Podcast – Evolving the EHR to Enable Patient-Centered Care

In this episode of Kidney Health Connections, Dr. George Hart and Sam Gopal, president of Acumen Physician Solutions, discuss the evolution and challenges of the electronic health record (EHR). Acknowledging the frustrations many physicians feel with record keeping taking time away from patient care, Gopal explains that EHRs are essential for capturing longitudinal patient data and analytics. He describes current efforts to make EHRs more user-centered, incorporating features like ambient listening and generative AI to streamline documentation and reduce administrative burdens, ultimately aiming to enhance physician-patient interaction.

In a discussion on the future of the healthcare, Gopal says we are at an inflection point. As EHR systems mature, they will evolve from mere digital repositories to essential tools for population health management. With decades of data now stored in EHRs enabling predictive analytics and proactive patient care, Gopal envisions EHRs evolving into supportive "copilots" that empower doctors by delivering relevant information while minimizing distractions. The goal is restoring the focus on patient-centered care.

Transcript:

Welcome to Kidney Health Connections, a podcast exploring the future of kidney health and the rapid shift to value-based care, where you can learn about the latest innovations that are helping patients live healthier, more fulfilling lives. Here's your host, Dr. George Hart.

Dr. George Hart: Hello, everyone. It's no secret that physicians of my generation have a love hate relationship with the electronic health record, or EHR. However, in this day and age, no one would deny that EHRs are an absolute necessity for running an efficient, effective practice. But many providers today are still frustrated with the EHR usability.

How do we help them get back to the bedside and minimize the time needed for documentation, yet help them focus on what we need accomplished, all the while balancing value-based care versus fee-for-service needs? How do we make this powerful technology work for us and not the other way around?

Today, we welcome Sam Gopal, who leads a team at Interwell Health developing Acumen Epic Connect, which is the most adopted nephrology specific EHR. We will discuss how the EHR has evolved and become more specialized and all that is required for helping physicians make the transition to value-based kidney care. Sam, it's good to see you and thanks for joining.

Sam Gopal: First off, George, thank you for having me. It's always a pleasure to chat with you. And you said something about providers of your generation being frustrated with EHRs. I think it runs the gamut, so let's address the elephant in the room. I think what we have today at our disposal is this absolutely phenomenal technology, but at the same time what we also have to address is that fundamentally we're trying to bring a human element into the equation here. You chose to enter medicine to take care of people, to address your patient needs. This is not an inaccurate guess, right?

Dr. George Hart: Absolutely.

Sam Gopal: And so, I think today…

Dr. George Hart: Remember, I grew up on paper.

Sam Gopal: Yeah, that's right. And while you were charting on paper, in your encounter, you were able to focus 100 percent on your patient. You could build that trusted relationship, and oftentimes, I think — I've seen you; I've shadowed and seen you practice — and you pick up on cues from body language, from that insight about the patient relationship, that would never happen unless you had that physical interaction opportunity.

And I think what's getting in the way today is less around the concept of the electronic health record, or all the benefits that you get from taking data out of those physical charts that are tucked away in a provider's filing cabinet, and being able to utilize that information digitally for all kinds of longitudinal information about the patient's journey and all the robust analytics capability. That's the promise of the EHR. But the reality is, at the point of care, it is an impediment. It gets in the way of you building that human connection with your patient.

 

 

Dr. George Hart: Well, sometimes, Sam, it's actually in the way. The computer will stand between the physician and the patient. So, I think you're really right in how you're characterizing this.

Sam Gopal: That's right. And I remember when I grew up, I'm not your generation, but I remember, I had to take some classes for touch typing. My kids, they grew up on their mobile phones and they don't know how to type. And so some of the younger doctors that I see coming into using EHRs struggle with keyboards and all the time it takes to get through the actual hunting and pecking for information during the visit.

So, it's a universal problem. And I think if we actually structure the issue, it's less about why is the EHR a problem and more about how do we make the technology more user-centric at the point of care. How do we bring in the right interfaces for providers to maintain their focus and view of the patient while accommodating all they need to do to document their encounter and their takeaways from the notes while being able to see all the other information that's coming in from the longitudinal view of the patient. That's what we're trying to solve here.

I'm excited and optimistic. I know historically we've struggled a little bit and some of this has to do with sequencing. It's about the tools that have been available at our disposal for that human interface. And it's been the keyboard, it's been the monitor, and it's been the computer on a cart. And that all gets in the way. It's bulky.

