Published in the July 2015 issue of Today’s Hospitalist
FOR MANY PHYSICIANS, the problems inherent in EHR systems were made abundantly clear last year when the country’s first Ebola diagnosis was made in Dallas. An ED doctor didn’t see a nurse’s electronic note that a patient he was treating had arrived from Liberia, the epidemic’s ground zero. The patient was discharged home, only to return days later to be diagnosed and eventually die in the hospital.
For doctors, the problem was all-too familiar. “An EMR has all these hidden pockets of information that are siloed to each of our individual roles in the hospital,” says Kendall Rogers, MD, chief of hospital medicine at the University of New Mexico Health Sciences Center in Albuquerque and long-time chair of the Society of Hospital Medicine’s information technology committee. “It takes extreme effort to integrate all that information.”
That wasn’t how the outside world viewed the situation. “You saw the response,” Dr. Rogers continues. “The blame was put completely on the providers, and the fix was supposed to be better training. But this is obviously a design flaw inherent in almost all existing EHR systems.”
Physicians have complained about EHR design and software for years, but not everyone has a dim view of the technology. Take Raj Mahadevan, MD, the founder of Cape Coral Hospitalists, a local private group based in Ft. Myers, Fla., who has used an EHR since 2010.
“I love it,” he says, naming the EHR brand with which he works. “It’s probably one of the most user-friendly systems. We have customized everything and, if used well, the system is superb.”
Huh? While Dr. Mahadevan admits there are still many changes he’d like to make to his local EHR, he’s a long way from the simmering frustration that many practicing physicians purportedly feel.
Take a closer look, though, and you’ll see that Dr. Mahadevan’s sense of well-being is due to a robust infrastructure of clinicians and IT resources working together to tailor their local electronic system. The reality is that for many hospitals, particularly smaller facilities, those resources are sorely lacking.
Ask hospitalists how successfully they’ve been in reconfiguring their hospital EHRs, in fact, and a snapshot emerges of digital haves and have-nots. Some physicians say their institutions can nimbly field requests for EMR changes and make those changes happen. But others are a long way from being able to do the customization they need.
“Some sites have achieved some great success,” Dr. Rogers says. “But that requires significant investment on their part, and most sites don’t have adequate IT support.”
Hospitalist Ned Jaleel, DO, parlayed his interest in hospital medicine workflows and health IT into a career with EHR vendor Meditech as lead physician informaticist in charge of acute product development.
According to Dr. Jaleel, EHR vendors are now paying much more attention to physician workflow to make their systems more user-friendly. He points to his company’s recent overhaul of the medication reconciliation process and critical care flowsheet, which leveraged “exhaustive focus groups” of clinicians convened to upgrade the EHR’s user experience.
But he understands frontline physicians’ frustration. “Physician leaders throughout hospitals are concerned about quality, so they can see the technology’s potential,” Dr. Jaleel says. “But for frontline doctors, interacting with an EHR is a recurring reminder that it’s preventing them from seeing their patients efficiently.”
As for how EHRs have affected physician productivity, Dr. Jaleel points to “some losses and some wins.” He is thrilled, for instance, that doctors no longer rush around hospitals trying to grab film and old charts that often went missing.
However, “physicians used to write a series of orders in 30 seconds with the Mont Blanc pen they received for their medical school graduation, hand those orders to somebody else to put into the computer and walk away,” he points out. “Now, we have to sit down and we may scroll through pages of order options. That places increased pressure on how EHRs are designed and built to accommodate user workflows.”
The right stuff
But in his four-hospital system, Dr. Mahadevan points out, all the hospitalists’ order sets, protocols and templates have been customized. Their extensive list of smart phrases saves them documentation time. In a month or two, the system will have a new electronic paging capability that will save nurses time trying to reach physicians.
Any request for an EHR change within the four community hospitals generates a “ticket” among vendor-support technicians. “You’ll get an e-mail update that they’re working on it,” he says. “When they see multiple tickets on the same issue, they know it’s a hot-button item.”
Dr. Mahadevan says that his hospital system took two important steps immediately before the EHR went live. First, it convened a group of nurses who were sent to the vendor’s headquarters to be trained. It also established a physician advisory committee, with one doctor named as medical liaison to the IT team.
“It’s 20 physicians who meet once a month,” he says. “They keep talking and refining.” Committee members also vet all EHR-change requests. The fact that the hospital system maintains an IT staff of 100 people also goes a long way to helping clinicians get the changes they need.
