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EHR implementation: How common blunders can alienate your patients

Many snafus associated with EHR implementation have little to do with the technology but rather how it is prepared before adoption and ultimately used.

By Pamela Lewis Dolan — Posted Sept. 24, 2012

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When Genesis Ob/Gyn took the first steps to installing an electronic health record system in its seven practices, there was a lot of focus on choosing the right system with the appropriate capabilities.

But after implementation, when the system continually went offline or ran painfully slow, resulting in long patient wait times and chaotic days of not knowing which patients were coming in and why, the Tucson, Ariz., group realized there’s a lot more to EHR implementation than the system and what it can do.

Many practices are adopting an EHR for the first time, with various surveys finding 70% to 80% putting in systems, double the rate of three years ago. Almost every health IT implementation comes with hurdles and blunders. It can be frustrating when blunders affect the patient experience, but many are common and can be prevented by learning from the mistakes of other physicians.

When a practice has no system to see which patients are scheduled, or the waiting room is full of angry patients while their physician tries to get back online, or the physician logs in only to find a blank screen, “it can be kind of a chaotic day,” said Becky Little, director of clinical operations for Genesis Ob/Gyn. “Not having the network or data, you’re kind of flying by the seat of your pants in terms of who is coming in and for what.”

Many of the common blunders can be linked to how the technology is implemented and how it is used. “For the most part, the technology works,” said Amit Trivedi, health care programs manager for ICSA Labs, a technology testing and certification organization. “It’s getting people to work with the technology that is more difficult.

“One of the toughest things is that folks view EHR implementation as a technology project, and it is because you are making a sizable investment in hardware, software, licenses and all that stuff. But it’s easy to forget that ultimately it’s a people and process project, not as much technology.”

Here are some common pitfalls:

Lack of necessary infrastructure

Little said a lack of infrastructure — the hardware and bandwidth used to connect the computers in a network — caused a lot of the hiccups Genesis experienced. She said this can cause unplanned downtime that can bring work to a standstill.

Before implementing, it’s always a good idea to look at the network on which the computers will be running, making sure it has adequate broadband to prevent the computers from running slowly, said Robert Cheek, a senior network engineer for Atlanta-based Network 1 Consulting.

A slow network can mean a delay in labs and radiology images, which means a delay in diagnosis. Or maybe the physicians can’t log on to an e-prescribing system. Then they can’t use the drug interaction safety checks, Cheek said.

Little said physicians should talk with other users while doing system assessments. Vendors often quote the minimum hardware specifications needed, and practices end up with systems that work but not at their optimal levels.

Lack of workflow assessment

Margaret Donohue, MD, chief medical information officer for Unity Health System in Rochester, N.Y., said the goal of an EHR implementation is to have the patient’s data follow the system through every step of the patient encounter. This requires a careful examination of work flow, which is the mapping of each employee’s steps through every task. When going electronic, every process should be remapped to include the electronic flow of data, she said.

Researchers from Denmark published a study online Aug. 22 in BMC Medical Informatics & Decision Making that looked at the use of video for documenting and studying changes in work flow. They found that video made the process more thorough “when it [came] to disclosing the complexity in clinical work practice.”

Without a good match between work flow and EHR system, people get stuck not knowing what to do, and information can be lost or not collected, said Richard Stokes, director of sales for Network 1 Consulting.

In a paper world, Stokes said, a nurse takes vitals, writes them in a chart and hands it to the doctor. In an electronic world, that information is entered into an EHR, which the doctor must log into to view. If employees are not educated about how the new work flow will change things, it will slow things down and steps will be missed.

Lack of training

If employees who are going to use the system aren’t trained adequately, it will slow everything down, Stokes said. “The longer they resist that, the tougher and the harder the implementation will go smoothly and correctly for the practice.”

Trivedi said many practices make the mistake of paying for only the minimum amount of training offered by the vendor. When the trainers leave, employees don’t have anyone to answer their questions. “Once that implementation is over, you’ll need people in the practice to take over” for the trainers, he said.

He said people in the practice who are designated “super users” need to set aside time for extra training. They should feel comfortable performing the EHR tasks that are required of them and act as the go-to experts for others in the practice when questions arise.

The practice flow could screech to a halt if someone gets stuck on a problem. Having a person on staff who will serve as a shadow during the first few weeks will help the process run more smoothly as others learn the system and feel comfortable with it.