You know, I remember the early days when we put a man on the moon. I was in Houston recently and visited the Apollo mission headquarters set up and we had computers that were bigger than refrigerators and we put people on the moon. Does that mean that space travel was a bad idea? But does that mean that we did it in the most efficient way?

You probably carry around in your pocket today a computer that's hundreds of thousands of times more powerful than what we used to originally put a man on the moon. And that's how we've evolved in terms of user interfaces and technology. And I'm optimistic that when we get our hands on some of the new capabilities that are coming out: ambient listening, the ability to pick up a conversation with generative AI, and the ability to then apply that and bring that into all of the administrative exhaust that has to happen to fill out a patient chart or analyze incoming data, summarize the notes from other venues of care, and really make the EHR and the user interface in particular more of a copilot for the provider than the center of attention.

It's a little bit like in retail. When we have activities that need to occur, as you're shopping, you go pick out a bunch of things, and then you have to go check out and pay. The initial friction was around the cashier transaction, and so a lot of retailers decided to put in self-checkout. What did that do? It actually transferred the task burden from the retail store employee to the actual customer. And to some degree, we've actually transferred the administrative burden of collecting all that patient information, analyzing all that insight, and providing the follow-up note and documentation for subsequent providers to act on, on the actual provider.

Dr. George Hart: Sam, can I give you a hug? Because I think you're capturing, you know, a lot of the challenge here. A physician, you know, at best might have 15 minutes of that time now with the patient. And the other 15 minutes is spent in documentation if they choose to try and stay up in the day. Or, if they don't do that, they spend hours either after their day or at home trying to do all this documentation.

How do we strike the balance here? You know, how do we make that what you're talking about, this immediate user interface with the physician, you know, more facile, yet address the population health issues that we're trying to capture?

Sam Gopal: Yeah, I think the bedrock of why the EHR is such a step function, foundational, necessary investment, is exactly what you described, the transition from fee-for-service to value-based care.

As we've all grown up and seen medicine evolve in the U. S. thus far, it's been about: Who's the patient in front of you? What are their needs? How are you going to address their treatment and plan of care? And how are you, as a physician, going to be reimbursed or rewarded for taking that action on that patient? And so the EHR, unfortunately by definition, it was designed to be this electronic repository of all of the information that you need about that patient to provide efficient care.

It also got blended in with all of the transactional realities of billing and collection for that encounter. Not just for you, but all of your other facilities and other organizations that you partner with. And so there's a fair amount of work involved administratively in that patient encounter that's tied to revenue cycle and billing and collection.

If we think about the transition from fee-for-service to value-based care, there's a paradigm shift. We're moving from an individual patient and what that transaction entails to actually looking at populations of patients and then doing very different things. Identifying who within that population is the most risky and needs the most attention and allowing you as a provider to focus on providing that intervention to the right patient at that right point in time.

None of this honestly would be possible without the EHR. If everybody, every provider, had their charts in a file, in a filing cabinet in their physical office, there'd be no way to bring all that information together for a population level review. And we're at that point. All of you have done humans’ work in going through the pain of the transition from paper charting to the electronic health record. Inefficient as it was, it set us up to be at this point in our journey today.

I genuinely believe we're at an inflection point where we now have the years and years of data, data that's been inputted into EHRs by providers and physicians such as yourself. Thank you for that. We also have all the other information around diagnoses and problems and information around patients that have been collected through the revenue cycle and billing process. And now we're at a point where we can apply all of that along with advances in automation, in predictive modeling, in generative AI to advance this further where we can finally address the human aspect of the user interaction at the bedside, at the point of care between the physician and the patient.

Dr. George Hart: You know, Sam, it strikes me, as I hear you describe all this, and I have to agree with you, we are at a point of inflection. Part of this is that the remains of that generation of physicians who were on paper are aging out and retiring, and this younger generation that's coming in has never known anything any different. You know, they've kind of grown up in this. Like you said, your kids learned how to keyboard when they were, you know, preschool, as did mine. So I think there is a familiarity and a comfort that is going to be there.

Is the private sector ahead of the government and the lawmakers in working through all of this? And what changes are you seeing at the level of the regulators that is helping us move this forward?

