November/December 2019

Know Thy EHR
By Susan Chapman
For The Record
Vol. 31 No. 10 P. 14

Understanding what the technology is and isn’t capable of can lead to more satisfied users.

Hospital staff can often be less than satisfied with their facility’s EHR, leaving organizations with the challenge of how best to optimize their systems while avoiding discontent. The problem is a common one, often caused by an array of issues—poor design, unmet expectations, and shoddy implementation, among others.

By understanding the underlying causes of staff dissatisfaction and addressing those problems, hospitals can better enable a smooth transition to a new EHR system or take better advantage of the current iteration.

The Challenges
The EHR’s design and an accurate understanding of the technology’s mission are pivotal success factors. It’s only natural that the expectations among hospital decision makers and staff are that the new technology will improve processes, not hinder them.

“EHR products are designed to collect information, [for example], to input blood pressure, heart rate, and other vital signs. What they don’t do well is present that information back to a clinician in a manner that the clinician is used to working with,” says James Leonard, director of health care business development at GRM Document Management. “[The EHR] creates cognitive dissonance amongst the caregivers. There is not much time spent on how that information is delivered to that clinician. But delivery is not the technology’s main focus or function. It’s actually all about collection.”

Leonard adds that EHR systems simply do not “act” in the same way as paper charts. “When clinicians use paper charts, they typically bookmark places with their fingers and flip back and forth among the pages, making clinical decisions based on what they see,” he explains. “With the EHR, the clinician has no way to find those bookmarks and see, for instance, how a medication may be impacting someone, an all-important lab result, or what the medication dosage was. EHR products are not designed to deliver the information that is stored in a way that is beneficial for the caregivers and the patients.”

Andria Jacobs, RN, MS, CEN, CPHQ, chief operating officer at PCG Software, points out that many times users become dissatisfied when mistakes within the system are not corrected or when those same mistakes get carried over into new EHR systems.

“If someone says this isn’t working right or it caused a patient incident and it doesn’t get fixed, then people want a new system,” she says. “They think the current program is the worst. The same is true for implementations of new EHRs. What we see is that people who are going to use it are not included in the real decision making. They don’t have an opportunity to fix things that they pointed out as errors in the preceding system. The project management becomes really important because the detail in the new system has to be correct. But if errors are simply transferred from the old system or you have perpetrated the same problems that existed in the preceding system, then nothing is solved.”

Jacobs points to a recent report published by the insurer The Doctors Company, which shows that EHR errors are becoming an increasingly common factor in malpractice lawsuits. The report states, “Claims in which EHRs contributed to injury show a total of 216 claims closed from 2010 to 2018. The pace of these claims grew, from a low of seven cases in 2010 to an average of 22.5 cases per year in 2017 and 2018.”

Research also underscores some of the issues highlighted by Leonard and Jacobs. For example, in their article “Defining Health Information Technology–Related Errors: New Developments Since ‘To Err Is Human,’” researchers Dean F. Sittig, PhD, and Hardeep Singh, MD, MPH, proposed that “HIT-related error occurs anytime HIT is unavailable for use, malfunctions during use, [or] is used incorrectly by someone, or when HIT interacts with another system component incorrectly, resulting in data being lost or incorrectly entered, displayed, or transmitted. These errors, or the decisions that result from them, significantly increase the risk of adverse events and patient harm.”

Like Leonard, Brenda Hopkins, MBA, BSN, RN, chief health information officer at eFax Corporate, believes that a large part of the problem is understanding what the technology can and cannot do. “In the specific case of EHRs, the truth about the technology is that it was built as a billing platform, and we’ve had to work backward to elegantly support the complexity of the patient care process if the EHR is the technology that will carry us forward. It was designed to capture billing codes and drop them cleanly. There is a great deal of room for improvement because the EHR wasn’t designed to support the patient care area from the beginning,” she says.

The EHR’s impact on patient care is why clinicians can become unhappy with the technology. “Physicians say medicine is an art and science,” Leonard says. “They balk at the idea of computers in medicine. Maybe there are five or six different things a physician may have to keep in the front of their minds to help the patient. If the EHR can’t pull together those five or six things, then the system is not helping them.”

Jacobs explains that this discontent has a trickle-down effect. “Unhappy doctors make for unhappy patients. Any provider that touches you and is frustrated can make for an unhappy physician-patient encounter,” she says.

Leonard believes that while many hospitals invest a great deal of money in the technology, they do not necessarily spend enough time implementing the EHR effectively, thinking it will automatically make patient care and processes better. “The new technology often has some workflow component to it, but the organizations don’t consider revising their current work processes, which could already be broken,” he says. “This leads to a level of dissatisfaction with how that EHR performs, when the reality is that it’s not the EHR when they didn’t put the processes in place before the technology was in place. The expectation is that the EHR is a panacea and will fix all the problems. When they are not fixed, then everyone becomes dissatisfied.”

Hopkins is skeptical of the notion that organizations believe that EHRs are a cure-all. “I think maybe in the early years of EHRs, there was that belief that the technology could solve all the problems,” she says. “But a lot of time has passed, and the reality of what these systems can and cannot do is much clearer. There is still optimism that you’ll achieve some efficiencies, which is the overall hope. An uninformed organization may look at software as the answer. In my experience, though, the success of the technology is built on the success of the governance and the championship of the people who are designing and implementing it. There are too many people now who know that people need to make it work how they want it to. Most vendors set up optimization groups to help. Everyone knows that they have to have partnership for success. In current thinking, sophisticated organizations don’t approach new technology as the solution to all their problems.”

