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Garbage In, Garbage Out

February 1, 2006
by Jim Feldbaum, M.D.
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Don’t expect technology solutions to fix broken workflow processes.
Are workflow issues bogging down your electronic health record/computerized physician order entry (EHR/CPOE) implementations? So much to consider, so many people and departments involved, how do you create a solution to hospital workflow gone astray? Do clinical departments expect your powerful computer systems to work it out? Surely, they assume, there exists a simple electronic solution. Maybe you need more or better software.

Well, don’t go there!
EHR and CPOE implementation brings immediate transparency to each and every element of care that it touches. Gaps between good policy and current practice that might have gone unrecognized or ignored in the "paper world" will become painfully apparent during the conversion to an electronic environment. Longstanding "work-arounds" will become evident when attempts are made to computerize everyday practices.

What I am warning is that implementing an EHR will at first stir up more issues than it solves. This should not be viewed as a hassle, but rather as an opportunity.

In Greek drama, an apparently unsolvable crisis was solved by the intervention of one of their many gods. The device is termed Deus ex machina or "god from the machine." In drama, it is a clumsy and improbable device used to dig an author out of a difficult plot situation. In modern stories, it is the "in-the-nick-of-time" charge of the cavalry or the moment when the impoverished hero is saved by a winning lottery ticket.

Well, this is real life. Don’t foster the expectation of a last minute rescue by your IS (information systems) department. Ownership of a tangled workflow web should be the job of clinicians to unravel.

Think about it. Who knows more about a department’s workflow than they do? Don’t let clinicians hand this one off. This could be their chance to rethink and streamline practices that might have long ago outlived their clinical usefulness.

Partnering with the machine
So how do clinicians partner with the machine? First, both physicians and nurses should prepare themselves to have their world shaken by the transparency that the computer will bring. They will require a committed leadership willing to embrace change and empowered to create solutions to problems and inefficiencies as they are uncovered. It is the responsibility of clinicians to assure that practice conforms to policy and that policy conforms to the goal of patient safety before asking IS to implement electronic solutions.

Second, don’t expect or empower your IS team to make or interpret policy and don’t encourage them to import flawed "on paper" practices into the electronic world. It is the task of the clinical partners to promote and develop a strategic plan for the resolution of flawed processes at the same time they improve and streamline workflow. It is the challenge of IS to craft and implement appropriate electronic solutions. Even simple orders and processes can present a challenge for IS to create an electronic counterpart.

Remember that a flawed process, whether electronic or on paper, will generate an unacceptably high number of errors and will produce them with a level of variation that will thwart attempts to provide safe and quality care. Making a flawed practice electronic will just accelerate the rate at which it becomes a safety concern.

The EHR and CPOE--when properly implemented--are powerful tools, but the role of IS must be clearly defined. It should be the responsibility of the IS team to translate good policy and procedures into efficient and coherent electronic processes in partnership with its clinical partners. The transition into an electronic world should be viewed as an opportunity for a collaborative effort between clinicians and IS to improve hospital workflow and to ensure safe patient care.

Jim Feldbaum is a physician and consultant specializing in clinical transformation and computerized physician order entry (CPOE). His experience includes participating in the implementation of a paperless chart and CPOE rollout in a community hospital with over 700 providers.