Some institutions are finished; others are just starting. But whatever their stage of electronic health record deployment, one theme is constant -- the toughest part of implementing an EHR system is not the technology, it’s getting doctors to use it.
Doctors want -- quite rightly, for both ethical and economic reasons -- to see as many patients as possible. For most, the fastest way for them to do that is to write with pen on paper, not to put data into a computer interface.
“The culture is the hardest part,” said Joy Grosser, CIO of Iowa Health System in Des Moines, Iowa. “The biggest challenge is changing the routine practice of care. You’re used to writing on paper and handing it to someone.”
Others echoed Grosser’s views. “Implementing EHR requires change, [and] change in the way physicians practice is controversial,” said Dr. Peter Deane, principal and CIO of Allergy Asthma Immunology of Rochester (AAIR) in Rochester, N.Y.
EHR systems fall into two main categories: ambulatory, for medical practices, and hospital, for medical institutions. Both categories include modules ranging from billing and accounts payable, to e-prescribing, to computerized physician order entry (CPOE), to patient records.
Not all modules -- billing, for example -- require doctors’ participation. However, charting, CPOE and other modules that require doctors and nurses to enter information into a computer system are the greatest sources of friction.
“Electronic systems are not as fast as a physician’s pen. It takes the physician more time,” said Linda Reed, vice president and CIO of Atlantic Health in Morris Plains, N.J. “Just getting a doctor to write something down slows them down. They want to see the patient and get back to their offices. That slowdown causes a lot of chaos. That’s where you see the biggest pushback from the physician perspective.”
AAIR’s Deane agreed. “Doctors hate doing data entry. The faster it is to put in the data, the better the system from a doc’s perspective. The rub is that the most flexible and intuitive record to use is a blank sheet of paper,” he wrote in an email.
Still, most hospitals and practitioners recognize that implementing an EHR system is inevitable. Many are spurred by the promise of tens of thousands of dollars in federal stimulus funds per physician, as well as millions of dollars for hospitals, for the achievement of meaningful use of health care records -- not to mention the specter of penalties in a few years if EHR technology is not deployed.
Keys to successfully implementing EHR
What are the best ways to get over the adoption hump? Interviews with doctors and health care IT professionals reveal three common characteristics of successful EHR deployments:
- The EHR system must be fast, intuitive and easy to use. If training is required, it should be minimal.
- The implementation, as in most successful IT rollouts, must have the support of top management and the buy-in of the physicians and staff who will be using it.
- The rollout should be gradual. A “big bang” approach is likely to cause frustration, anger and resistance.
Iowa Health’s Grosser credits her institution’s successful deployment to the formation of a governance team led by the physicians using the system, to provide selection and implementation oversight. As a result, “We have very high utilization,” she said.
Other technology leaders vouch for this approach. “What is the secret of implementation? Governance,” said Dr. Simeon Schwartz, a hematologist and oncologist who is responsible for implementing EHR technology at Westmed Medical Group in Purchase, N.Y. “It’s not a democratic process. What if UPS truck drivers could decide whether or not to use the UPS tracking system?” At the same time, “You can’t have a czar or a dictator. But the board has to have a commitment that everyone is going to implement EHR by such and such a date. If you don’t have 80% to 90% buy-in, your implementation will be eroded,” he added.
During the decision process at Westmed, input was solicited from all interested parties. Once the decision was made, however, the discussion was over. Deadlines for adoption were put in place, and doctors who missed deadlines were fined $100 per day. At Westmed, 160 doctors and 500 total staff now use the GE Healthcare EHR system.
Ciccarelli took a similar tack in implementing EHR technology. “Once people sense it’s being forced on them, they walk away from it. Recognizing that the major obstacle is buy-in, we had them pick the system. We picked teams, they evaluated and chose the system,” he said, adding that, when vendors attempted to speak with executives, not the teams, they were shown the door.
