The Elastic Electronic Health Record: A Five-Tiered Framework for Applying Artificial Intelligence to Electronic Health Record Maintenance, Configuration, and Use

Properly configuring modern electronic health records (EHRs) has become increasingly challenging for human operators, failing to fully meet the efficiency and cost-saving potential seen with the digitization of other sectors. The integration of artificial intelligence (AI) offers a promising solution, particularly through a comprehensive governance approach that moves beyond front-end enhancements such as user- and patient-facing copilots. These copilots, although useful, are limited by the underlying EHR configuration, leading to inefficiencies and high maintenance costs. To address this, we propose the concept of an "Elastic EHR," which proactively suggests and validates optimal content and configuration changes, significantly reducing governance costs and enhancing user experience, as well as reducing many of the common frustrations including the documentation burden, alert fatigue, system responsiveness, outdated content, and unintuitive design. Our five-tiered model details a structured approach to AI integration within EHRs. Tier I focuses on autonomous database reconfiguration, akin to Oracle Autonomous Database functionalities, to ensure continuous system improvements without direct edits to the production environment. Tier II empowers EHR clients to shape system performance according to predefined strategies and standards, ensuring coordinated and efficient EHR solution builds. Tier III optimizes EHR choice architecture by analyzing user behaviors and suggesting content and configuration changes that minimize clicks and keystrokes, thereby enhancing workflow efficiency. Tier IV maintains the currency of EHR clinical content and decision support by linking content and configuration to updated guidelines and literature, ensuring the EHR remains evidence-based and compliant with evolving standards. Finally, Tier V incorporates context-dependent AI copilots to enhance care efficiency, quality, and user experience. Despite the potential benefits, major limitations exist. The market dominance of a few major EHR vendors-Epic Systems, Oracle Health, and MEDITECH-poses a challenge, as any enhancements require their cooperation and financial motivation. Furthermore, the diverse and complex nature of health care environments demands a flexible yet robust AI system that can adapt to various institutional needs that has not yet been developed, researched, or tested. The Elastic EHR model proposes a five-tiered framework for optimizing EHR systems and user experience with AI. By overcoming the identified limitations through vendor-led, collaborative efforts, AI-enabled EHRs could improve the efficiency, quality, and user experience of health care delivery, fully delivering on the promises of digitization within health care.