As EHR is increasingly implemented nationwide, both opportunities and challenges emerge.
In sleep medicine, we are living on the cusp of a change that reflects opportunities for better information exchange and improved quality in clinical pathways. The opportunities are attributable to recent nurturing strategies from federal healthcare strategies and the national sleep medicine quality guidelines.
The United States has lagged behind much of Europe in the implementation of information technology in healthcare1 and has been sluggish in particular in electronic health records (EHR) implementation due to the fragmented structure of the healthcare system and barriers such as privacy concerns between systems compounded by the lack of economic incentives for addressing integration and solving interoperability barriers.2 This fragmented care and orientation of incentives have likely contributed to the United States’ lower rankings in healthcare. In chronic disease management, the United States ranks 11th (in other words, last) relative to other industrialized countries, according to the Commonwealth Fund.3
The current explosion of capability in information gathering and exchange and the rollout of the Health Information Technology for Economic and Clinical Health (HITECH) Act and the Patient Protection and Affordable Care Act (PPACA) have provided an engine for change and spurred a near doubling4 of the use of EHR in office-based practices. Since the 2010 rollout, there have been broader outcome benefits, including improvement in patient satisfaction and provider adherence to standard care5 as well as a reversal of negative trends6 in uninsured patients and hospital readmissions. The federal initiatives have resulted in dramatic increases in EHR products and development. In sleep medicine, the American Academy of Sleep Medicine (AASM) has complemented this by encouraging a more standardized approach with quality standards7 and leveraging of telemedicine and information technology8 to improve quality and efficiency of care.
At the ground level, not all processing has been smooth. Change has an uncomfortable side, including unexpected outcomes, that must be managed. Preoccupation with electronic monitors may degrade patient communication10 and standardized templates may not reflect detailed information11 necessary to care. Integration of EHR must be complemented by methods for preserving information and communication that are requisite to excellent care. Incorporation of dictated components of patient assessment and preservation of necessary face-to-face time with patients will need to balance virtual tools such as templates and electronic communications with patients. Encouraging healthy change in habits is the local work of local leadership and needs to be supported by change management strategies in order for innovation in information processing to be successful.
The purpose of leveraging information technology is to improve care in sleep medicine. Empowerment by information technology can improve quality by addressing shortfalls in provision of end-to-end care and patient-centered care by connecting patients and processes such as team coordination and automated data transfer. Efficiencies are created by virtual methods that improve access to care in sleep medicine.
There are ways that telehealth-EHR integration might be leveraged more broadly. Examples include:
- home-centered diagnostic care with expansion of home diagnostic strategies and patient access to the EHR for completion of electronic assessment questionnaires;
- patient EHR access for bidirectional virtual communications for completion of action items from visits;
- home to EHR data transfer from sleep schedule monitoring devices, CPAP, and dental devices;
- virtual visits or self-directed follow-up care to replace routine clinic follow-up visits for coaching and counseling;
- care coordinators using daily updated EHR-based databases for facilitating individual coaching and population management.
Examples of optimization in EHR include these best practices: alerts and the development of pre-populated evaluation, communication, and ordering templates for improving efficiency and standardization of care. Many of these examples are currently in limited implementation in sleep medicine nationally. Virtual care coaching has been shown to improve adherence to therapy in CPAP management,12 and data transfer directly into EHR and middleware has already been achieved by manufacturers and includes the capability for identifying patients who do not achieve outcome benchmarks in care and for ensuring retention of patients in care pathways for end-to-end care strategies.
Though controversial initially, the current national directions in healthcare including EHR optimization and integration are making early strides to improve some health outcomes. In sleep medicine, teaming these recently supported national initiatives with redesign of clinical pathways to leverage standardization and virtual methods can provide a better foundation for comprehensive care, end-to-end clinical pathways, and patient-centered care. In this process of change, we are creating new territories that will require self-examination and steering in addition to the commitment for better solutions.
Conrad Iber, MD, is medical director of the Fairview/University of Minnesota Health Sleep Medicine Program and former president of the American Academy of Sleep Medicine.
1. Schoen C, Osborn R, Squires D, et al. A survey of primary care doctors in ten countries shows progress in use of health information technology, less in other areas. Health Aff (Millwood). 2012;31:2805-16.
2. Blumenthal D. Wiring the health system—origins and provisions of a new federal program. N Engl J Med. 2011;365:2323-9.
3. Davis K, Stremikis K, Schoen C, Squires D. Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally. June 2014.
4. Health and Human Services. Report to Congress: Update on the Adoption of Health Information Technology and Related Efforts to Facilitate the Electronic Use and Exchange of Health Information. October 2014.
5. Adler-Milstein J, Everson J, Lee SD. EHR adoption and hospital performance: time-related effects. Health Serv Res. 2015.
6. Blumenthal D, Abrams M, Nuzum R. The Affordable Care Act at 5 years. N Engl J Med. 2015;373:1580.
7. Morgenthaler TI, Aronsky AJ, Carden KA, Chervin RD, Thomas SM, Watson NF. Measurement of quality to improve care in sleep medicine. J Clin Sleep Med. 2015;11:279-91.
8. Singh J, Badr MS, Diebert W, et al. American Academy of Sleep Medicine (AASM) Position Paper for the Use of Telemedicine for the Diagnosis and Treatment of Sleep Disorders. J Clin Sleep Med. 2015;11:1187-98.
10. Margalit RS, Roter D, Dunevant MA, Larson S, Reis S. Electronic medical record use and physician-patient communication: an observational study of Israeli primary care encounters. Patient Educ Couns. 2006;61:134-41.
11. Quan SF. The electronic health record: the train is coming. J Clin Sleep Med. 2009;5:101.
12. Fox N, Hirsch-Allen AJ, Goodfellow E, et al. The impact of a telemedicine monitoring system on positive airway pressure adherence in patients with obstructive sleep apnea: a randomized controlled trial. Sleep. 2012;35:477-81.