Physician adoption of Electronic Health Records is reportedly well received in Western Europe. Governments there have worked closely with physicians and subsidized the costs of new technology. While in the United States the initiative enacted in 2004 by the U.S. government to have adoption of EHRs nationwide by the year 2014 physician adoption has lagged behind. In spite of support from the executive branch and associated federal healthcare departments to promote EHRs at the time to move the process forward. The tipping point came in 2009 when federal financial incentives were provided. Through the Health Information Technology for Economic and Clinical Health (HITECH) Act funding was implemented influencing hospital systems and the physicians who practiced at these facilities.
Nevertheless, with the end of this ten year projected timeline for widespread adoption in the United States fast approaching, physicians have yet to completely embrace the transition. It was once thought that particularly difficult CPOE adoption comes from the smaller practices, where the physicians in the group don’t have a healthcare system supporting the transition. There is little incentive for a small medical practice to invest in an EHR for their clients as most would be cost prohibitive. However the trend may be changing. Nevertheless, In general, United States physicians also tend to resist the mandates for adoption, feeling as if it imposes constraints on their practice. Projections show it could take up to an additional decade: potentially up to year 2024, for wide spread adoption.
In spite of wide spread implementation of the electronic medical records (EMR), physicians are acutely aware that the glowing messages of computerized provider order entry (CPOE) sold to them during the product demonstration in many ways don’t match their experience once introduced into their practice.
While healthcare IT vendors and healthcare technology staff may tend to minimize the remarks of the physicians and other primary care providers reacting to the complexity of the new software, much can be learned from these professionals that could actually help assist us identify better work flows and over time improve the products we represent.
Reports find that in nations such as the United Kingdom, 97% of primary care physicians are using an Electronic Medical Record (EMR) second only to the Netherlands at 98% usage. These statistics seem to be a remarkable achievement and should stimulate some investigation. What is being done in these places that other countries including the United States have overlooked or have not overcome? Surely there must be a way we can streamline and standardize a method to improve physician adoption of EMRs. Attitude, approach and acceptance of the process are the guiding principles but what does that look like in practice?
Here are some academic and empirical lessons learned through the eyes of those who design, build and implement order sets for CPOE and those who have studied the outcomes. We will examine seven keys to successful physician adoption of electronic medical records.
1. Financial Incentives
While the United States still significantly trails other countries in adoption of the EHR a recent study done in 2013 by the Robert Woods Johnson Foundation finds that hospital and physicians in the United States are embracing the adoption of Electronic Health Records, largely due to the funding from the federal government.
The 2009 American Recovery and Reinvestment Act (ARRA) implemented legislation through the Health Information Technology for Economic and Clinical Health (HITECH) provisions to encourage physician adoption of the electronic medical system with the goal of promoting significant adoption of the EMR. The financial incentive promised to physicians serving Medicare patients that move to an electronic system are eligible for an incentive of up to $44,000.”
Since the funds were committed in 2010 the nation’s seen adoption of EHRs triple. Current estimates are that 44 percent of hospitals alone have implemented electronic health records into their healthcare delivery system. As a result many family practice physicians are now adopting the EHRs and thus entering more physician orders through an electronic record. It would seem then that the significance of these finding is that physicians are growing increasingly more comfortable with electronic order entry.
However a different study reveals a less favorable trend, as cited below suggesting that significantly fewer physicians are utilizing CPOE than was first thought:
“ Despite incentives, just 1 in 6 uses the new technology…doctors who are using electronic health records in a meaningful way are eligible for a $44,000 bonus from the U.S. government, many still haven't adopted the new technology …however doctors who aren't on board by 2015 will be subject to government penalties…while this indicates a rapid increase in the number of doctors using the new technology, if the adoption of electronic health records continues at the same pace, it's likely that many doctors will be subjected to fines for not having the technology in place by 2015…one of the biggest barriers may be cost. The incentive money helps, but it probably doesn't cover the whole cost..."
This would lead us to believe that a physician’s focus may more accurately and appropriately be directed toward patient care and less toward how the patient provider encounter is recorded. While this cannot be discredited, for physicians to miss the mark and not receive funds causing fiscal penalties will further frustrate an otherwise conscientious healthcare provider.
Success for physicians depends on wise planning to coordinate the transition to an EMR with the right support from their sources of funding, and clinical practice. These, in hand with customized product development from the vendor, are vital to satisfy the expectations of HITECH; Meaningful Use; Accountable Care Organizations and most importantly the physicians themselves who remains committed to their patients and their practice.
2. Providing Consistent Support from Government, Hospital Administrations and Vendors
Healthcare Legislation
While adequate funding is vital to successful adoption we see that the message itself needs to be stable and consistent from all stakeholders and targeting accurate message to support the success of the physicians practice with the goal to achieve full CPOE adoption, and meet the meaningful use guidelines.
American healthcare is under great scrutiny. The US federal government backs progress of standardizing health services, and was the catalyst behind the current initiative to move EHRs forward, however of late there are questions arising as to the appropriate use of the funding. While it is important to institute an effective cross check for the distribution of the funds, the message is best if not turned to skepticism of the desired outcome.
