Evolving role of Electronic Health Care Informatics, and the current and future challenges in terms achieving the Right Balance
How to adopt the right balance between the electronic documentation in health care professionals workflow and quality of patient care?
Wow- now that is the billion dollar question! We have transitioned to a new, arguably more demanding E H R within the last 14 months requiring additional documentation by all care providers and frankly many believe that it has only slowed things down and NOT improved care. We are struggling to demonstrate the added value to our providers outside of ease of external reporting of measures, compliance and ease of billing. As a research organization, our hope was to extract large amounts of clinical data to enhance clinical research and that has proven far more difficult than initially planned- further undermining support for the new E H R. My only suggestion is to identify quick wins in specific areas where documentation has clearing improved safety (e.g. near miss) or improved care and showcase those events. Hopefully, you can develop a small core group of supporters who will influence the remaining providers toward a tipping point of wide spread adoption.
This is an incredibly universal challenge in health care delivery. I think the point in jsjr’s comment about focusing on a win that ALL would agree is a win (e.g., avoiding a near miss is unquestionably good; saving a few dollars may not necessarily be seen to be as good by all parties). Outside of health care, companies like Alcoa (focus on patient safety) have used efforts to improve non-financial performance as a driver of subsequent improvements in productivity and (in turn) financial performance. Within health care, there are examples of systems that celebrate “positive deviance”; this might have some relevance to celebrating the quick wins that jsjr mentions.
Not sure how the new EHR is more demanding and requires more documentation than any other. The requirements are usually more to do with regulation and billing and coding compliance challenges. Keys to EHR success include having engaged providers who become superusers and can help streamline documentation, reduce mouse clicks, eliminate duplicate documentation, automate data field population, reduce note-bloat, judicious use of the copy/paste function (some have eliminated this function as it invariably increases note length, introduces errors and sustains poor communication), adapts for your environment with requiring intense specialization. Physicians blame a great deal on the EHR system, some of which would be there if they were documenting in paper and would be more challenging in paper format than EHR.
We have found that the electronic medical record has such amazing qualities including but not limited to: transparency, accessibility of information to all physicians involved in the care, better coordination of testing, etc. However, at times, we have seen a decrease in the quality of the documentation. Some physicians are utilizing the copy/paste functionality despite a policy that forbids it. In doing so, the documentation of the patient’s care can fall below the quality that is warranted. This deterioration in the communication of the patient’s condition/deterioration/progress/etc could result in lower quality outcomes than expected.
While I agree with the previous posts, one of the challenges that we have had is comparing “before” and “after” when the documentation was so poor prior to implementation of an electronic record. Does it really take more time if the paper version had complete documentation (or in some cases any documentation)?
None of us would advocate a return to paper charts given the notable successes in areas like reduction of medication errors with EMR use. It will be a win-win for patients and providers if EMR system tools are used efficiently with pre-built templates, shortcuts, messaging systems in real time, reminders for high priority tasks, triggers, portals, smart pens, speech recognition software…etc. I find it more useful in our practices to encourage approaching the work flow from the team perspective and consistently train, train and train.
We normally see the interaction between physician and patient as two parties relationship. I think a way forward is to envision a three party relationship: a triangle of communication. This should be taken quite literally in the lay-out of your office: create a triangle around a desk and not a patient face-to-face with physician with a computer in between. The computer with the EMR open is the third party and all other parties (patient and physician) can read and input on the system. At the university of Chicago they have introduced a acronym: HUMAN LEVEL: Honor ‘Golden Minute’; Use ‘Triangle of Trust’ ;Maximize Patient Interaction; Acquaint yourself w/chart; Nix screen;Let the patient look on; Eye contact; Value the Computer; Explain what you’re doing; Log Off. (ref’s: Lee & Alkureishi, MedEdPORTAL 2013; Mann, Permanente Journal 2004; 8(4);49-51.)
The basic message is that if the computer is introduced as trustable third party which can help in communication, making health care safer and more efficient and can be used as a source of information (storage and retrieval). In this way the computer/EMR do not have to stand in between patient and physician but is a helpful third partner
I think we have had a lot of success with revising the ambulatory EHR system, but working very much in concert with the disease site team. There is a framework that we are setting in place that everyone receives (functionality to see who has checked in, vs who still has things left to do), but their has been great customization in the structure of the notes, depending on the demands for each site. I think this process, while timely, has brought good will to the teams who otherwise might be disenfranchised.
This is a problem that a lot of organizations are struggling with. When we begun the deployment of our EHR we were given a statistic that stated that there was about an 8 week period before the clinicians went back to full productivity. 8 years later, I don’t believe that is anywhere near accurate. Clinicians are challenged by the extra amount of work that is now required to work through the EHR. Some of that has to do with poor design, many implementations duplicated paper workflow, and it just doesn’t translate in terms of technology. An option is to look at workflow redesign where possible. Other options are to provide supporting mechanisms such as scribes, to lessen the load on the clinicians. Ultimately, after an organization has matured enough in their us of the EHR, the data amassed as a result is invaluable and can help to demonstrate the value. But that will take time. And to other’s point, data is only as good as what the clinicians provide so it can be a potential pitfall. Finding quick wins can certainly help but I really think it’s important to understand where the day to day challenges are and work with the clinicians to determine if there are opportunities to make their day to day work less challenging.
I’m in line with a lot of the previous comments. In DK we are in the process of implementing the Epic model of EHR in all eastern DK, but we have had EHR – and a lot of other electronic systems – in the last decade although not integrated with each other. We struggled with the previous programs due to e.g. server capacity problems and the lack of integration, in the beginning we also struggled dut to “everything just being knew and different”. The previous programs helped with the standardization of care – everyone could see that, and it was easily transparent to all health care professional engaged in the individual patients. And that story should be told!
With Epic however, a lot of tasks have shifted hands and a lot of administrative tasks that were done by secretaries previously, is know done by doctors – that has actually changed the engagement of doctors, who tend to only apply only the highly needed in EHR (and not necessarily all the nice-to-know also in terms of quality improvement etc.). That compromises safety.
Therefore, my advice is, that all electronic and digital solutions should be used smart by all – and should be used by the right professions at the right time as the patients transition through e.g. treatments – so all engaged health care professionals feel motivated and have the capacity/time to register not only data need to know but also al the nice to know. And thereby support patient safety not only at the individual level but also in quality improvement in general. Education in and implementation of EHR solutions must be planned thoroughly and with a reality-check to make adjustments so work-arounds and individual solutions made by the health care professionals do not rule the usage of the systems.
Our Health System implemented an EHR well before the days of ACO’s & Meaningful Use. While we were one of the early adopters within the United States, it clearly came at a cost. We clearly did not anticipate the impact on productivity. As a result, associate and patient experience scores were low and clinical documentation was challenged. We are now planning the install of a new EHR to replace our ‘beta’ system. Our work teams are led by clinicians as opposed to traditional IT resources to process map how the technology will interact with people and process. If done correctly, clinical documentation should be integrated into the clinical workflows as opposed to after the clinical episode.