Failing to get buy-in

Trivedi said it’s important that either the physician or the practice manager explain to employees the reasons for switching to an EHR. You don’t want disgruntled employees, he said. “It’s easy for one person to derail the whole project if they feel it is threatening or if they don’t understand why it is being done.”

Ultimately, everyone in the practice should understand that the EHR is a tool and is not meant to replace anyone, Trivedi said. “You’re still going to need human elements.”

“If they don’t want to do it and they don’t understand why you’re doing it, it’s going to be difficult to get everyone on board and enthused about the process and have the same hope for it to succeed as well,” Trivedi said.

Not preparing patients

Whether a practice plans for it or not, productivity is sure to suffer during the first few weeks after implementation. Therefore, experts say practices should limit the appointments for a given day and explain to patients their reasons for doing so.

Dr. Donohue said that during her EHR’s implementation, the number of appointments was reduced and patients were not happy about it. But some of the frustration was eased with communication, including posters and letters explaining the change. Unity also surveyed patients about how they liked having electronic records. This not only told the patients that the practice cared what they thought, but also let the practice know about their concerns.

Computer treated as third wheel

Dr. Donohue said many practices don’t spend the time figuring out how to make the computer part of an equal triangle of computer-physician-patient. Instead, she said, the computer is thrown into the middle of the patient-physician relationship with no thought given to the role it is going to play.

“Now the computer is part of that interaction [between patients and physicians], and I think most patients are positive about that. … But it really is something you, as a physician, have to figure out,” she said. “And that’s hard for a lot of physicians.”

Dr. Donohue said physicians need to look at their typical patient-physician encounter and identify places that can be augmented by the computer. They can, for example, engage patients while they are documenting by telling them what they are writing, or use the computer as part of the interaction by showing the patients things on screen instead of merely telling them. “Otherwise, patients feel that it’s in the way.”

Little said Genesis Ob/Gyn learned many lessons after implementing and switching systems several times throughout the course of trying to get the seven-practice group on the same EHR. In the end, they were successful. “But obviously, we floundered,” she said.

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ADDITIONAL INFORMATION

Common EHR implementation mistakes — and their effects

Often the most obvious way implementation mistakes play out is a decrease in patient satisfaction. Patients are left waiting while employees or physicians try to play catch-up or fix what is wrong. Experts list common problems and their impact:

ProblemImpact
Lack of necessary infrastructureComputers could be knocked offline or run slowly, resulting in a patient backlog.
Lack of work flow assessmentImportant steps in the patient encounter could be missed or not documented.
Lack of trainingDisgruntled employees will become more unhappy and affect the entire implementation process. Mistakes are possible, or the practice could run more slowly because employees can’t do their jobs.
Not preparing patientsLong wait times will become a bigger problem as patients are not informed as to what is wrong. Patients used to a certain work flow may notice unexplained changes.
Computer not integrated into patient encounterPatient will view the computer as an intrusion as opposed to a useful tool.
Lack of employee buy-inNegative feelings from employees could rub off on patients. Employees also will be less willing to learn the new system.
Lack of privacy and security policiesThe practice will be at a higher risk of a data breach.

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Positives and negatives of EHRs

The Centers for Studying Health System Change surveyed 60 physicians from various practice sizes, medical directors at EHR vendors and other experts to determine how electronic health records affect communication with patients and other clinicians. They found both positive and negative impacts. Suggested ways of improving the negatives included training and more attention to work flow redesign.

Pros

  • Patient communication is less interrupted as physicians are able to order tests without picking up a phone.
  • Patient education is made easier by physicians pulling information from the record at the point of care.
  • Doctors have quick access to information that is shared among physicians.
  • Patients feel more comfortable knowing that information from other physicians is easily available.

Cons

  • Physicians are tempted to hunt for information or alerts while visiting with a patient.
  • A wealth of data results in less communication with patients, as doctors feel they have all the needed information.
  • Face-to-face time among physicians diminishes as more communication is done electronically.
  • There is a temptation to focus on check boxes instead of open-ended dialogue.

Source: “Electronic Medical Records and Communication With Patients and Other Clinicians: Are We Talking Less?” Centers for Studying Health System Change, April 2010 (link)

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External links

“Video observation in HIT development: lessons learned on benefits and challenges,” BMC Medical Informatics and Decision Making, August (link)

“Electronic Medical Records and Communication With Patients and Other Clinicians: Are We Talking Less?” Center for Studying Health System Change, April 2010 (link)

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