- Editor’s note: The following is a two-part piece on EHR implementation and adoption pitfalls and advice for avoiding them. Read part two here.
EHR system development, implementation, and adoption in the US has been a struggle, to say the least. The technology is not perfect, care team workflows are being disrupted, and providers are resisting change. Those who are not resisting often find themselves struggling through it. In all reality, you can’t really blame them — imagine the early days of aviation — would you want to be a guinea pig strapped into one of the first planes? Eventually, EHRs will operate like 737s, but until then, providers are being forced to work with what’s out there.
Through our experiences working side-by-side with providers, we have seen many things and learned many lessons. These are just a few of the stories and lessons we have walked away with.
Exhibit A: The magical EHR
It’s important to preface this by saying that EHR vendor sales strategies are nothing short of spectacular. Who wouldn’t want the EHR that will automate every single process within your practice, require no training, improve your efficiency by 99%, improve quality outcomes, and allow you to see 30 additional patients per day while instantly decreasing costs? Rumor has it that in the next release, the system will also have the ability to print money and bend the medical cost curve with the flip of a switch! Unfortunately, we find that many clients that make the investment quickly find out that EHRs are not magical and do the absolute opposite of printing money.
The truth is, today’s EHRs are not great; they don’t always do everything you need them to do, and the more you customize them, the more they begin to resemble the Apollo Mission Control Center in their degree of complexity, and perform like the initial Healthcare.gov rollout (too soon?). Although technology has come a long way, healthcare continues to take its sweet time catching up to the rest of the industry.
One provider in particular began an EHR implementation in October, with plans to go live by the end of the year. Unfortunately, seven months and many clinical meetings later with the implementation team, the provider was still not up and running on his EHR. The provider had been “misinformed” by the vendor that the new EHR he was installing was capable of automating his chemo infusion data within the standard EHR module. Unfortunately, the system did not have this capability. For months, the provider refused to accept this answer from the implementation team, insisting that this was possible because “the vendor told him so.”
Eventually, the provider, implementation team, and other constituents reconvened to discuss the issues. In the end, they agreed on a phased approach to implement an additional module for the chemo infusion data and went live several weeks later.
This scenario is not uncommon. Despite their robust functionality, EHR systems are not capable of doing everything. Unfortunately, initial conversations during the sales process with the EHR vendor misled this provider into thinking the system could do things that is simply could not. Additionally, had the implementation team worked to reset provider expectations earlier in the process, together they could have come up with an acceptable Plan B option acceptable to both.
Exhibit B: Post-its and their consequences
Remember when you first started using a cell phone and you told yourself, “I’m only going to use this for emergencies.” Remember when text message started becoming a thing, and you told yourself, “I’m only going to use this for emergencies.” Well, times have changed, and I will estimate that 30 percent of people reading this article are probably doing so via smartphone or tablet. The truth is, we eventually give in, and we have to admit, smartphones have made us considerably more agile and ultimately, made our lives easier.
We have talked about “paranoid” providers who do not trust the system and back everything up on paper, but there are also the “stubborn” providers that do not trust the system and refuse to use it completely.
During a practice assessment, practice coaches noticed that medical assistants (MA) were spending an inordinate amount of time working on orders in the EHR. Additionally, one practice coach noticed an overflowing recycling bin full of yellow Post-it notes with medication orders scribbled on them. Upon discussing this with the MAs, they learned that the provider had been placing orders on Post-it notes and sticking them to the back to the exam room door, only for the MA to enter them in the system. When the provider was asked about this, he simply replied, “I hate the system, and I let other people deal with it — I don’t have time for it.” Despite escalating the issue and engaging other executives within the organization, this provider still refused to change his ways.
It was not until a quality audit revealed that the wrong immunization had been administered to a patient due to this process. Upon deeper investigation, it was learned that a Post-it from a previous appointment was not taken down from the door and was documented in the wrong visit, causing the confusion.
Fortunately, there was no harm caused to the patient, but this isn’t always the case. This situation could have been much worse and could have potentially cost a patient his life. Workarounds such as these are used every day, and resistance to change is very prevalent. Although the provider’s makeshift documentation may have allowed him to see a couple extra patients per day or spend less time in the EHR, the liability involved was not worth it.
Partnering with the provider early on to design workflows could have helped him utilize the technology to support his practice, rather than avoiding it. In addition, implementing proactive monitoring of key processes to assess adoption is also critical.
Read the final installment of EHR nightmares here.
Greg Chittim is a Director at Arcadia Healthcare Solutions with responsibilities including the analytics service line and strategic marketing. He has a deliberate focus in health information exchange, Direct Project messaging, clinical quality analytics and reporting, enterprise technology implementations and general strategy and operations. Greg works directly with the Office of the National Coordinator for Health IT (ONC) as a Subject Matter Expert on the Technical Assistance team. Through the ONC, Greg has worked with nearly 30 states on their Direct strategies and tactics, and is the Champion for the nascent Direct Community of Practice.