EHRs Rush in Where Doctors Fear to Tread

This article appears in the March 2013 issue of HealthLeaders magazine.

Resistance to new technology may be futile, but it remains an issue for healthcare.

"Physicians do have to spend more time at computers now, which diminishes the amount of time we can spend at the bedside and interacting with patients and actually doing those things like surgical procedures and interventions that only we have the skill and the knowledge and the training to do," says Steven J. Stack, MD, chairman of the board of the American Medical Association.

Stack, who also heads the AMA's health information technology advisory group, says physicians flock to new technology when it helps them provide better diagnosis or treatment in a more timely fashion. "Just look at robotic surgery," Stack says.

But Stack faults the rush to deploy electronic health records for much of the continuing resistance to tech. "There are poor user interfaces with clumsy drop-down menus [and] a one-size-fits-all approach to the documentation process," he says. "As you would imagine, the documentation for an ophthalmologist focusing their entire professional life on a few centimeters of the human body contained in the eye is very different from a general internist taking care of the entire wellness of an entire human being."

As recently as 2007, the majority of all outpatient care in the United States was provided by physician group practices of fewer than three or four doctors, Stack notes. "There's no IT staff or CIO in the office," he says. "The CIO is either the physician themself or the practice manager. That's a real problem. And the cost to upgrade and maintain and troubleshoot is enormous."

While the industry scrambles to equip each provider with its own interoperable electronic healthcare system, what can be done to counter such fears and resistance? A wide range of providers says the answer lies in changing the culture of organizations, and even sometimes resorting to flashy incentives such as giving physicians iPads.

Still, continuing resistance should be a wake-up call to technology vendors to make rapid improvements in the quality and usability of their products, say some physician critics.

"The health IT industry needs to be transformed into a quality- and evidence-driven industry, not a purely profit-driven, unregulated free-for-all, where, in my view, hospitals are used as beta testing," says Scot Silverstein, MD, adjunct professor of healthcare informatics at Drexel University in Philadelphia.

That concern is echoed at the highest levels of healthcare. "Many of these [EMR] technologies are not yet very well designed," says Dawn Milliner MD, chief medical information officer at the Mayo Clinic, the 4,000-physician, 70-hospital system. "They're not very intuitive. Physicians work very hard. They do rapid, constant work, day in, day out, night in, night out, that requires a lot of concentration, a lot of effort, interacting with the patient and the record, if not simultaneously almost simultaneously, and when things are clumsy or cumbersome or take longer than old conventional methods, it's understandable that physicians get frustrated," Milliner says.

Silverstein also notes how doctors deal with less-than-ideal technology. "Physicians, being pragmatists, they get this IT thrown in front of them that's designed as if it's for maintenance of widgets in a warehouse, and they say, ‘This stuff's awful, slows me down, I can't find what I need, it's a lot harder to use than paper,' and so they may have been very skeptical." He cites a 2012 report from the Institute of Medicine saying that the magnitude of risk from health IT remains unknown.

Yet for every note of criticism, there seems to be a success story. Mercy Health—a 31-hospital system based in Chesterfield, Mo., that serves communities in Missouri, Kansas, Oklahoma, and Arkansas—completed its transition to electronic health records in a five-year period by emphasizing the standardization of care that technology brings to the organization, says William Walker, MD, chief quality and safety officer.

"Variation is harmful to patients at a net population level," Walker says. "We have to agree to do it one way, because while we're doing the thought work, the care is often rendered through the hands of other folks—nurses, physical therapists, whoever that is. We've got a graduate nurse in the middle of the night who's inexperienced and doesn't have a lot of supervision, and she's having to reinterpret two completely different sets of orders. Wouldn't it be better if we had an expected approach?"

Yet the responsibility for making EHRs effective continues to rest on the care team as well as the technology, Walker says. "We have not put enough structure around the information that doctors enter and whether or not that can be discretely tapped, and I'm as guilty of that as anybody."

