By Trenor Williams, M.D.
With electronic health record (EHR) adoption rates increasing at a staggering pace over the last four years, the number of hospitals that have achieved Stage 4 or higher levels of EHR adoption as rated by HIMSS Analytics has increased by 600%. With the rapid approach of the Meaningful Use Stage 1 attestation deadline, value-based payment reform, and provider organizations’ internal pressures to improve all aspects of performance, we expect adoption rates to accelerate further in 2013.
Additional external factors contribute to and compound the pressures of rapid EHR adoption, including healthcare reform, ICD-10, Meaningful Use, public reporting and value-based purchasing. Internal factors includeboard and management expectations to demonstrate return on investment, quality initiatives, system integration, and provider satisfaction and retention. Given these external pressures and internal operational complexities, organizations are starting to invest additional resources post-implementation to improve and optimize the use of their EHR system.
EHR optimization can provide multiple benefits:
What happens if you don’t work to optimize your EHR? Expect to see significant losses on your clinical, financial, and operational returns on investment. A recent example can be seen in Wake Forest Baptist Center in North Carolina. After struggling to implement their EHR, the additional costs and lost revenue had a definite effect on their first half reporting numbers. According to a recent article in the Winston-Salem Times, “The center provided the information in a second-quarter financial report submitted to bond agencies in which it also reported a $49.6 million operational loss and a gain of $7.4 million in overall excess revenue.” Such losses can be easily avoided.
Optimization is the design and implementation of strategies to achieve optimal use of your existing EHR system. Optimization efforts are typically focused on improving workflow and usability, as well as developing and standardizing clinical content such as order sets, preference lists and documentation templates. Optimization should not be confused with system enhancements and upgrades, which, while also important, are intended to provide new capabilities and technical improvements. Ideally, EHR optimization should be incorporated into your initial EHR planning to ensure sufficient post-implementation resources are dedicated to continuous, ongoing improvement of your EHR system.
Although there is a tendency to focus primarily on system changes, the scope of optimization is much broader and should, at a minimum, include the following elements:
1) Functionality: What the application can do for the user. Optimization efforts should include the following areas: system design, suboptimal build, inactive functionality, and functionality that exists but has not yet been taught or has been inadequately taught to clinicians.
2) Workflow: The act of completing a task or an entire process, including the specific roles of individuals and understanding how data is transmitted and shared. Improvement efforts can be focused on processes from the perspective of the individual clinician or patient, a multidisciplinary team or a specific population.
3) Infrastructure: The basic facilities, services and installations needed for optimal system functioning. The general areas of infrastructure that benefit from continuous evaluation and potential redesign in a clinical transformation initiative include people, governance and information technology.
4) Content: Substantive and often customizable material contained in each application. There are numerous opportunities for improvement to clinical content, including orders, order sets, patient lists, decision support, charting tools, custom content, upgrades and release notes.
5) Reporting: The regular provision of information to decision makers within a system to support them in their work. Reporting can include both the EHR and other electronic systems. In its most ideal state, good reporting takes data, converts it into information. The end-user then incorporates it into knowledge, and an appropriate action is taken. The key questions to ask when evaluating data include:
Reporting can occur at the corporate, hospital, specialty and individual level. Similarly, the targets of the reporting can range from a single patient to a large population with a specific condition.
The evaluation and optimization of system functionality, patient and provider workflow, organizational and physical infrastructure, and application content can greatly enhance an organization’s ability to realize its clinical, financial and operational goals. As expectations of continuity of care increase, systems will need to maximize these efficiencies in both the inpatient, outpatient and community settings.
Dr. Williams is the CEO and Co-Founder of Clinovations. He has a long history of leading CPOE implementation, ambulatory EHR strategy, and clinical transformation engagements. Currently he is supporting inpatient and ambulatory HIT engagements at several large integrated health systems. Williams has significant experience developing benefits realization, physician adoption, clinical transformation strategies as well as working with 3rd party vendors to develop evidence-based clinical content.
Williams is Associate Editor of the book Improving Medication Use and Outcomes with Clinical Decision Support: A Step-by-Step Guide, which received the 2009 HIMSS Book of the Year Award. Prior to beginning his consulting career in 2002, Williams was the Medical Director of Family Practice at Mammoth Hospital in California and was a Lieutenant Commander in the U.S. Naval Reserve. He holds a B.S. in Biology from Virginia Polytechnic Institute, M.D. from Marshall University, and completed his family practice residency at Kaiser Permanente in Los Angeles.