Improvements in patient care will come through a standardized platform for gathering patient data. Gathering the data is only the first step, mining the data to improve the health of populations is where healthcare will be transformed. We cannot lose sight of the tremendous value of analyzing trends in patient data and how it can shape the future of how healthcare is provided. If doubt or mistrust prevail, we as a society have more to lose. We’ve seen other field who took on technology to improve processes and outcomes successfully, so too healthcare needs to advance.
The Role of a Hospital Administrator
Hospital Administrators are vital to set the tone, momentum, and expectations for the entire hospital/hospital system acceptance of electronic charting. They first must believe in the product and the process of converting legacy documentation to modern methods for electronic charting, then stand by the chosen vendor through all stages of the transformation. This may sound simple and obvious however there will be challenges during the phases of adoption that will test even the strongest supporters. Hospital administrators will set an example and motivate others to those within the hospital system that expect to have their work lives and practices respected and managed properly.
A Challenging Case Study:
Physicians at smaller hospital venue in the Silicone Valley of California, part of a larger healthcare system had recently undergone an EMR implementation with a well-established and dependable vendor. There were the usual training opportunities in place, with lots of time to get the staff and physicians up to speed with the product. However physician training was not mandatory, and ultimately use of the EMR wasn’t required of them. Essentially the hospital administration didn’t provide any tangible expectations for the physicians.
As imagined, without training or commitment with the expectation to move from paper to electronic charting the process of implementation deteriorated rapidly. Right away during implementation bright and technically savvy physicians found fault with the software. Reportedly it couldn’t do what they expected and they felt it was too time consuming. In spite of every effort to bring in developers, software engineers, and additional trainers the physicians would find little they could appreciate about the product and quickly lost interest.
Despite efforts by the Hospital Administration to rally the physicians back into its use, the physicians eventually mounted such intense resistance that the Medical Board members of the hospital deemed the vendor’s product “unsafe”. Overwhelmingly, the board voted to prevent it use until the vendor could meet certain demands to prove there was no risk in using the product, which by the way, had been proven multiple times with multiple clients over multiple years. Nevertheless, no amount reassurance would help bring them back. Ultimately physicians at that particular hospital still charted in whatever way they pleased paper or electronic, or sometimes both.
Through this example we see hospital administrators made great attempts to bring the process back into focus, but eventually couldn’t hold its ground. Lesson learned: In a conversion from paper to electronic charting it is proper to establish a commitment from the end users by encouraging a contract, and by mandating the training and use with the physicians ensuring expert and effective support from the vendor. Hospital leadership must stand firm, within reason, alongside the vendor, in support of the process during this kind of change.
Vendor Support
Time tested EHR businesses are best suited for providing the most predictable and reliable services throughout the process of implementation. Companies like these have developed databases, established a degree of standardization, and are best equipped to provide skilled resources to support implementation. They know the rules behind Meaningful Use measures, they know what’s expected for them to provide a product that will satisfy the client and meet the demands of government regulation. Vendors must be willing to work with new client sites in engaging physicians as early as they can in process so nothing comes as a complete surprise at the time of implementation. In addition, customization of the product is one way to draw physician’s interest. In software demonstrations reasonable expectations can be outlined. Furthermore, an honest description to what can and cannot be modified could remove any unrealistic demands from the end users.
3. Intuitive Technology
While the practice of medicine has long been referred to as an art as well as a science, there still seem to be a “disconnect” in completely bridging the gap for technology in healthcare. Smartphones, tablets and their touchscreens have shown us that technology can be relatively simple and efficient to use. Physicians expect this kind of experience to be available when they chart. They expect it to be intuitive, and similar to the way they think and practice. However, even with relatively simplified technology of the day, there is still a learning curve for all users.
Time saving is the most sought after quality of any charting method. However by the nature of changing the process of entering health data from paper to electronics time savings is not reported by end users early in the adoption process.
Change IS hard…. Here are some trigger points for pain…and how to alleviate the response:
- Give the client the difficult news up front...
- Initially using an EHR does slow the work flow down
“…Some physicians may be concerned about drops in productivity as a new system is implemented. "What we've seen is that when you first put it in, it does hinder productivity a bit as people get used to it. But, over time, productivity picks back up and enables doctors to do a whole other realm of things they couldn't do before...”
Ways to alleviate initial change in productivity from a physician standpoint include a couple practical steps if hardware budgets will accommodate the need. Here are two recommendations to help physicians feel as though they have access to charting:
- Voice recognition software to speed up data entry to replace typing
- Have devices in close proximity and have enough for use, physicians will not go out of their way to find a device
The application will never be “perfect” for everyone… suggestions for improvement are welcome but change doesn’t typically come quickly in EHRs ; Vendors need to be willing to offer reasonable customization to the existing software.
Reassurances can be helpful…
A computer doesn’t have to take time away from the patient/provider…it can actually be integrated into the experience by showing the patient screens that display graphic trends, or screens that illustrate a point about the importance or severity of a condition.
Security / Confidentiality is actually better than with paper charting, because every entry gives a date/time stamp of what provider/clinician opened the record. This is better than currently, where anyone can open the paper record and view anonymously any details.
If individual physicians are willing to embrace the changes early on, they will be able lead others when the house wide implementation occurs. Physician “champions” as they are called can do much to serve as examples, even catalysts to further physician adoption of EMRs/CPOE.
In part two we will be looking at keys 4-7:
4. Early Engagement: Process and Software
5. Mandatory Training and Willing Participants
6. Medical practice protection reassurance
7. Customized attention for future time savings