Mercy's solution: an aggressive deployment of what it calls care paths, which build upon the notion of order sets to capture all the care, intervention, and evaluation required for a patient's entire length of stay, Walker says. Without incorporating these care paths into EHRs, hospitals haven't done much more than install very expensive electronic typewriters, he says.

Early proof that care paths are working: their use allows Mercy to intervene earlier in sepsis episodes. "We have cut mortality by 50%, average cost per case by over $3,000, length in the intensive care unit from 81/2 days to about 3 or 4 days, and the patients are healthier and happier and going home sooner," Walker says.

A key to overcoming physician resistance is being realistic about the hit productivity takes during the transition from paper records. At Mercy, that usually takes three to six months, says Jim Best, vice president of clinical business solutions.

Without pre-live training, physicians could take up to a year before they attain the same productivity levels they had prior to the EHR transition, he says.

"Then they usually have to go back and retrain and relearn, because they were more worried about just keeping the patient flow going than they were learning a new tool," Best says.

Leadership has to do its part, selling the transition to EHRs as hard as any sales job, says Kshitij Saxena, MD, medical director of medical informatics at Adventist Health System, a 31-hospital organization based in Altamonte Springs, Fla., which spans 12 states in the South and Midwest.

"You have to go and tell it to them in front of hundreds of doctors who are ready to kill you," Saxena says. "You go and give them the benefits. You go and tell them the negative side of it as well. You tell them up front, the first three weeks there will be yelling and screaming. Please be prepared. And then you tell them the ways where the pain can be minimized."

Buy-in from the rest of the C-suite is essential, Saxena says. "You make the training mandatory. You would never sit on a plane that was being flown by an untrained pilot, right? Same goes for the doctors. The ones who do not know how to deliver safe patient care, do not know how to use systems so that there can be no safety issues, they shouldn't be allowed to practice," he says, suggesting an analogy to board certification.

It's also essential to have physicians engaged during the design phase. But how do you get these busy professionals to take time out of their practices to do so? Saxena's answer: You pay them for the time it takes to get them, and the EHR, up to speed.

"I would prefer to bring in those physicians, get their input at the time of design, and make them the physician champions at the time of go-live instead of bringing 100 people from the vendor at the time of go-live," Saxena says.

After a 30-month rollout, the Adventist system generated a million electronic physician notes in the past 12 months. "It's not that we didn't have hurdles or obstacles," Saxena says, "but if you create the culture, if you design the steps right, it usually works out."

All Adventist physicians were compensated for completing EHR training, some received cash and some received payment in the form of an iPad, Saxena says. This paid a dividend when those physicians tapped into new hospital infrastructure that let them round with their iPads, reinforcing the physicians' ownership of the EHR system.

Calculating a return on investment for all this technology remains elusive, but Mercy estimates that half the system's recent growth is attributable to having technology and infrastructure in place. "We've added about 500 to 600 additional integrated physicians into our networks in our four states," Best says.

"Since meaningful use has been in play, physicians have been attracted to us, wanting to be a part of a health system that knows how to manage meaningful use," he says.

Most dramatically, Mercy's hospital in Joplin, Mo., was destroyed just three weeks after its EHR went live. Because it was all electronically stored, "we were able to retrieve the records within two hours," Best says.

Joplin patients showed up at the hospital in Carthage, Mo., about 20 miles from Joplin, a small critical access hospital that was doing its best just to help Mercy. "We walked in the door that very same evening with packets of complete, 100% intact patient records," Best says. "They were so impressed we began an immediate relationship with that hospital, and they eventually became part of Mercy less than a year later."

Such success stories will continue. Meanwhile, the industry is redoubling its efforts to improve. For instance, in December 2012, HHS' Office of the National Coordinator issued its first Health IT Patient Safety Action and Surveillance Plan for public comment.

"We've still got some bugs and kinks to work out, but I think you would find that if you took a survey of docs, overwhelmingly, all of us would heartily embrace better technology that enabled us to have all the data we needed when we needed it and not waste time and money repeating things we would like not to repeat," says Stack.

Reprint HLR0313-6

This article appears in the March 2013 issue of HealthLeaders magazine.