EHR Use During the COVID-19 Pandemic: Advances, Challenges, and Opportunities

On January 30, 2020, the World Health Organization declared a global health emergency due to the rapid spread of the COVID-19 virus.(1) The COVID-19 pandemic quickly highlighted several gaps in the U.S. healthcare system, especially related to emergency preparedness and EHRs. EHR optimization was necessary to address the needs of healthcare systems and researchers as the world began trying to rapidly collect and analyze data to manage patients, understand disease trends, and determine successful disease treatment regimens. Despite encountering several challenges, EHR optimization provided several benefits during the COVID-19 pandemic. This article reviews literature related to EHR use during COVID-19 and reflects on the role of EHRs moving forward.

Implementation and Growth of EHRs

Significant advancements have been made in EHRs since their mandatory implementation in 2014 as a result of the American Recovery and Reimbursement Act. Before this time, challenges in implementation had led to poor adoption of EHRs.(2) Beginning in 2014, EHRs began replacing paper charts, in an effort to adopt a paperless charting system and maintain patient records for easy accessibility and sharing. Studies support that EHRs help to reduce rates of inpatient hospital mortality and readmission and increase patient safety.(3) Since 2014, dramatic enhancements have been made in the functionality of EHRs; from tracking metrics, external program integration, offering clinical decision support, and data sharing. Most recently, EHRs have played a major role in the response to the COVID-19 pandemic, offering benefits to both healthcare providers and patients. The rapid spread of the pandemic forced healthcare workers to test the limits of EHR functionality and adaptation. During this time, several challenges with EHR use were identified. A crucial question to focus on is this: to what extent are EHRs helping with the response to the COVID-19 pandemic? Additionally, what changes related to the EHR can be anticipated moving forward?

Adapting to the COVID-19 Pandemic

The COVID-19 virus created a critical need for standardizing data collection and increasing data sharing in healthcare, including interoperability. Hospital Universitario 12 de Octubre, a 1300-bed tertiary hospital in Madrid, Spain, addressed this by enhancing their EHR to provide the healthcare system and researchers with the ability to collect and share necessary data.(4) This was achieved by standardizing relevant COVID-19 concepts, such as categorizing patients by infection status and level of risk for contracting COVID-19. In addition, the recording of different COVID-19 testing methods required identification and standardization. Clinical alerts that notified hospital staff of patient status also were created. After standardizing COVID-19–related language in the EHR, it was then possible to share the hospital data into databases, and repositories were built to allow for the sharing of real-time data.

Similar EHR adaptations began occurring in the United States. In California, Sudat et al.(5) explored the role of EHRs in the response to COVID-19, beginning in March 2020. Hospitals in California were instructed to provide daily reports with metrics related to COVID-19. Given the nature of EHRs, it was possible to collect metrics extending beyond quantitative medical information. For instance, hospitals were required to provide 66 data elements daily and 37 others weekly. Such metrics included COVID-19 hospital occupancy, COVID-19–related emergency department visits, use of surge beds, personal protective equipment resources, hospital staffing, and in-hospital deaths.(5) Concerning hospital management, Sudat et al. demonstrated that EHR data was crucial to understand occupancy levels and guide the pandemic response.(5) For example, understanding which intensive care units (ICUs) have capacity within a specified region can allow for instant redirecting of COVID-19 patients from another local hospital that has over-occupied ICU units.(5,6)

Such findings, which identified subgroups most at risk, allow for intervention direction and policy recommendations to improve the outcomes of populations that may be left behind while the pandemic response is applied to the general population.

Madhavan et al.(7) published a study aiming to summarize the collective experience of 15 organizations in utilizing EHR in response to the pandemic across different geographical contexts within the United States. In addition to the specific case of California explored by Sudat et al., many other EHR-based initiatives are highlighted in this study. Examples include initiatives based on building (1) specific registries for SARS-COV-2–tested individuals and for those diagnosed with COVID-19 or (2) activation of clinical data networks to access COVID-19 data included in EHRs.(7) Building a disease-based registry involves a variety of domains and offers a number of advantages. These domains include the availability and accessibility for a centralized harmonization and curation of data. This allows for a smooth process of understanding, analyzing, and crunching down numbers and statistics in an accurate and time-efficient manner to understand the epidemiologic dimensions of the COVID-19 crisis among specific populations or geographical settings. Moreover, the clinical data network involves a distributed network of clinics, hospitals, healthcare facilities, and research centers. This provides the ability to use EHR data in clinical setting–based care, as well as for a variety of research purposes that can direct policy making and enhance the response to a pandemic.