But those are luxuries not found in all community hospitals. Former hospitalist James Levy, PA-C, is now vice president of human resources for iNDIGO Health Partners in Traverse City, Mich. The local private group, which serves seven different facilities, specializes in working at rural hospitals with between 60 and 120 beds.
What all those hospitals have in common, says Mr. Levy, is “they’re financially stressed, chronically in a lot of cases, but more acutely so in recent years.” That’s a big reason why, he adds, “administrations routinely adopt these systems but never factor in time and money on ongoing development and adaptation.”
Across those hospitals, there’s variability in terms of EHR vendors, Mr. Levy explains, with some systems more feature-rich than others. One hospital’s EHR was billed as a basic toolkit that could be locally customized. However, “pretty extensive” system adaptations turned out to be incompatible with the vendor’s subsequent software updates.
“Instead of adapting our EMR to the way we do it, we needed to adapt to the way the EMR was built,” he says. “In terms of clinical process, that didn’t always make sense.”
As for customization in the other hospitals, Mr. Levy says, “smaller hospitals are very responsive to us bringing in the order sets that have worked well elsewhere for us and using those to organize provider order entry.”
But in larger hospitals, “making changes of that kind requires bringing issues to multiple sections of a number of committees,” he points out. “That can get very frustrating and bureaucratic and slow.”
Oversight in community hospitals
Dean Dalili, MD, MHCM, is senior vice president of medical affairs with Hospital Physician Partners (HPP), a national practice company that staffs both EDs and hospitalist programs. While he helps oversee nearly 30 hospitalist groups in community hospitals, Dr. Dalili is based in a community hospital in Florida that has CPOE but does not yet have electronic documentation.
The most efficient system he’s seen to handle and prioritize potential EHR changes was at Johns Hopkins, where he was a resident. “They had a formal committee led by a physician where all requested CPOE changes were addressed through a single group with multiple stakeholders represented,” Dr. Dalili recalls.
But in community hospitals, the process is much more haphazard. And in many community hospitals, he notes, the medical executive committee “is typically dominated from a governance perspective by outpatient private practice physicians. They have quite a bit of influence over the processes that take place in the hospital” “including making needed changes to EHRs “”but they don’t themselves use the technology.”
To work around that roadblock, Dr. Dalili says that HPP across all its sites institutes what it calls a joint operations committee. “That’s ER and hospital medicine meeting biweekly with case management and nursing to talk about throughput, quality or patient safety issues,” he explains. “What these working groups find is that the origin of a lot of errors is the CPOE system, which ultimately has to be fixed.”
The joint operations committee may take some of the oversight of potential EHR fixes away from the medical executive committee. “Or we’ve partnered with the medical executive committee to report some fixes we think need to be made,” Dr. Dalili says.
One big source of CPOE frustration in his hospital is multiple log-ins. “Several systems now have a single sign-on, which is nice,” says Dr. Dalili. “But sometimes, data are warehoused in multiple systems and we need to log in and out of different applications to get the information we need.”
Another issue is the number of clicks. “You have to click on different screens to get the data you’re trying to retrieve, whether it be vital signs, labs, dictations, culture results or imaging,” he notes. “There is a lot of navigating within single files that takes a lot of time.”
That’s particularly a problem because of another issue that Dr. Dalili says can crop up in community hospitals: slow computer processing time. “Most of us are using old desktop hardware that has not been updated,” he says. “Even with new EHR systems, sometimes we’re hamstrung by hardware limitations as much as by software.”
Dr. Rogers from New Mexico points to another problem with customizing software that academic centers as well as community hospitals encounter: limited IT support that’s constantly scrambling to meet regulatory requirements. IT departments are focused not only on meaningful use and ICD-10, Dr. Rogers says, but on data reporting for such things as hospital-acquired infections and bundled payments.
“All these different payment systems and quality measures depend on data capture and collection,” he says. Figuring out ways to automate that capture and deal with all the regulatory requirements “takes up the entire strategic plan of most local IT departments. Any request that’s purely clinical and can’t be tied to a payment plan or quality indicator falls to the bottom of the list.”
But that’s not always the case, according to Brian Clay, MD, chief medical informatics officer at the University of California, San Diego.
“Our IT team can actually be very nimble,” says Dr. Clay. “There absolutely is bandwidth to do optimization and enhancement.” Further, the UCSD hospitalists are “comfortable” with their four-year old EHR, and the system changes they’re now championing are designed to make the hospital more efficient.
Dr. Clay gives two recent examples. One big change was revamping orders for cardiac monitoring to be indication-based and to cut down on unnecessary telemetry.
