Is your health IT working against you?
Many hospitals across the nation are already working with health IT, including electronic health records (EHR) and bar code scanning-especially as CMS' Medicare and Medicaid EHR incentive programs (commonly referred to as "meaningful use") promise to provide incentive payments to eligible hospitals as they adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology.
Though many hospitals are currently at various stages of their implementation, with many balancing a hybrid of paper and electronic documentation, the ultimate goal of health IT is to automate and integrate data and work flow processes to capture patient information all in one place, in real time, with the ability to automatically collect quality measures data.
Many healthcare professionals are putting their faith into an electronic interface that will provide safer and better-quality care by alerting them if they attempt to administer the wrong medication; providing a complete record of scans and tests to avoid duplicate, unnecessary, and potentially harmful testing; and matching up the correct patient and medication through scanning.
However, technology is only as smart as the people creating and using it. A study in the March edition of the American Journal of Managed Care has proven that poorly planned and implemented health IT can affect the quality of patient care. The study investigated U.S. Department of Veteran Affairs (VA) hospitals, most of which implemented some version of EHRs and barcode scanning in the 1990s-well ahead of the rest of healthcare, according to Joanne Spetz, PhD, professor of economics at the Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco. Spetz was lead author on the study, which was conducted through 118 interviews with nurses, pharmacists, physicians, IT staff, and managers at seven VA hospitals.
Wendy Whittington, MD, MMM, chief medical officer at Anthelio Healthcare Solutions, a $250 million health IT company based in Dallas, agrees that if organizations aren't careful, health IT can harm instead of help.
"I think we absolutely need to move into the new age and become electronic in healthcare," says Whittington. "But you can't just assume that by going with an electronic health record you're solving all these care problems without really putting some effort into it."
Whittington warns that bad processes or work flow problems will still exist after EHR implementation. "A good quality director is going to say, 'I'm all for putting in this EHR, but as we do it, let's just make sure that we're not just automating a bad process and let's measure outcomes,' " she says. "That's another thing that we see really lacking. In the rush to get those meaningful use dollars, there's a lot of hurry in putting in systems and there's not always a lot of careful planning of how to measure the success of it." A quality director must know, through data, that implementation was a positive move for the hospital, says Whittington.
Although there is no silver bullet to EHR implementation or to ensure a perfect upgrade, Whittington does advise identifying what pieces of patient information hold the most importance. "What is useless information that's going to be a distraction? Electronic health records often do such a good job at collecting everything that they make us scroll down through 30 screens to get to the punch line," she says. "Do your best to really bring to the surface what physicians really care about and what they really need to see."
Also, Spetz and Whittington note that EHRs and other health IT implementations are not shortcuts to better care or more efficient processes. Whittington says that many people tend to trust EHRs too much, when the truth is that they can contain mistakes just like paper records. An EHR is shared among many systems and has many users who can change and add information to the record. The entered information is not necessarily correct. Thus, someone still needs to verify information before acting on it.
"When we are truly patient centered, you would hope that you get to one source of truth for the EHR, possibly the patient," says Whittington.
And she warns that even if you've had the same EHR system for a while, it may be time for a change, especially if you are finding that staff conduct work-arounds.
"It's more necessary to optimize and revamp rather than worry about the initial installs. A lot of times we put the systems in and we think we're done"-when in fact it's often the beginning, Whittington says.
Evolution of EHR and bar codes at the VA
The American Journal of Managed Care study began in the early 2000s. At that time, most hospitals were thinking about health IT implementation, but few had begun the process. Many in the field were wondering whether health IT would alleviate, or even solve, issues such as the nursing shortage and quality of care problems, says Spetz. She and a team decided to evaluate the effect of health IT at the VA, something the organization had not done yet.
"We had what was the biggest implementation of IT possibly in the world," says Spetz, "and it was time to study what worked and what didn't."
The involvement of clinical personnel in health IT implementation ranged widely throughout VA institutions, says Spetz. Because many hospitals had already started homegrown EHR systems, they were able to smoothly transition when the computerized patient record system (CPRS) was officially rolled out, she says. The VA hospitals had been developing their EHR system for a long time before its official implementation, with each hospital adding pieces and sharing them with other hospitals, so by the time of the CPRS rollout, clinicians were familiar with the technology.