In combating pandemics, special attention must be given to vulnerable populations that may be disproportionately affected by the pandemic. Examples of such populations include chronically ill patients, psychiatric patients, and patients with substance use disorders. Wang et al.(8) investigated the use of EHRs in patients with substance use disorders during the COVID-19 pandemic. The findings of this research allowed for extensive analyses of COVID-19 risks and outcomes among such a vulnerable population, which was only possible with the use of EHRs.(8) Such findings, which identified subgroups most at risk, allow for intervention direction and policy recommendations to improve the outcomes of populations that may be left behind while the pandemic response is applied to the general population. For example, a retrospective case study was conducted by searching EHR data from 69.1 million adult and senior patients in the United States, accounting for 20% of the U.S. population. From this population, the study identified 1,064,960 patients with dementia; 15,770 with COVID-19; and 810 with both dementia and COVID-19. The study concluded that people with Alzheimer disease, or other types of dementia, are at increased risk of developing COVID-19. This increase is thought to be due, in part, to memory deficits hindering the ability of those individuals to take COVID-19 preventative precautions; such as wearing a mask and washing hands. In addition, racial disparities in the likelihood of contracting COVID-19 were found.(9)

Telehealth

The COVID-19 virus also created the essential need for EHR adaptation to facilitate telehealth. The telehealth platform allows patients to have an encounter with their healthcare providers while also adhering to social distancing measures and minimizing the odds of being exposed to the virus. In short, EHRs provide healthcare providers and patients a platform to facilitate virtual interaction. A brief commentary published about the healthcare experience of a specific healthcare institution in Georgia showed that the availability of telehealth through EHR allowed over 70% of patients in that institute to continue receiving care virtually from a safe distance.(9) In addition, telehealth changed the nature of patient visits. Given the ability of EHRs to provide a holistic approach to the patient, it was often beneficial to have multiple healthcare team members join telehealth visits and provide a better perspective and quality of care to the patient. More importantly, everything discussed and planned for in a telehealth visit goes into the patient’s EHR, allowing efficiency and accuracy.(10-12) Telehealth visits also improved the accessibility of care, not only by allowing virtual visits but also by minimizing the required time off a patient needs when attending an in-person healthcare appointment. Instead of a physical in-person visit, which usually requires a patient to take a half-day off from work, telehealth via EHR allows a patient to take roughly 20 minutes out of their day and visit with a healthcare provider from the comfort of their couch.(10-12)

Although telehealth requires an adjustment from the previously common in-person visits, telehealth visits are widely applauded by healthcare providers and patients. A study performed at a large academic center in the Netherlands evaluated user satisfaction with video conferencing by providing surveys to both the healthcare providers and patients about their video conference experience.(13) Qualitative data were evaluated to contrast satisfaction outcomes with the actual use of the video. A quantitative technical assessment was performed using data from the EHR record. Results indicated that both patients and healthcare providers were pleased with the video conferencing, with an average patient rating of 8.3/10 and an average healthcare provider rating of 7.6/10. Video conferencing also was found to take less time than initially planned, and the frequency of video conferencing use increased.(13)

Challenges

Although EHRs have demonstrated numerous benefits in the response to COVID-19, many challenges have been identified. The limited published literature on the use of EHRs in responding to the COVID-19 pandemic highlights many challenges and shortcomings in using large-scale data to inform public health decisions. This includes the harmonization of a large number of records to provide data and information for healthcare providers, public health researchers, and policymakers. Furthermore, although urban centers in the United States and elsewhere have high EHR adoption rates, the inequality in EHR utilization across geographical contexts and subpopulations presented a challenge in access to information in a time-sensitive manner in response to COVID-19.(14) When adoption rates of EHRs are not at an adequate level, which is especially the case in rural areas, such models are not fully representative of the true epidemiologic scenario. Other challenges reported included inconsistency in fixed-field real-time diagnoses such as the hospital problem list, difficulty identifying positive patients who received test results from other healthcare facilities, and difficulty identifying COVID-19 patient deaths with confidence without being able to utilize discharge diagnoses.(5)

A retrospective chart review was performed in one of London’s major teaching hospitals to evaluate the completeness of chart diagnosis. This was done by assessing the populated problem list. The study reviewed the widely used EPIC EHR, which had been installed in that hospital one year previously. Charts of patients with either a suspected or confirmed COVID-19 diagnosis were reviewed. In the study, a missed diagnosis was defined as either a new diagnosis or a past medical problem that was not listed in the problem list section in EPIC. Results showed that almost 40% of important diagnoses were missing from the problem list, and were mentioned only in the free text notes.(15) Without accurate history and diagnostic information, medical errors can result and hinder proper medical management. One issue that arises is that healthcare providers want to add more diagnostic information to the choices available from coded diagnosis lists. In certain scenarios, providers cannot always determine clearly whether the diagnosis is “resolved” or “active.” One suggestion is to create a less restrictive problem list.(15)

When an acute change occurs, such as the COVID-19 pandemic, rapid EHR updates are required to keep up with clinical practice needs.

