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Leadership: the Possible, not the Probable

June 17, 2008
by E2556BEF60524A5689D02EEBDAEFEDB6
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This past Friday the Health IT Now! Coalition briefed lawmakers in support of subsidies for electronic health record systems. At this event a RAND researcher described expected EHR benefits including prevention of 400,000 deaths and savings of $80 billion over 15 years. In contrast, today's edition of CHIME's official magazine, Healthcare's Most Wired led with a story claiming that "a review of current literature reveals that the electronic record's effect on quality is still under debate". And a few weeks earlier the Congressional Budget Office concluded that "By itself, the adoption of more health IT is generally not sufficient to produce significant cost savings.”Â

These opposing viewpoints could be characterized as PROBABILITY vs. POSSIBILITY. Â

The PROBABILITY is that when many organizations take on the very complicated, expensive and difficult task of implementing an EHR, some of them will fail. And those failures will bring down the average expected benefit. Since more failures occur early in a technology's life cycle, the average benefit for all previously implemented EHRs may be very small, or even negative.

The demonstrated POSSIBILITY is that an individual hospital or system can realize substantial benefits from an EHR. The growing body of evidence of EHR benefits exists mainly in individual studies of components of an EHR (such as CPOE, safety alerts, or electronic clinical documentation), or specific types of benefits (such as ADE prevention, or order communication timing, or nursing efficiency). Taken together, these studies contain compelling proof of EHR benefits.

Which approach should be used? It depends on the question. To predict total national benefit from the adoption of EHR technology we must account for the expected failures. That means looking at all positive and negative results. Of course, as EHR technology matures and as we learn more about how to implement it successfully the failure rate should become smaller.

On the other hand, to forecast the expected benefits of an EHR for an individual hospital we need to assume a successful implementation. Why not account for the possibility of individual failure? Because hospitals with failed EHR implementations either did something wrong in their implementations (inadequate funding or staffing, poor planning, insufficient training, selection of the wrong vendor), or had recognizable characteristics (e.g., lack of physician support, too many competing priorities) which should have stopped them from trying.

Hospital leaders who are deciding whether to implement an EHR must honestly and carefully assess their organization's readiness and commitment to proceed. The major risks and key success factors are well-known. But if they are ready and willing to proceed, they must plan on success, not hedge their bets. That means studying and following the path of successful EHR implementations, and avoiding the mistakes of those that failed.

In other words, they must expect, and manage to the POSSIBLE, not the PROBABLE.



Failure during EHR projects are often associated with the typical gold plating, or what I call the Rolling Stones factor. In this case, Doctors always are getting what they want, instead of what they need. I want all my records scanned and images available online. I want interfaces to all my labs and all pharmacies. I want radiology images linked and available, and I want it day one, or I might as well keep my paper record.
We have raised medical records expectations beyond what they receive now. If a paper chart is misfiled, if a lab result is not in the paper chart or if current radiology image is not brought in for the visit, the care is still provided. We do not want to evolve into an electronic record, we want to flip a switch and we want to have it all, and we want it now. Ok, that song was by Queen, but I think you get the point.