Sam Gopal: That's a terrific question. In my career, I've had the privilege of working in a variety of different industries, whether it was semiconductor or automotive. I spent a little bit of time in the Department of Defense and now I'm in healthcare with you. Of all the sectors and the industries that I've looked at where technology has provided transformative change, I think healthcare is one of the most challenging.

Everywhere else where technology has done good things fast, there's been this agile principle of go fast, break things, figure it out, fail fast and cheap, and then scale. Unfortunately, healthcare has also this constraint of “first do no harm.” So, by definition, we're at a paradox of wanting to go fast and try new things, while fundamentally also not doing any harm. Reconciling those two are at odds with each other. And so, we have to be very thoughtful about how we apply new technologies and new ideas into this specialty or this industry where we have to genuinely take care of patients and it's life or death.

The closest analogy I can think of possibly is around our defense or our military, where when we're applying technology to weapon systems, we're dealing with life and death. That's a very different calculus around harm, and what to do or not to do. But I'd like to think about our mission around healthcare as being a much, much more noble one. And so when we think about that, we think about, on balance, we want to, we want to tend towards minimizing risk at the trade-off of going a little bit slower if necessary.

So, to answer your question, I think the private sector is tugging at us to say, “Hey, look, we've got large language models that can then take all the information that's available to us. You've got repositories of information in these EHRs today. Why don't we put those through predictive models, segment our patients into stratified risk cohorts, and then apply interventions that we've seen are successful and help providers make those decisions at the bedside in an assisted way with clinical decision support? Help focus their expertise on understanding through their relationship with the patient in front of them what needs to happen.”

Those are the kinds of things we're working towards. But I think we ought to be also mindful of, “Hey, we can't go too fast where we'reputting at risk the patient privacy equations around how we use information at large about the patient.” We've got to get appropriate consent, informed consent.

We've also got to be thoughtful about sharing information for treatment purposes and not for other healthcare operational type needs that may come out of this. So there's a lot of parameters around the regulatory framework within which healthcare has to function that makes this a truly hard and challenging problem.

I'm excited about the level of interest that has come up more recently, particularly in kidney care, with all of the VC firms that have invested in this, trying to solve for this really hard and challenging problem. I think we've got great, bright minds at it. I think we've got the tools to go work with, and I'm really excited about what we're going to do next.

Dr. George Hart: A great answer, Sam. And I'm used to thinking of the healthcare industry in the context of a comparison to the airline industry, where you have redundancies to prevent failure, because failure is just not an option.

Look, we're here in Wisconsin. We're at the home of Epic. We're going to spend some time over there later today and what a fascinating contribution Epic is making to this landscape. What are the benefits of taking what we do at Acumen, which is part of Interwell, and attaching that to this chassis that is Epic?

Sam Gopal: Yeah, for those that follow the EHR industry in particular, I think Epic is fascinating in the sense that they're in a category of one. Almost every other EHR evolved when the government put out the Meaningful Use program, and there were some incentives and there were corresponding mandates that went along with it. The goal was to incentivize providers to adopt and digitize the records that they had for patients into an electronic format. There was less of an emphasis around what the standards should be around how providers go about doing that.

There was a wide-open race with multiple vendors going into this, trying to develop EHR systems. Most everybody developed a proprietary database by facility, by organization. So most every EHR vendor sought to solve the needs of a health system, an educational institution, an acute care center, et cetera, and then built their EHR around the patient chart and the experience of the patient in that facility, primarily funded by supporting the revenue cycle operation of that facility.

Epic took a slightly different view, which was to say let's put the patient at the center. Epic has a unique design, where it's a single patient chart for a patient across an instance. And that fundamentally has served them really, really well in terms of eliminating the need to point-to-point interface with other systems to follow the journey of that patient across multiple venues of care, especially if they're using Epic.

So if you think about it, you as a provider want to know what happened to Mary when she was at the PCP and when she went to the vascular access center, or when she went to the lab to go get that information drawn, or when she shows up at your office. And if all of those facilities are on Epic, you seamlessly get that information through Care Everywhere at your fingertips.

Dr. George Hart: Let me stop you for a second. Let me tell you how I hear what you're saying because it's exciting. So, the challenge I see with healthcare is that it's fragmented. It's isolated. It's in silos. And providers aren't communicating easily with each other. In fact, the way healthcare is organized these days, there's a whole generation of providers who've never met.

So, I like to use the phrase, “Strangers working with strangers to take care of strangers.” It's very episodic, transitional, transactional kind of care. What I hear from you, though, is Epic's trying to solve for that in a way that no one else did in the very beginning and is effectively trying to do today. Do I have it right?