A recently published study found that in addition to other factors, poorly designed EHRs played a role in clinician burnout.(16) Opinions vary in deciding what constitutes a poorly designed EHR, because that judgment depends on various factors, including user preference and EHR functionality in a specific workplace setting. The challenge is that EHRs must continue to keep up and adapt to the changes in the healthcare industry. When an acute change occurs, such as the COVID-19 pandemic, rapid EHR updates are required to keep up with clinical practice needs.(16)

The need for EHR optimization, specifically in the area of interoperability, has caused healthcare systems across the country to consider the long-term cost and sustainability of EHRs. This has led to investigations of ways to reduce costs, such as reducing EHR-associated purchasing costs. A survey conducted by the College of Health Information Management Executives (CHIME) showed that 77% of hospital chief information officers (CIOs) reported operating cost pressure as one of the main challenges in progressing with IT initiatives.(17) This survey was conducted one month prior to the implementation of COVID-19 restrictions in the United States. The CHIME survey reports that 61% of CIOs did not receive the expected value in more than half of their projects with managed service providers. One area of unnecessary cost is redundant contracts with vendors that offer the same functionality. In addition, there is a lack of IT cost transparency.(17) Four specific areas for healthcare systems to focus on are EHR vendors and contracts, productivity and utilization rates for EHR optimization projects, key performance indicators, and smart EHR transition and modernization.

Opportunities for Improvements in Cost, Quality, and Access

One of the main goals of EHRs is to provide patients with the best possible quality of care. Advances in EHRs since the start of the COVID-19 pandemic have paved the way for improvements in cost, quality, and access. In August of 2019, the University of California, San Diego (UCSD) became one of the first college campus–based student health services in the country to adopt and implement an interoperable EHR alongside UC San Diego Health, UCSD’s affiliated health system. The integration significantly improved access and availability of patient health records, for both students and providers. In addition to enhanced patient care management, the interoperability of the EHR system, between the electronic sharing of meaningful patient data and associated outcomes, served as a timely and valuable strategy in response to the many challenges posed by the COVID-19 pandemic. Other benefits included a seamless transition to immediate virtual health visits via telemedicine, continuous clinical decision support, and improved reporting of data and analytics.(18)

As a hybrid patient model emerges, EHRs will continue to play a crucial role in patients attaining quality healthcare.

EHRs must continue to adapt to rapid changes in healthcare. As a hybrid patient model emerges, EHRs will continue to play a crucial role in patients attaining quality healthcare. Healthcare systems and providers must identify how to optimize EHR use while efficiently managing long-term costs. Costs can be reduced by evaluating vendor EHR contracts for redundancy and effectiveness and consolidating them. Reevaluating EHRs and establishing processes, language standardization, and productivity metrics can also aid in cost reduction.(17)

Conclusion

After over a year of responding to the COVID-19 pandemic, EHRs continue to aid with response in three main domains: (1) enhancing data access using analytics; (2) implementing EHR dashboards to guide quick macro level response; and (3) facilitating the use of telehealth to increase accessibility during a pandemic that requires social-distancing measures and minimizing exposures. Throughout the pandemic, one of the biggest limitations of EHRs that emerged and caught the attention of experts is the need for further interdisciplinary collaborations. In the context of clinical operations and health providers, there is a call to engage more fully with researchers, analysts, and data scientists as part of the clinical team.(5) The expertise of the involved parties in utilization of EHR data provides essential feedback for healthcare provider’s everyday practice and allows them to do their job more effectively and adequately. This benefits patients and informs the community, especially in vulnerable scenarios such as that of a pandemic. An ongoing challenge to this is interoperability. Despite the EHR’s ability to share information between different healthcare systems, there still are inconsistencies among EHR systems. Sharing data is challenging because of the heterogeneity of the data formats and standards.(19)

Healthcare has changed drastically throughout history, and traditional in-person visits are no longer always a feasible option. EHRs have brought about a new wave of cultural change that allows patients, doctors, and multidisciplinary healthcare teams to interact virtually with one purpose: to work together in managing health and toward achieving the best possible patient quality of care. Telehealth can be considered one of the positive outcomes that this tragic pandemic brought to the forefront. Healthcare providers are encouraged to continue utilizing telehealth to enable efficient and accessible care to their patients.

Whether it is to direct policy making by providing time-sensitive accurate data, aid in research efforts to identify gaps in the current response, or to provide the best possible care to their patients, healthcare providers have a responsibility to build a suitable EHR infrastructure and enable a cultural change in their practice settings to utilize EHRs. Proper utilization would prepare providers for future health crises, facilitate access for their patients, and provide a tool for the next generation of researchers to efficiently strengthen our understanding of future health issues.

