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What Does EMR Optimization Actually Mean? So Much More Than Just Working Out the Kinks

October 29, 2015
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It was a pleasure to hear from Doug Thompson, a senior research director at The Advisory Board, earlier this week, on the meaning and execution of EMR optimization

It was a pleasure and a privilege to moderate a Healthcare Informatics webinar Tuesday that was led by Doug Thompson, a senior research director at The Advisory Board, and also included a brief, informative presentation by Daron Sinkler, healthcare industry director at Lexmark Healthcare.

The title of Thompson’s presentation, “Enhancing and Optimizing Your EMR for Usability and Long-Term Value,” accurately described its content, and its content was useful and insightful. Essentially, Thompson articulated in a truly useful way why EMR optimization—the beyond-implementation work to make any electronic medical record/electronic health record an engine for organizational performance improvement in patient care organizations—needs to be strategically, and not tactically driven.

Thompson began by placing all of this into a meaningful operational and historical context. “By the end of 2013,” he noted, “the majority of U.S. hospitals had reached EMRAM Stage 4 or above,” referring to the HIMSS Analytics EMR adoption model that has become universally known and understood in U.S. healthcare. “That’s the level at which real benefits from implementation of clinical information systems can begin to occur,” he said, noting that the capabilities of CPOE (computerized physician order entry) and “CPOE-driven supports, including electronic order sets, will drive most benefits. What’s more,” he added, at this point in time, most hospitals have surpassed Stage 5 as well. So there’s no technical reason why most hospitals couldn’t achieve value. Nonetheless, so far, studies are showing that benefits aren’t being derived. One reason is that under  the pressure of moving ahead to meet the requirements of the meaningful use program, most EMRs have been implemented using a Big Bang approach, and very rapidly. Unless a hospital’s staff are able to use an EMR to substantially change how they do their work,” he stressed, “they could actually incur higher costs, the opposite of what was intended by the MU program.” Everything he said applied equally well to medical groups as well as to hospitals, of course.

And he asked a great question: “What would happen to a hospital that makes large investments in any technology year after year and fails to see benefits, and anticipated quality and efficiency improvements don’t come to pass? The history of this,” he said, “is that failed implementations in terms of improved performance can cripple a hospital, while benefits can improve standing in a competitive marketplace.”

In fact, he noted, “Most of what hospitals are calling EMR optimization isn’t really optimization in the dictionary sense: most hospitals are actually doing remediation of technical flaws not fixed in the initial implementation. But once fixes and enhances are addressed, you can improve performance through careful, intentional effort, and unavoidable trial and error. We interviewed many hospitals,” he noted, “and we were surprised by the variety of definitions we heard for the term optimization. Many orgs think of it very tactically as, what happens after go-live. Others have a technical focus on enhancing technical capabilities. Others want to standardize clinical and operational processes and enhance other functions.”

Instead, Thompson told his audience, it is imperative to follow a benefits-driven method of EMR optimization, which includes the following six elements:  a benefits framework (agreeing on objectives); benefit sentences (aligning expectations); benefits modeling (clarifying how things work); benefit requirements (specifying the changes planned for); organization for benefits (defining roles and responsibilities); and benefit measurement (tacking and managing to benefit).

Now, stated in that manner, these elements seem utterly commonsensical, don’t they? Yet I absolutely believe Thompson when he says that most hospital organization leaders have not approached EMR optimization with this kind of approach in mind. Instead, we at HCI keep hearing about organizations whose leaders are flailing around clumsily once they’ve done the initial EMR/EHR implementation, scurrying about like chipmunks, attending to design and implementation flaws, and putting out countless end-user dissatisfaction fires. This is totally understandable, and it is how so many things have historically worked—and sadly, still work—in hospitals across the country today.

But that’s not how things should work—and Thompson hit the nail on the head when he noted that the very fact that, under pressure to meet meaningful use requirements, most hospitals have implemented their EMRs/EHRs using a time-pressurized “Big Bang” approach, which, though necessitated by the rigors of the MU program, has inevitably led to a lot of unintended consequences, including numerous glitches and flaws, and widespread end-user, especially clinician end-user, dissatisfaction. He mentioned that it in his and his colleagues’ estimation at The Advisory Board, between 50 and 70 percent of EMR/EHR implementations have been executed using the “Big Bang” approach, meaning a lot of unintended consequences, with their attendant “mopping-up” work, have come about in the past few years.