ZachEvans

Believer. Husband. Dad. Coach. Healthcare Thought-Leader. All-Around Good Guy.

EHR

Why Are Electronic Health Records A Challenge to Implement?

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A couple of weeks ago I was privileged to participate in a discussion panel presented by the Nashville Technology Council whose broad topic was healthcare innovation. I sat on the panel with Steve Little from InfoWorks and Bob Chaput from Clearwater Compliance and the panel was moderated by Travis Gregg from Trinisys. One of the questions that was posed by the audience was: “Why are electronic health records such a challenge to implement?”

This is a timely topic for several reasons, not the least of which is the upcoming Meaningful Use: Stage 2 requirements for eligible providers as well as recent, high-profile electronic health record (“EHR”) implementation struggles. When it came my turn to field that particular question I gave three primary reasons why it is difficult to successfully implement an EHR:

  1. Pressure from financial incentives. Many people outside of the healthcare or technology industries may not be familiar with CMS’ EHR incentive programs but the billions of dollars available to eligible providers (both hospitals and individual) that meet specific criteria has dramatically impacted the marketplace. Providers are doing their best to capture as many of the incentive dollars as they can in order to off-set the costs associated with implementing an EHR while the vendors are happy to have a government-funded marketing campaign for their software and services. This financial pressure, while certainly pushing some providers in to the electronic age, is causing some to partner with vendors that may not be the best fit while also encouraging new vendors to enter the market place and established vendors to speed up their development cycles. All of this pressure can add up to poor decision making regarding solutions that may not be ready for wide-scale use.
  2. Immature implementation methodologies. Going hand-in-hand with software that is not ready for prime time, many vendors have looked to further capitalize on government funding by expanding in to implementation services. Likewise, consulting companies around the country are seeing a massive near-term opportunity to build up a healthcare practice helping providers implement their newly-selected EHR solutions. While this may be a standard operating procedure for mature solutions, implementations face great difficulty due to immature (or incomplete) implementation methodologies. Much like yesteryear’s ERP implementations, providers are looking for strong project management leaders driving proven implementation plans but are struggling to find either. This deficiency leads to poorly adopted systems that are not tightly integrated, driving up costs and frustration levels.
  3. Focusing on the wrong fundamental issue. Often led by the CIO, many EHR implementation struggles are seen being driven primarily by technology issues when, in reality, these are the wrong issues to focus on. The issue that causes many EHR implementations to struggle is that the implementing organization failed to adequately understand the scale of the clinical transformation required to be successful. Medical providers on all levels have been documenting the care they render since they first began as a clinician, but they all tend to do it just a bit different than their colleagues. Even with the advent of evidenced-based medical protocols, providers still like to argue about the “evidence” being used and why their patient falls outside the standard. The real challenge is implementing a system that allows for the “practice” of medicine while also enforcing protocols that the larger organization agrees upon. As simple as this may sound, this is in fact a massive undertaking that is often underestimated.

Electronic health records are absolutely worth-while investments for providers of all shapes and sizes and have the capacity to greatly–and positively–impact patient care. Like most great enterprises, however, there are great risks to bear and long roads to travel to unlock all of the potential rewards. EMR implementations do not have to be as great of a challenge to implement as they often times are but they will not go as smoothly as they could without addressing the three points discussed above.

The Grass Isn’t Always Greener

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If you’re in healthcare IT (or just IT in general) and you don’t already ready John Halamka’s blog, you really should. His recent post on The Perfect EHR is well worth the read for any IT leader fighting pressure from their business counterparts to replace an existing core system with something (anything) new.

It should also serve as a cautionary tale for senior executives thinking of approving a change just because a core constituency group keeps asking for it.

A really key point is made in the quote below:

…after listening to many “grass is greener” stories, I believe that what a provider perceives as a better EHR often represents trade offs in functionality. One EHR may have better prescribing functionality while another has better letters, another is more integrated and another has better support. The “best” EHRs, according to providers, varies by what is most important to that individual provider/practice, which may not be consistent with enterprise goals…There will always be dissatisfaction and a claim that something is better. However, I’ve never seen a change in product fix workflow and process issues.

In a soceity (both on a personal and professional level) that relies increasingly on techology, it is always tempting to think that the latest-and-greatest will solve all of my issues and problems. The fallacy with this thinking is that the underlying technology may not be the root cause or the final fix for what is actually wrong.

Technology companies, however, are really very good at holding up the shiny new toy in front of all of us and telling us that if you just have THIS all of your problems will go away. You very recently saw that with the iPhone 4S and at least one reporter is pointing out this exact same issue with the not-yet-released-but-rumored iPad 3.

(Disclosure: I am a very happy owner if an iPhone 4 and an iPad 2 and have no intention of upgrading either device any time soon.)

So, before you advocate for a rip-and-replace of software or even just a basic hardware upgrade ask yourself two questions:

  1. What do I truly stand to gain from the upgrade?
  2. Are there underlying process issues that, if corrected, would remove the perceived need to upgrade?

After all, as Model-Netics teaches us in Acres of Diamonds, the first place to look for a better opportunity (and outcome) is usually in your present situation.

A Well Designed EHR?