Sam Gopal: I think you've nailed it. I think Epic made a choice in the design of their EHR early on, whether it was, whether it was genius or it was circumstance, doesn't really matter. It’s helped perpetuate this opportunity to put the patient at the center and evolve the ecosystem of data and information around that patient. And that's a great way to think about this, because providers can collaborate around that patient chart.

And so, in so doing, we now have the opportunity to leverage that platform that Epic has built. And Acumen in particular, with our Acumen Epic Connect product, is specializing on kidney care and nephrology. Epic is vast. It has modules for every specialty and every organization that's out there. And we've chosen to streamline the user experience for nephrologists.

So tying this back to your original question around provider frustration with the EHR — too many clicks, too much information, I'm at a loss for what to do next — it can be overwhelming. And so at Acumen, what we've tried to do is leverage the great things about Epic — the infrastructure of a single patient chart, the ability to seamlessly interoperate information with other venues of care — and pull all that together, but present it in a way that makes the user journey streamlined and specialty specific.

And hopefully we're making a difference.

Dr. George Hart: So, and this is our, kind of our last question. And I'm going to bring this back to the provider, to the physician. You know, they live in this Acumen Epic ecosystem, you know, it really runs their day in and out so that, you know, they need it to be efficient. How are you engaging with the 2,400 providers that you serve to help build a model that is ready for prime time in the future?

Sam Gopal: Yeah, I think we have a privilege and an opportunity in that we work with a very small group of folks in the unique specialty of nephrology. Of all the various specialties I've seen, nephrology is fiercely independent. There's way more private practice providers in nephrology than I've seen in other specialties.

Dr. George Hart: Is independent a nice way of saying stubborn?

Sam Gopal: Well, you know what you want.

Dr. George Hart: Exactly.

Sam Gopal: Which is a good thing. And so we've narrowed our focus on serving your needs in the nephrology space. And so we have opportunities like we're going to go into today with our user group meeting at Epic’s campus. And we've tried to leverage what those learnings are, and we're essentially affecting behavior change in the journey from fee-for-service to value-based care. There is a lowest common denominator. Whether you like it or not, you're in your EHR, like you said, all day, every day.

Today, you've got one foot in the boat where you're working with scheduled patients that you have to bill every transaction for. You also have another foot in the other boat where you're trying to go to population health and understanding who to take care of. And you're having to do all of this in the same system. At Acumen, we recognize that. And we're trying to make that shift a little bit more seamless, a little bit more intuitive. And we want active participation and feedback from our providers to help us do that in a way that's most usable for them.

Dr. George Hart: So, Sam, I told you that was the last question, it's not. I have one more, which is this: Pull out your crystal ball. Tell me, tell me where this is going. Is it more AI? Is it, are we going to get docs back to the bedside? Give me where we're going to be in five years.

Sam Gopal: Yes to all of those.

The other thing I love about Epic is that it does have discrete information on everything that the provider is doing in the system. We've set ourselves an internal goal of saying we're successful when the provider is using the system less a part of their encounter. So we really want to minimize the work the provider has to do to gather the information to make their judgments. We want to serve up summaries of all the encounters that have happened across the patient's journey and other venues of care.

We want to provide that at the point of care, at the right appropriate moment, have the provider make their judgment, and then be able to, during conversation, capture that information in an ambient listening way, put that into the note, have you review with citations and tiebacks to data in the chart so that you can feel confident about what you're putting in as your progress note for your referring partners, and then be able to make that seamlessly go out to the patient as part of their after visit summary in their MyChart portal so the patient and their caregivers can be all included in the care journey for that patient.

Dr. George Hart: I mean, what a great, you know, hope, right? Is to empower physicians to augment, amplify what they're doing, yet free them up so that the patient feels like and deserves to be the focus of everything that went on during that encounter.

Sam Gopal: That's exactly right. The less we can be in the middle of it; we don't want to be in the middle of your encounter. We want to get out of the way. And in so doing, we want to eliminate the friction and be the mechanism by which you can connect all of your partners.

Dr. George Hart: Sam, this was great. This was really a lot of fun. I hope our listeners have enjoyed the conversation as well.

For more patient information on how technology is advancing kidney care, please visit our website at interwellhealth.com. And subscribe to the Kidney Health Connections podcast on the listening app of your choice.