The next generation of EHRs require three major improvements, according to a paper published in the Journal of Medical Internet Research (JMIR).

"The vast amount of information and clinical choices demands that we provide better supports for making decisions and effectively documenting them," wrote authors Leo Anthony Celi, MD, MPH, MS, of Beth Israel Deaconess Medical Center, and colleagues.

The three necessary upgrades for future EHRs are the following, according to the authors:

1. Data incorporation: EHRs need "bidirectional data streams"--electronic notes that offer data streams for the whole EHR database and vice versa. The system should be automatic and an "intrinsic property of clinical information systems." Tools such as natural language processing and machine language could help manage free text and unstructured data. 
2. Integrated monitoring: "Bedside and telemetry monitoring systems have become an element of the clinical information system but they do not yet interact with the EHR in a bidirectional fashion to provide decision support," the authors wrote. "In addition to the raw data elements, the monitors can provide data analytics that could support real-time clinical assessment as well as material for predictive purposes apart from the traditional noisy alarms." 
3. Real-time formulation of the note: Free text can be difficult to work with, the authors noted but it offers "a needed narrative element into the otherwise storyless EHR." However, more complex systems will need to be created so the computer can develop a "processes interpretation of the text." Until then, clinicians can lessen confusion by reducing their free text entries.

These changes would result in "a more fully functional EHR that better supports both workflow and clinical decision-making," the Celi and colleagues wrote. "Further, these suggested changes would also contribute to making the note writing process an educational one, thereby justifying the very significant time and effort expended, and would begin to establish a true learning system of healthcare based on actual workflow practices." 

Government efforts, such as the recently released interoperability roadmap, support these advances, the authors wrote. They say an EHR that supports workflow and clinical decision-making is the key to an interoperable health IT system that improve individual and population health.

The goal is to keep clinicians in charge of the decision loop in a “human-centered” system where technology plays an "essential but secondary role."