of having a stack of CDI requests linger in an inbox in the EHR or a physical desk, clinicians can now complete CDI requests quickly and easily on the go.

• Real-time Device Data. This is an area where Airstrip still dominates. Airstrip started with maternal heart rate monitors and have since extended to other medical devices as well as EHR data. The goal for Airstrip is to be the mobile interface for clinical workflow and mobile-relevant clinical data. They offer desktop tools but the real success of Airstrip is in focusing on the mobile experience of clinicians.

• Data Entry. Data entry into EHRs is a massive time suck for clinicians. There are a few different approaches to unbundle this functionality from the EHR. The most widely used today is scribing, with companies like Augmedix and iScribes as examples of technology-enabled virtual scribing. Scribing is essentially a Mechanical Turk operation with audio, and sometimes video, recordings of patient encounters documented in the EHR by people other than the providers conducting the encounters. Newer voice-based tools intelligently automate the creation of cards of documentation based on physician speech recording during encounters.

• Virtual Visits. Despite what the EHR vendors may say, telemedicine is not exactly a core EHR function. Increasingly, virtual care is being delivered by clinical staff via mobile apps and services like Spruce Health and Zipnosis.

These are just a few examples. There are lots more opportunities to unbundle specific functionality of the EHR. While not replacing the EHR or even obviously threatening its dominant place in clinical and health IT, the approach of unbundling the EHR chips away at one of the two primary pillars of the EHR moat — the EHR as the primary clinical user interface and the EHR as the primary clinical data repository.

By leveraging mobile, new mobile-first EHR tools have the potential to engage very valuable users — clinicians. Once engaged, there are opportunities to extend functionality with interconnected apps and data (iOS shortcuts would be very interesting ways to link clinical apps into workflows). And, the hardest part of the process, integration with EHR data, is only done once at each site so an extension to new offerings is considerably easier after the first one.

Unbundling the EHR is where we are going to see the most successful disruption of the EHR in enterprise health IT. It’s a matter of timing and the market is now ripe as we shift towards a post-EHR world.