Realizing the EHR Vision—When Simple Isn’t Always Easy– A Physician Executive’s Perspective
As a physician executive, I’ve learned a few solid lessons when it comes to change management. A mantra that serves me well: We will make this simple, but it is never easy. The most important foundational element when managing culture is first understanding, and then communicating, the “WHY.” When talking with clinicians and care systems personnel about electronic health record (EHR) implementation or fundamental health information technology (HIT) changes, the WHY must be articulated early and often. Because EHRs touch so much of a clinician’s world, the topic is always a “hot button,” and will trigger strong emotions. Also, through a purely financial lens, it’s important to start with the end in mind—what is the REAL sought-after deliverable, and how will you ensure that the deliverable is executed and measured?
Getting to the WHY: Beware
First, many half-truths, and full untruths, have been promulgated by the EHR industry. Understanding what your clinicians are hearing from EHR vendors can help you better articulate your WHY. The list below presents a few of the most common misleading statements about EHR implementation, and the clinician’s perspective on each. (These will likely NOT be the WHYs you communicate as part of your change management strategy.)
- Ability to establish and maintain effective clinical workflows. EHRs, in general, have proven to initially (sometimes permanently) disrupt workflows. If disruptions continue, the patient/doctor relationship is compromised and can diminish.
- Ability to access records remotely. This functionality can certainly be a bonus if it allows physicians to improve their market reach. But for many clinicians, the ability to access records remotely has led to “Saturday date nights” with their computers and EHRs.
- Fewer medical errors. Patient safety is always paramount. EHRs do help reduce patient errors when it comes to prescriptions and physician orders. But again, from a clinician’s perspective, the increased navigation requirements can be frustrating, resulting in a hunting-and-pecking exercise to locate what the clinician wants ordered. We have not fully realized the benefit of embedding best-of-class knowledge into workflows inside EHRs, though I have observed some small advances that have resulted in clinician adoption. These successes contribute to my continued support of human-centered design.
- Improved patient safety. Yes, this could be an effective WHY for all stakeholders. However, when stated without defined case studies and real applications, it becomes noisy rhetoric.
- Stronger support for clinical decision-making. This is true provided the data is trusted and reliable. Also, access to data at the point of care is paramount. Many clinicians still spend inordinate time searching for data they trust is complete.
- Improved care coordination. Interoperability, often promoted, but seldom delivered, must be a central part of the strategy and execution.
- Cost savings and efficiencies. Costs and administrative burdens often escalate when implementing EHRs. Any claims that costs are reduced and efficiencies realized should be thoroughly questioned. One should ask: How exactly does this EHR save money? Do you have any case studies? Was it actual money or some other attributed value?
- Shared best practices. While a worthwhile and lofty goal, shared best practices will only truly be realized with efficient interoperability of data systems and an adoption of a value-based outcome revenue stream.
- Patient engagement forum. Ouch! This one can really hurt! EHR patient portal adoption rates are weak, and for good reason. Most patient portals are an afterthought, with no user experience focus. Successful forthcoming digital health models will not be built on a one-size-fits-all solution. According to a New England Journal of Medicine study, a majority (59%) of clinical staff believes the most effective patient engagement strategy is simply spending more time with patients.
The How: Effective Messaging
The real issue at hand is the disconnect between “vendor speak” and the realities of the clinicians’ experiences with the product. To help answer a clinician’s two most pressing questions—“What is in it for me?” and “How does this help my patient?”—the WHYs should be repositioned with the clinician’s point of view in mind. The following practical answers and example applications can promote clinician buy-in:
- Access to useful and meaningful data repository and exchange capabilities that can be used for:
- Improving clinical care of the current population we serve, employing real case study and metrics. Examples: Create registries for a practice’s diabetic population; identify women over the age of 50 who have never had a mammogram, etc.
- End-user reporting for Quality Improvement. Example: Identify and share best practices to determine how other clinics are doing so well on their quality bonuses.
- More effective payment-revenue capture and improved accounts receivable performance. Example: Provide patients an unambiguous financial picture, leading to a clearer understanding of explanations of benefits.
- Clear user interface. Example: Get the information I need, when I need it, and in a way that is consistent with how I talk with my patients.
- Third-party interface (such as pharmacy). Examples: Obtain confirmation that an e-prescription I’ve placed has been received. Or, access my community health information exchange and acquire results from other area clinicians. This functionality provides me the means and information to better care for my patient.
Tapping EHR Potential
The EHR has been built, and largely used, as an electronic version of a paper-based medical record. Acting upon the truth that the data is the patients, we are merely stewards. And in best serving our patients, we must ensure that the interaction between caregivers and EHRs enhances that experience. In order that we might further realize the incredible EHR potential, reimbursement models must evolve to support the care of the patient, not the transaction of care. Also, full interoperability must be instituted on a platform with which all EHRs and health information exchanges can interface. It is important we ask the right questions (from a clinician’s perspective) of our vendors, and take additional steps to ensure EHR effectiveness:
- Look for HIT system providers who are investing in interoperability and interface management. Systems should work with health information exchanges with open application-programming interfaces (or APIs) and possess capabilities for connecting with other best-in-class systems (e.g., population health management platforms, data warehouses, patient engagement platforms). System tech firms should be willing to admit such systems have an accessible place in the ecosystem; they are not the ecosystem.
- Evaluate if the vendor invests in user experience, human-centered design, and design thinking as a development tool.
- Invest in scribes, period. In the current insurance-based regulatory market, it is irrefutably foolish for the highest revenue-producing staff to spend valuable time in data entry.
- Consider new models of care.
- Invest in knowing your own cost of care so you can make rational decisions that will not surprise you.
Intelligent Data Integration: Effecting Measurable Change
The future of the “quadruple aim”—better patient experience, better health outcomes, smarter spending, and a stable and engaged health workforce—will be brought forth not with data alone, but with intelligent data integration.
We must be able to trust the data as real (data quality from the best source), and know on what data we should focus (impact deciphered from noise). We can then derive real insights from the resulting analytics, leading to resource allocation for actionable interventions that can be validated, then shared as best practices. All the while, we must keep in mind we are designing for humans, so one size will not be tolerated.
But, if you are looking for my simple one-sentence answer to clinical change management with EHR or HIT adoption: hire and retain a strong, well-trained project manager, period.
Amy Mechley, MD, is a board-certified family practice physician licensed in Ohio and a strategy and integration principal at PYA.