Satisfied EHR users may not be taking full advantage of the system.
|
| John Glaser |
When a health care organization invests in an electronic health record, it’s usually part of a larger strategy to improve the management of patients with chronic diseases, control the costs of care, reduce medication errors and streamline care operations.
Organizations understand that achieving these goals requires that the EHR is used by clinicians. That’s why, in addition to the initial system purchase, significant resources are directed to training, process reengineering, design of screens and post-implementation support.
Most organizations gauge use by surveying their clinicians and asking if the system improves care, reduces administrative tasks and helps them manage patients. The assumption is if providers like the system they will use it, and if they don’t like it they won’t use it. This is true: If it takes too many steps to complete a transaction, if the navigation is incomprehensible or if system availability seems to be under the control of a random number algorithm, clinicians won’t use the application.
Satisfied users, however, are not necessarily effective users. The structured problem list may be incomplete with some problems being buried in progress notes. The medication list may include antibiotics prescribed five years ago. Decision support may be ignored.
Common Complaints
I recently had the following conversation with one of our physicians.
| Physician: | I love the new EHR. It’s terrific! It’s so easy for me to find my notes and those of other doctors. | |
| Me: | That’s great. How do you like the medication and problem list features? | |
| Physician: | I don’t use those. I don’t have time for that. But I love the new EHR! |
The dialogue above indicates that we may have achieved one of our goals—improved accessibility of patient data. But it also indicates that we may fail to achieve other goals—reducing medication errors through the application of clinical decision support and understanding care variation for certain patient problems.
There are a handful of common reasons why clinicians’ use of the EHR is less than fully effective. First, the application may be poorly designed. It may have an inconsistent look and feel, a confusing data presentation or transactions that require too many clicks to complete.
Perhaps the clinical decision support warnings, alerts and reminders are not well-placed in the workflow, are not tiered according to importance or do not quickly take the user to remedial actions.
In some case, the “fit” between the EHR and the clinical workflow was not well-conceived, resulting in additional tasks and organizational confusion. Or using the application may take more time than performing the old paper process, leading harried clinicians to skip it or take shortcuts.
Ineffective or suboptimal use can significantly diminish the organization’s ability to achieve its goals. It is difficult to analyze care costs and quality, for example, if 40 percent of the problems and 25 percent of the radiology orders are missing. Reaching pay-for-performance chronic care management goals is hindered if providers ignore diabetes or smoking cessation reminders because they feel pressed for time or believe that the guidance is unnecessary. The value of regional interoperability is reduced if health information exchange participants believe they are exchanging incomplete data.
Dig Deeper
Achieving effective clinician use of IT applications is an ongoing effort. Here are a few ways to make progress:
Recognize the importance of effective use. Satisfied EHR users are a nice reward after a grueling implementation, but they are not equivalent to effective users. Appreciating the distinction will lead to efforts to improve use.
Define and measure effective use. What does effective use mean to your organization, and how should it be measured? One criteria might be a complete and accurate medication list, determined by comparing the EHR list with medication claims from the patient’s health plan. Following health maintenance reminders to schedule a mammogram is another useful metric. Reminder compliance can be determined by comparing the number of reminders generated to the number of mammogram procedures ordered.
Some measures are basic and undoubtedly important to all organizations, such as following clinical decision support warnings about potentially lethal medication interactions. However, many measures will reflect the organization’s specific goals and tactics.
Develop strategies for increasing the effectiveness of use. Improving EHR use requires a mixture of broad and specific strategies. Broad strategies include:
- Provide ongoing training on key EHR features. Usage problems often crop up when physicians don’t know that there are easier ways to perform a task. The irritating “long way” leads them to bypass steps in a process. It’s difficult to get clinicians to attend post-implementation training, but continuing education credits and payment can increase class attendance.
- Structure pay-for-performance contracts to include incentives for effective IT use. The completeness of a medication list, for example, can be one of the criteria that determines the ability of the physician to receive the at-risk portion of reimbursement.
- Engage clinicians in discussion and education regarding the importance of effective use. These conversations should center on both the link between use and organizational goals and also understanding the problems that interfere with use. They can be supplemented by collecting physician-specific reports on use measures.
Specific tactics center on instances of use that are disappointing to the organization’s leaders. If the completeness of the medication list is an issue, improvement approaches could include exploring if changes can be made to the e-prescribing screens and navigation to reduce the time required to prescribe and populate the medication list. The organization might consider other alterations to the application, such as using natural language processing to identify medications in the note that are not on the list or comparing the problem list to the medication list to identify the potential absence of medications.
The organization also should explore the ability to leverage the SureScripts-RxHub medication transaction infrastructure to determine if medication histories from pharmacy benefits managers and retail pharmacies can be used to suggest entries into the medication list. The organization might also consider using personal health records to engage patients in ensuring the accuracy of the list.
Finally, assess practice workflow to see if efficiencies can be found in the internal medication management processes to free up providers.
Ongoing Challenge
Regardless of the steps taken, organizational leaders should acknowledge that improving the effectiveness of use is a never-ending task. The strategies may move from one area to another as progress is made and new issues and opportunities arise, but this issue will always be a challenge.
Usage will never be perfect. There will always be reasons outside of the control of the provider (such as DEA limitations on prescribing narcotics) and imperfect human behavior that will thwart the ability to achieve 100 percent. Still, the difference between a 75 percent use grade and a 95 percent use grade is significant and worthy of pursuit. Such a difference may be determine whether the EHR’s goals—and those of the organization—are achieved.
John Glaser is vice president and CIO of Partners HealthCare in Boston, senior advisor, Deloitte Center for Health Solutions, and a regular contributor to Most Wired OnLine.
GIVE US YOUR COMMENTS!
HHNMostWired welcomes your comment on this article. E-mail your comments to hhn@healthforum.com, fax them to Most Wired Magazine Editor at (312) 422-4500, or mail them to Editor, Most Wired Magazine, Health Forum, One North Franklin, Chicago, IL 60606.