References

1. Velavan TP, Meyer CG. The COVID-19 epidemic. Trop Med Int Health. 2020;25:278-280. DOI:10.1111/tmi.13383

2. Jha AK, DesRoches CM, Campbell EG, et al. Use of electronic health records in U.S. hospitals. N Engl J Med. 2009;360:1628-1638. DOI:10.1056/NEJMsa0900592

3. Yanamadala S, Morrison D, Curtin C, McDonald K, Hernandez-Boussard T. Electronic health records and quality of care: an observational study modeling impact on mortality, readmissions, and complications. Medicine. 2016;95(18):e3332. DOI:10.1097/MD.0000000000003332

4. Pedrera M, Garcia N, Blanco A, et al. Use of EHRs in a tertiary hospital during COVID-19 pandemic: a multi-purpose approach based on standards . . . Medical Informatics Europe, Public Health and Informatics Conference (Virtual), 29-31 May, 2021. Stud Health Technol Inform. 2021;(281):28-32. DOI:10.3233/SHTI210114

5. Sudat SE, Robinson SC, Mudiganti S, Mani A, Pressman AR. Mind the clinical-analytic gap: electronic health records and COVID-19 pandemic response. J Biomed Inform. 2021;116:103715. DOI: 10.1016/j.jbi.2021.103715. Epub 2021 Feb 19.

6. Patel P, Tsionas M, Devaraj S. EHR investments, relative bed allocation for Covid-19 patients and local COVID-19 incidence and death rates: a simulation and an empirical study. SSRN. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3793919

7. Madhavan S, Bastarache L, Brown JS, et al. Use of electronic health records to support a public health response to the COVID-19 pandemic in the United States: a perspective from 15 academic medical centers. J Am Med Inform Assoc. 2021;28:393-401. DOI: 10.1093/jamia/ocaa287.

8. Wang QQ, Kaelber DC, Xu R, Volkow ND. COVID-19 risk and outcomes in patients with substance use disorders: analyses from electronic health records in the United States. Mol Psychiatry. 2021;26(1):30-39. DOI:10.1038/s41380-020-00880-7

9. Jason C. How EHR systems improve COVID-19 public health response. EHR Intelligence. January 7, 2021. https://ehrintelligence.com/news/how-ehr-systems-improve-covid-19-public-health-response . Accessed June 1, 2021.

10. Jason C. How EHR telehealth integration evolved patient care during COVID-19. EHR Intelligence. https://ehrintelligence.com/news/how-ehr-telehealth-integration-evolved-patient-care-during-covid-19 . Accessed June 9, 2021.

11. Jason C. 3 ways providers use EHRs to treat COVID-19 patients. EHR Intelligence. June 29, 2020. https://ehrintelligence.com/news/3-ways-providers-use-ehrs-to-treat-covid-19-patients . Accessed June 1, 2021.

12. Kreimer S. Patients with dementia face higher risk for COVID-19: EHRs reveal adverse outcomes and disparities. Neurology Today. 2021;21(5):30-31. DOI:10.1097/01.nt.0000738072.99199.82

13. Barsom EZ, Meijer HAW, Blom J, Schuuring MJ, Bemelman WA, Schijven MP. Emergency upscaling of video consultation during the COVID-19 pandemic: contrasting user experience with data insights from the electronic health record in a large academic hospital. Int J Med Inform. 2021;150. DOI:10.1016/j.ijmedinf.2021.104463

14. Pryor R, Atkinson C, Cooper K, et al. The electronic medical record and COVID-19: is it up to the challenge? Am J Infect Control. 2020;48(8):966.

15. Poulos J, Zhu L, Shah AD. Data gaps in electronic health record (EHR) systems: an audit of problem list completeness during the COVID-19 pandemic. Int J Med Inform. 2021 Jun;150:104452. DOI:10.1016/j.ijmedinf.2021.104452. Epub 2021 Apr 1.

16. Kroth PJ, Morioka-Douglas N, Veres S, et al. Association of electronic health record design and use factors with clinician stress and burnout. JAMA Netw Open. 2019;2(8):e199609. DOI:10.1001/jamanetworkopen.2019.9609

17. Zand P. EHR sustainability and long-term costs in the COVID era. For the Record. 2020;32(6):30-31. Accessed June 9, 2021. http://search.ebscohost.com/login.aspx?direct=true&AuthType=shib&db=rzh&AN=146857147&site=eds-live

18. Reeves JJ, Longhurst CA, San Miguel SJ, et al. Bringing student health and well-being onto a health system EHR: the benefits of integration in the COVID-19 era. J Am Coll Health. 2020;Nov 12:1-7. DOI: 10.1080/07448481.2020.1843468. Online ahead of print.

19. Dagliati A, Malovini A, Tibollo V, Bellazzi R. Health informatics and EHR to support clinical research in the COVID-19 pandemic: an overview. Brief Bioinform. 2021;22:812-822. DOI:10.1093/bib/bbaa418