Bar code scanning, on the other hand, had not been used before, and it was implemented after a brief beta testing period. Hospitals had been asked to achieve full implementation of the software within a year, and each hospital formed different types of committees to lead the adoption.
"You kind of ended up with different leadership teams taking on the work, with varying levels of communication and support and feedback from staff, and I think you really saw that play out in the success," says Spetz.
Some groups, led by nurses and pharmacists, cautiously rolled out the software by piloting it in a small, controlled environment, such as a locked-down psychiatric ward requiring patients to come up to a window for medication (thus eliminating the need for mobile carts and scanners). Other sites rolled out the technology all at once. At one hospital, pharmacy took complete control over the software rollout.
"I don't know if it mattered who specifically took on the vision, but you had to have clinical leadership there. You had to have some people on the clinical side who are going to use the product on a daily basis, champion it-and not champion it blindly," says Spetz.
'Two steps forward, one step back'
Clinical involvement is only part of the success equation. When introducing new health IT, healthcare providers must accept that problems will arise during implementation and upgrades. Acknowledging this may be critical to a smoother and safer implementation or upgrade, says Spetz.
"When problems arise, you have to take a step back, ask what's not working, get honest feedback about it, and brainstorm how to move forward-that kind of an approach was generally very successful. Sites that were trying to be rigid in their implementation and didn't have that thoughtful clinical leadership really just had a lot more trouble," says Spetz. She notes that in the VA hospitals, an aggressive approach-trying to make everything work at once, no matter what-was less successful in the end than backing off on a part of implementation that didn't seem to be working.
"It was a little bit more of a two steps forward, one step back kind of process, but I think it got them where they wanted to go more respectfully and with less pain," says Spetz. Being too rigid or trying to accomplish too much may lead to potential adverse events, which in turn may cause a hospital to stop using a system, she warns.
You also need a vendor that will support a flexible mentality. "It starts with your vendor. It doesn't necessarily have to be that you have to use one of the flagship and more expensive vendors, but you need to be pretty careful about your vendor," says Spetz, adding that hospitals should research what size and type of hospitals a vendor usually serves, and where your particular hospital stands in that range. Of course, sales representatives have an objective to sell, so hospitals need to be diligent and involve clinicians in their decision-making-this also helps with physician buy-in later in the training process.
Although it's critical to ensure an EHR product will work for your hospitals and clinicians, it's also important to remember that the system will not be a glove-tight fit with your existing needs. Certain work flows and processes will have to change. "IT does not strictly conform to historical work flow patterns of everybody, and there's certain ways it will force people to change their work flows, and that might be okay," says Spetz.
With bar code scanning, for example, the VA found that having one nurse dispense medications for all patients on the unit, instead of having each nurse dispense medication for his or her own patients, was much more efficient once bar code scanning was implemented. "Once they had the cart, it was their cart for an hour and a half, two hours," says Spetz. The clinicians noted that the process change pushed them into working with a more team-based model of nursing care-and Spetz adds that there is evidence that the change caused a significant decrease in the medication error rate.
Plan on problems
Spetz cautions hospitals not to discount the human factor when implementing new technology, whether a hospital is rolling out an entire new EHR system or just introducing a new module. In either case, think about providing extra support during the rollout in the form of clinical and IT staffing-both on call and on the floor. The expense needs to be budgeted. Upgrades, and similar support during their implementation, must also be in the budget.
"We know that the clinical staff is stretched pretty thin in most cases. If the staff has a regular patient load and are figuring out a new computer system at the same time, and IT support isn't physically on the floor and you have to call a help desk and wait 20 or 30 minutes for help, that's just going to be a disaster for patient care," says Spetz. If you are implementing a new technology or module or performing some sort of upgrade, chances are things will take more time and problems will arise, she says.
Other than the inefficiency that accompanies implementation, not factoring in extra help also breeds a sense of resentment among staff who may feel that a new system is being forced on them without the proper support. This will cause them to feel that their needs are not being met, that they are disrespected, and that the IT system is bad. Such a sour memeory will serve as a barrier to the success of any future IT implementation.