As with many issues involving behavior, change comes slowly. Tact and persistence are critical, and those seeking change must accept the fact that it won’t happen overnight. A rapid, forced implementation should be avoided. Not only are tempers likely to rise, but productivity could lag; lost minutes can add up, costing practices precious dollars they can ill afford to lose.
The implementation at AAIR has taken longer than anticipated, Deane said. Because it’s been gradual, however, he hasn’t seen a loss in productivity. “Implementation in a practice such as ours -- a physician-owned practice --takes a consensus, which can be hard to come by with doctors,” he said. “There’s been persuasion involved in implementing the system. All agree that it’s necessary, but differ on having to use it every minute of the day.”
For data input into EHR systems, keyboard, mouse still rule
Because data entry is the principal point of conflict, what is the best method of data entry? Despite such technologies as handwriting recognition, speech recognition, touch-screen and stylus, the traditional pairing of keyboard and mouse is still the fastest and most reliable input method, many agreed.
“Full keyboard and a mouse is the best. Tablets are ridiculous,” said Westmed’s Schwartz said. Half the doctors in the group use voice recognition technology, though he finds it inefficient, he said. Further, the EHR system’s interface should provide a balance between discrete and non-discrete data, he added: “A pick list doesn’t give you a good picture of the patient; too much free text is just as bad.”
Ciccarelli, who is in the early stages of implementing EHR technology, is unimpressed with tablet computers, and believes keyboard-and-mouse input works best. Nevertheless, the ultimate choice will rest with the doctors and nurses who will be inputting the data, he said. “We will work with doctors for the method they think is the best,” he said. For example, a dictation transcription service now in use will probably continue to be used when the new EHR system is in place, he added.
Reasons for disappointment with EMR software
When vendors of electronic medical records (EMR) software sell to nontechnical buyers such as doctors, disappointment is likely to result, Atlantic Health’s Reed said. That’s because the doctors may not ask tough questions and be led to expect more than the vendor will actually deliver.
“Most office EMR contracts that I have seen are two-page sales orders -- they do not indicate what the systems will do or not do. Most physicians don’t know how to get or what to get from the vendor in the contract,” Reed wrote in an email.
Promises of intuitive interfaces may lead doctors to overlook the need for training, Reed wrote. “Docs don’t realize they can negotiate EMR items like training and implementation. Since they don’t understand what they are contracting for, they may not realize that ‘implementation,’ as defined by the vendor, is two four-hour sessions, and training is a four-hour webinar, leaving them ill-prepared to use the technology they bought, throwing chaos into their patient care schedules and extending the time required for many to get the value they anticipated,” she added.
Savings, rewards for successfully implementing EHR
When EHR technology is implemented, productivity could dip at first, despite the best intentions and efforts of staff, until the system becomes part of the daily routine. However, most everyone expects benefits in productivity, accuracy and cost savings to be realized eventually. One physician particularly resistant to the system soon found himself wondering how he ever got along without it, Westmed’s Schwartz said. “Once doctors switch from pen and paper to keyboard and mouse, they recognize the benefit,” he said.
Implementing EHR requires change, [and] change in the way physicians practice is controversial.
Dr. Peter Deane, principal and CIO, Allergy Asthma Immunology of Rochester
Iowa Health System’s Grosser told a similar story. “Once they started using it -- I can’t say enough about how well the physicians have managed using the system. They’ve done a great job,” she said.
Atlantic Health’s Reed stressed the need for persistence: “The longer the EMR is in, and the more data builds up, is when the physicians realize they can’t live without it. The key is to keep at it and not bail out before that reward point is reached.”
Ciccarelli said he expects his hospital will go live with its implementation in November. Although he’s guarding against an expected decrease in doctor productivity at first, the overall benefits will pay back the technology investment two to three times, he said: “I don’t know if doctors will be more efficient or not when it’s done, but because of the tie-in to different departments, there will be efficiencies. Physician order entry can save a secretary two hours per day. Nurses can save an average of an hour a day. They can use the time to give better care.”
Stan Gibson is a contributing writer based in Boston. Let us know what you think about the story; email firstname.lastname@example.org.
This was first published in February 2010