Realizing the EHR Vision: Simple Isn't Always Easy

Amy Mechley, MD

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 change 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, we must remember to articulate the “why” early and often. 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 we ensure that the deliverable is executed and measured?

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 categories of misleading statements about EHR implementation, and the clinician’s perspective on each. (Note: These will likely NOT be the “whys” that you communicate as part of your change-management strategy.)

  • Ability to establish and maintain effective clinical workflows. REALITY: 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. REALITY: 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. REALITY: Patient safety is always paramount, and EHRs do help reduce 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 hunt-and-peck exercise to locate what the clinician wants to order. We have not fully realized the benefit of embedding best-in-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. REALITY: 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. REALITY: 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 an inordinate amount of time searching for data they trust, and ensuring that it’s complete.
  • Improved care coordination. REALITY: Interoperability is often promoted, but seldom delivered. This must be a central part of any change strategy and execution.
  • Cost savings and efficiencies. REALITY: Costs and administrative burdens often escalate when implementing EHRs. Any claims that costs are reduced and efficiencies are 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 that was saved, or some other attributed value?”
  • Shared best practices. REALITY: While a worthwhile and lofty goal, shared best practices will only truly be realized with efficient interoperability of data systems and the adoption of a value-based outcome revenue stream.
  • Patient-engagement forum. REALITY: 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 believe the most effective patient-engagement strategy is simply spending more time with patients.

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 clinicians’ point of view in mind. The following practical answers and sample 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 studies and metrics. Examples: create registries for a practice’s diabetic population; identify women over the age of 50 who have never had a mammogram.
    • 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 with an unambiguous financial picture, leading to a clearer understanding of benefits.
  • Clear user interface. Example: get the information doctors need, when they need it, and in a way that is consistent with how they talk with their patients.
  • Third-party interface (such as pharmacy). Examples: obtain confirmation that an e-prescription a doctor has placed has been received; access doctors' community health-information exchange, and acquire results from other area clinicians. This functionality provides doctors with the means and information to better care for their patients.

The EHR was built, and has been largely used, as an electronic version of a paper-based medical record. Acting on the truth that the data is the patient’s, 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 EHRs' incredible 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 electronic health records and health-information exchanges can interface. It is important that we ask the right questions (from a clinician’s perspective) of our vendors, and take additional steps like the following 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 that such systems have an accessible place in the ecosystem; they are not themselves the ecosystem.
  • Determine whether the vendor invests in user experience, human-centered design, as a development tool.
  • Invest in scribes, period. It is irrefutably foolish for the highest revenue-producing staff to spend valuable time on data entry.
  • Invest in knowing your own cost of care, so you can make rational decisions that will not surprise you.

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 (high data quality from the best source), and know on what data we should focus (impact distinguished 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 that we are designing for humans, so “one size fits all” will not be tolerated.

But if you are looking for a simple one-sentence answer to clinical change management with EHR or HIT adoption: Hire and retain a strong, well-trained project manager.

Amy Mechley, MD, is a strategy and integration principal at PYA, a health care management advisory and accounting  rm. She also serves with the Ohio Governor’s Office of Health Transformation on the task force for patient-centered medical-homes redesign for Ohio providers.