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What We Always Knew: In EHR Implementation, It's About the Leadership and Vision

August 2, 2012
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A new Commonwealth Fund study underscores what industry-leading pioneers have always known


I’ve been fascinated by the Commonwealth Fund’s report, published in early July, “Using Electronic Health Records to Improve Quality and Efficiency: The Experiences of Leading Hospitals,” authored by Sharon Silow-Carroll, Jennifer N. Edwards, Dr.P.H., and Diana Rodin. The three authors, all researchers and analysts at Health Management Associates, interviewed leaders at nine U.S. hospitals, seven of which are part of larger integrated health systems, including well-known pioneer health systems such as the Danville, Pa.-based Geisinger, the Norfolk, Va.-based Sentara, and the Roanoke, Va.-based Carilion organizations. In conducting interviews with hospital and health system leaders, the researchers wanted to identify common success factors and common characteristics of organizations that had leveraged their electronic health record (EHR) implementations to improve patient safety, care quality, cost-effectiveness, and other qualities.

And the summary paragraph in the report’s abstract contains text that says it all. “Successful implementation,” the study’s authors wrote, “depended on: strong leadership, full involvement of clinical staff in design and implementation, mandatory staff training, and strict adherence to timeline and budget.” This, of course, is the gospel that we at Healthcare Informatics have been preaching for years, based on the urgings of healthcare IT pioneers nationwide, and gleaned from the experiences of those pioneers in recent years.

As it turns out—and, not surprisingly at all, really—the authors note, regarding the nine hospital organizations included in the study, “These leading hospitals adopted comprehensive EHRs prior to the availability of HITECH meaningful-use incentives. Executive and clinical leaders believed that a comprehensive EHR would improve healthcare quality, consistency, and patient safety. At most of the hospitals,” they went on to write, “adopting a comprehensive EHR was part of a strategic plan to integrate inpatient and outpatient care and provide a continuum of coordinated services across their systems.” They went on to say that leaders at these nine organizations (they interviewed mostly CIOs and chief quality officers) agreed that “The EHR was expected to improve communication among providers across care sites,” and that “[T]his level of coordination would be necessary for further delivery system reform (such as forming an accountable care organization), and that patients would benefit from and value having a complete and coordinated resource for their medical information across the system.”

My very favorite element in the entire report, in fact, wasn’t even in the narrative text itself, but in a subhead: “Solution: Strong Leaders Who Are Both Forceful and Realistic.” Exactly. The study’s authors noted how strongly senior executives and leaders at all these organizations led their colleagues in keeping EHR implementation, for strategic and mission-driven reasons, at the very top of the agenda, over periods of years. For example, they noted, “Sentara held ‘eCare’ meetings for four years: twice each month for sites that were preparing for EHR implementation and for those already operational. Sentara,” they added, “also holds executives accountable by setting targets related to EHR use…”

In other words, among the industry-leading hospital and health system organizations whose leaders helped make connected, integrated EHRs a reality years before their peer organizations did, a very strong leadership component was present from the beginning, and was sustained throughout implementation and beyond, into the phase involving leveraging implementation for actual performance improvement.

None of this is news, but honestly, we need more and more studies just like this one to continue to reinforce the key learnings that have already been internalized at pioneer organizations nationwide, and to make those learnings easily available to those at non-pioneer organizations whose leaders are now under pressure to meet meaningful use- and healthcare reform-related requirements in the next few years, in an operating environment that is both demanding and increasingly, for many, frenetic with activity.

I personally believe that even leaders at those organizations that are “behind the curve” will need to show considerable leadership in order to succeed at their EHR implementations. As this excellent Commonwealth Fund study strongly implies, the promise of stimulus funding, and its flip side, the threat of reimbursement cuts alone, will simply not be enough to ensure implementational success. In the end, as we’ve all known for years, technology is the (very complex) facilitator; it’s the people and process issues that inevitably create the greatest challenges going forward. Let’s keep learning from the industry’s true leaders, and fully appreciate the extent to which the human factors will always be critical in all this.