Kaiser Permanente's health system, which Spetz is familiar with but was not part of the study, had travelling nurses serve as "super users," or users familiar with the system, to help implement the organization's EHR as they went from hospital to hospital. The super users not only provided IT-related help, but also extra clinical support during the EHR rollout.
"That extra staff piece is really important," says Spetz, who also encourages piloting new technology unit by unit.
"Above all of this, you need to have a good leadership team," she says. "Doing this when you're just coming out of bankruptcy? Bad idea. Doing this when your C-suite has turned over? Probably not the right time. You need to have that organizational stability and you need to have people on the implementation team that include the clinicians, people who are respected in the organization, and who are really willing to exhibit the kind of collaboration that is needed." Before implementation of a new system, module, or upgrade, recognize that health IT often requires collaboration across different professional groups.
Whittington also advises careful and thorough communication. When clinical and IT people are collaborating, it's important to ensure that everyone understands each other. "I would insist on overcommunicating, making sure that we say what we mean," she says.
It's also vital to break down the silos in your hospitals because the groups involved in EHRs can include any of the following:
- Quality, reporting, and safety initiative groups
- Clinical documentation improvement groups
- CD-10 groups
- Health IT groups
"Very often within hospitals, we speak an entirely different language," says Whittington, who also advises thinking ahead of who should actually own EHRs "A lot of times it's owned by the IT people because of the install, but they really should be the last people that should have a say in how it works. They don't know what you need," says Whittington.
Looking toward the future
Unlike most hospitals, VA hospitals have outpatient and inpatient care all on the same documentation system.
"That kind of ability to integrate the information across settings I think has been a big piece in the VA's success in the big picture," says Spetz. "If you're not a large health system, and you don't have the ability to have that kind of integration with whatever it is your community physicians are doing for their EHR system, then where exactly you're going to get the full benefit of your system within the hospital is a little less clear to me."
Hospitals should consider what EHR system community physician groups are using and be a leading force in demanding interoperability with those community groups, says Spetz.
- Patient care delay. "When you have a hybrid medical record, meaning some documentation is on paper and other is electronic, and maybe even some documentation is on an older electronic system that doesn't interoperate with the new system, you're sometimes forced to hunt down information, which delays care," says Whittington. Decentralization of information makes physicians hunt all over the record for the specific data they need. For example, patient weight entered in one part of the record may not propagate to other places, causing the physician who's trying to determine drug dosage to stop what he or she is doing and search for the information. "The promise is eventually, EHRs will bring information all into one place, but right now it's not so easy," says Whittington.
- Unnecessary tests and studies. Information may be in the wrong format or place, leading to a duplicate order from a physician who thinks a test or scan was never ordered. For example, a physician might see a radiology report instead of an image, or a table instead of a graph. It's also unwise to assume that all systems have the ability to communicate with one another. "Unless you are really fastidious in putting your systems in and getting them to communicate, you can't just assume that EHRs will warn or show you that a test was recently ordered," says Whittington.
- Contraindicated treatments. Drug allergy alerts within an EHR are useful, and EHRs do have the potential to decrease adverse drug events; however, alarm fatigue is a very real danger. Some systems give clinicians so many notifications that they don't listen to any of them and they get in the habit of overriding warnings. Whittington also notes that the EHR may incorporate information from different sources, some of which may be incorrect. "Somebody, ultimately, has to be responsible for the electronic health record that you're acting upon at that moment and verify the information is true and exact," she says.
- Treating the wrong patient. Many EHRs make it easy for physicians to order treatments for the wrong patient. There are lots of promising new technologies designed to combat this problem, but the danger still exists. Back in the paper chart days, it was of course possible to write on the wrong chart, but it's even easier to make that mistake digitally.
- Lack of follow-ups. While this problem can be remedied by fixing a broken process and automating that process once it's corrected, all too often we assume that the installation of an EHR or the automation of a process is the only solution needed. We often forget that an automated bad process is still a bad process. Physicians can be lulled into a sense of comfort that "the system" will catch potentially overlooked items, causing them to be lax in following up on test results or other pieces of information.