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A dirty little secret about a lot of EHR implementations is that there are often negative impacts on productivity post implementation. This is about much more than leading your team through the valley of despair associated with almost any change. This is about the fact that an EHR implementation fundamentally changes the way nurses and physicians actual practice. A recent article by Paul Roemer over at healthsystemCIO.com points out a very important reason for this:

You EHR was not designed to work efficiently in an non-linear exam. Chances are good that your EHR was never really designed at all. Were designers, professionals with advanced degrees in human factors — cognitive psychology, heuristics, taxonomy, and anthropology — asked to determine how the EHR would need to work? Did they watch users work prior to writing code? Did the EHR firm iteratively build prototypes and then measure how users used it in a research lab that tracked hand and eye movements? If not, that is why I think it is fair to characterize EHRs as having been built, not designed.

Most software, including EHRs, were built using linear logic. Step 1, Step 2, Step 3, etc. When you’re dealing with patients who often are scared, confused, in pain or all three (or more besides) linear logic breaks down. Healthcare providers need the ability–provided by their EHR–to jump around with the patient to make sure that everything gets documented as completely as possible in order to take advantage of all of the benefits that EHR offer. It’s also another good argument for the need for patient-centered EHRs.

Patient-Centered EHRs

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In recent years (especially with the advent of the Patient Protection and Affordable Care Act) and new (actually really old) term came back to the forefront of our healthcare system: Patient-Centered Medical Home.

The Patient Centered Medical Home is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family.

The reason that this is a new idea is that as recently as fifty years ago our healthcare was (primarily) managed by family physicians that knew us personally and took care of most of our needs. (We also paid for most of our care out of pocket, but that’s another post.) With increased specialization and insurance reimbursement, however, our healthcare system fractured in to the model we have today: We typically run to a disconnected specialist first before talking to our primary care physician.

HMOs tried (in vain) to reintroduce this hub-and-spoke model but consumers never got comfortable with the idea that someone in a cubicle hundreds (or thousands) of miles away got to decide if they needed a procedure or not. The patient-centered medical home tries to improve this model by placing a primary care physician at the center of the wheel to work with you on the best course of your care.

Supporting this model (or at least it’s supposed to be supporting the model) is a significant amount of technology that enables coordination of care across access points and stakeholders. The problem with much of this technology (especially EHRs) is that they’re not patient-focused at their cores. Too many EHRs (and the practice management systems that wrap them) are built with the payers and providers at their middle instead of the customers they both serve: Patients.

Usability is terrible. Interoperability is virtually non-existent (although it is getting better as the first HITECH incentive payments have started flowing). Providers are in revolt (see the usability comment above). And the patient is locked out of having visibility in to almost any of it.

I love the idea of the patient-centered medical home. I think it’s where healthcare really needs to go. Unless we put the patient at the middle of all of the enablers of the medical home, however, I do not believe we’ll be able to capture all of the possible benefits.

Why Sharing Our Data Is Difficult

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Unless you’ve been living under a rock (or simply don’t care about the topic–which is much more likely), you’ve heard a lot about electronic health/medical records, sharing of healthcare information, and how this panacea will dramatically increase the quality, and decrease the cost, of healthcare. There’s a big problem, however. Hardly anyone is doing it (yet), which begs the question: Why is this so hard?

We could go down the route of talking about the lack of inter-connected RHIOs, HIEs, and other IT-related alphabet-soup short-hand names but I think there’s a deeper problem that’s keeping the public at large from demanding such sweeping changes (and funding them). One word: Privacy.

We want our cardiologist to be able to get our electronic health record directly from our primary care physician but we’re simply not comfortable with a few, or perhaps just one, entity housing all of our healthcare data (or at least facilitating the dissemination of that data). We’re afraid that Big Brother is watching and will do evil things with our data (without our knowledge, of course) if we don’t control it.

Tim O’Reilly makes what I think is one of the best points about what we’re actually afraid of when it comes to our healthcare data:

Technology is taking us a direction where more and more is known about us…It’s hard to be completely anonymized. I think we need a complete fresh look at what tradeoffs we’re making and why. A good example is health care privacy. It’s true that there are some diseases that still have stigmas around them, but our need for privacy is mostly about adverse selection from insurance companies. The problem we need to solve is adverse selection due to pre-existing conditions, not to treat the info like it’s toxic waste. If we look at the benefits of using the information – they are incredible.

Is it possible that we’ve been asking the wrong question when it comes to privacy? I think so, perhaps. The root problem is what people may do with the data, not the fact that they have access to the data in the first place. While I’m not a big fan of governmental regulation, this is something that can be controlled by regulation and could help spur along additional data-sharing advancements.

So, if we could solve problems such as adverse selection (and a host of others), would you be more willing to have your healthcare data readily available to those that need it in order to provide you with better quality and lower cost care?

(PS: For those of you still concerned with the technical interoperability issues, one needs only look at the financial services industry to see that this problem can be overcome. Need an example? Go to the ATM of a bank where you don’t have an account and withdraw some money.)

(PPS: If you’d like some more information about privacy–especially online privacy–you can check out a research paper I wrote in graduate school entitled Online Privacy: A Global Perspective.)

UPDATE: Seth Godin makes a good point that privacy isn’t the real problem. Rather, being surprised by what is done with our data is.