Training is a unique issue. Often, it is conducted by the vendor, which typically employs a “train-the-trainer” methodology. The vendor trains a small number of employees, and those people are then responsible to train the rest of the staff.

“It’s OK to do that,” Leonard concedes, “but a couple of problems result. The trainer is more focused on ‘this is how our EHR works,’ and it doesn’t involve the idea of mock patients. I like to do training on an EHR product by role-playing that a patient is in the room with the health care provider. But that is not typically done. The training is done in a room with everyone in front of a computer, but it’s not presented in the context of a patient interaction. Then, when practitioners are with patients, they don’t know what to do.”

While this approach frees the vendor to train staff quickly and move on to the next client, it can reduce the accuracy of the information that is imparted. “It’s like a game of ‘telephone,’” Leonard says. “The people that are originally trained by the EHR staff, who were trained by the vendor, only get 60% of the information. The next group gets only 60% of that. Plus, the original training wasn’t done in a patient context. There is a massive problem of how training is done and delivered and even how the methodology is created.”

Jacobs believes “super users”—individuals trained by the vendor who can then help colleagues—can be beneficial. “If there is no help with the system, then that produces frustration. So super users can play a vital role in helping to alleviate that frustration,” she says. “But super users are not always compensated for their time. They are expected to do their regular jobs and also provide support. That can create frustration, too.”

Jacobs says the timing of the training is equally important. “People need to be trained close to the time they are going to be using the software,” she says. “People are trained too far away from the time of implementation. Users want to care for patients. But project managers are focused on tasks and getting things done on time, even if it means that clinicians are trained far earlier than the time the software is implemented.”

Dennis R. Delisle, ScD, FACHE, vice president of operations at Jefferson Health in Philadelphia, points out that the problems attributed to training may actually go back further—to the design and testing phases—as well as forward—addressing issues after the EHR system has been implemented.

“Programmers and analysts do not always understand what is happening once the technology is being used in real time. They don’t know how it will work until it’s live,” says Delisle, coauthor of Transformation and Your New EHR: The Communications and Change Leadership Playbook for Implementing Electronic Health Records. “When you go live, you start managing issues as ‘service tickets.’ From the analysts’ perspective, they are being reactive to issues. But they don’t really see what is happening on the floor, with the patients, at the computer. To improve EHR systems, you need to get the analysts out of their cubicles to the end users to watch how they experience and use the tools.”

Changing the Mindset
In order for an EHR to be successfully adopted, an organization needs to create a culture in which the technology is viewed as an asset and not as a detriment.

“During the time of meaningful use and the funding that came out of that, the EHR programs should’ve been headed by clinical departments with IT support,” Leonard says. “Instead, we had IT select an EHR solution with limited involvement from clinicians. The decision would be basically already made, but we’re going to include the caregivers like we’re giving them a voice, but, in reality, that is not the case. You see this with CIOs who are tied to a particular vendor. You use a suite of things from one provider so you stick with that provider. You involve clinicians at the end but not really in the process of selection and decision making.”

Hopkins says organizations must take an aggressive mindset. “They have to engage users at the very beginning. Users need to feel that they are part of the process,” she explains. “You engage the users in the design decisions as much as possible and even before the purchase, in the RFP [request for proposal] process, to make sure it meets their needs. Also, organizations need to engage executive sponsorship to address costs and complexity.”

Hopkins recommends examining the vendor’s best practices. “Most [vendors] use a model system that is the best practices from all their clients. If you can live with the model system, it helps ensure a flow through the continuum of the application,” she says. “Organizations have to weigh what is more important—the flow of the information or meeting the department’s needs.”

Indoctrinating caregivers into new technology is critical, Hopkins notes. “You have to catch a physician in medical school to learn how to provide health care with technology. If you don’t, they’ll go about their process and treat patients. And they take an oath to keep patients safe. It’s scary for them to learn one way, and then do something another way,” she says. “Doctors do SOAP [subjective, objective, assessment, and plan] notes, which are hard and fast ways that they treat a patient. We are trying to bring in the technology and telling them to do something designed by an engineer when they were trained a different way. It all comes down to behavior that supports success.

“[The implementation] will only be successful if the behavior of the user is in line with what the technology is built for. Physicians do not have confidence in the EHR because they were trained deeply in how to care for the patients. Senior physicians do not want to be asked to change how they treat patients. Physicians are alpha thinkers; they have to be very assertive in the way they care for their patients.”

Randy Tomlin, CEO and chairman of the board at MobileSmith Health, says that in order to reap the benefits of EHRs, patients need to be connected to the system in a real-time environment, both before and after a physician or hospital visit.

“We’re cramming all of the record-keeping in the 28 minutes the doctor is allowed to talk to the patient,” he says. “When you take an exam, you prepare ahead of time. If we can connect patients to the EHRs ahead of time, practitioners can do prep work and understand comorbidity issues, [and] drugs that need to be used or improved. All of those questions can be done before those 28 minutes. Physicians can stay in contact with patients afterward and converse before. We’ve got to change processes; they have to become interactive. It’s going to occur, but it’s going to require changing operational methods and behavior.”

All the experts agree that the goal of technology should be to improve the efficiency of patient care. But, as Jacobs notes, “Technology doesn’t take care of patients. The staff at the hospital are there to take care of patients. The EHR is a template that uses all sorts of processes, and it should do so with the aim of supporting those who are committed to patient care.”

— Susan Chapman is a freelance writer based in Los Angeles.