“Now, rather than just ordering a monitor, you select an indication, which is tied to a default duration on the order,” Dr. Clay explains. “If I select syncope, I get cardiac monitoring for 24 hours, and then it’s set to expire.” All told, he estimates, that change took a task force about 100 hours over several months to get everyone on the same page in terms of guidelines and indications.
But another recent change grew out of a resident’s observation: how many differentials with CBCs were being ordered. “When you type in CBC, you get several options to choose from, and the one at the top is a CBC with a differential,” he points out. “We realized that a lot of people were choosing that just because it came first.”
The fix was to change the order of the display. “We didn’t even tell people about it,” says Dr. Clay, “but the number of differentials being ordered fell by 25%. That’s maybe 25,000 or 30,000 a year at $10 each, so easily a quarter of a million dollars a year in savings.” Further, the adjustments “were simple enough to make within a week.”
What would Apple do?
For iNDIGO’s Mr. Levy, “The fact that we have a number of different competing and proprietary EHRs, none of which will talk to each other and all of which are mutually incompatible, is a national scandal.”
But sharing important enhancements “like the changes UCSD has made “can be challenging even within one vendor community, let alone having it filter up to a vendor to be incorporated in future iterations. Dr. Rogers, for instance, customized a dashboard “that shows every piece of information you need to make glycemic control decisions for a patient, rather than going to 15 or 20 places in the chart. But I haven’t been able to successfully share it with anyone.”
Even sites that share the same EHR vendor, he explains, “would have to take my template and build it almost from scratch because of how the databases are constructed, the lack of standardization between terminology and how each individual site has built its system.”
Meditech’s Dr. Jaleel points out that his company “as well as other EHR manufacturers “is starting to collaborate with many more third-party vendors. But that trend is still too small, says Dr. Rogers, and rapid EHR innovation has been stifled.
“Apple would have died a very quick death if, rather than building a framework and inviting everyone to build applications, it instead said, ‘Send us all your requests and we’ll get to them eventually,'” he says.
Dr. Rogers notes that the federal Office of the National Coordinator for Health Information Technology is making a push for interoperability. He also sees some hope in the rise of SMART platforms (substitutable medical applications, reusuable technologies), applications that can be layered on top of existing EHRs and can run on any of them.
But he thinks it will take a new round of federal regulations to allow for true interoperability and rapid innovation.
“Think of all the efforts we’re making at the local level,” Dr. Rogers points out. “If that effort was being spent in a common ‘app store’-like community, we could be building on each other’s work instead of everyone working from the ground level. But we’re just not seeing that.”
While some physicians have well-functioning EHRs, Dr. Rogers adds, “I don’t think we’ve had that breakthrough where we’re moving toward rapid innovation, and I think that’s going to occur only with some type of regulation related to interoperability. That’s the point I’m waiting for.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
“Can we talk?”
MANY DOCTORS COMPLAIN THAT THEIR EHRs aren’t built to mimic their typical workflow. They also bemoan the fact that, in many hospitals, transcriptionists have been let go and doctors now spend hours doing data entry.
But another big area where doctors worry about the impact of digitization is communication. While a high-profile example occurred in the initial diagnosis of an Ebola patient in Texas, missed communication plays out in hospitals to some extent every day, according to a study posted online last year by BMJ Quality & Safety.
Hospitalist researchers at the University of South Florida talked to doctors, nurses and patients both before and after an EHR was introduced. They found that while doctors and nurses post-EHR communicated as frequently, face-to-face communication was reduced (51% vs. 67%).
In addition, fewer nurses and patients after implementation could accurately predict their length of stay (26% vs. 34%). That indicated to the research team that fewer discussions of patients’ care plans were taking place.
“After the electronic medical record came out, everyone was sitting in a room filling out documentation, and you looked at the chart to figure out how your interventions were working instead of calling the floor,” says lead author and hospitalist Stephanie Taylor, MD. “There are nuances to face-to-face communication, verbal and nonverbal cues that you pick up on, that you don’t necessarily communicate through the record.”
Part of the fix “at least in terms of the care plan and discharge “was for doctors to include in their notes the anticipated day of discharge and expected length of stay.
More importantly, says Dr. Taylor, the hospital boosted the number of computers on the floors. Now, “it’s easier to do documentation at the bedside or the nurses’ station, so physicians are physically available more frequently.”
The center also initiated “huddles” or multidisciplinary rounds on each floor to bring clinicians face to face at set times. “Both things have helped,” she notes, “but reimbursement is tied to documentation, not communication. Until we incentivize interpersonal communication among providers and between providers and patients, it may not get much better.”