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.
Sharing with his audience a Maslovian figure of a pyramidal hierarchy of definitions of EMR/EHR optimization, Thompson told his audience that those have ranged, from the bottom slice of the pyramid—“tactical”—up through “technical,” “process,” and up to “outcomes-driven.” At the technical level, for example, the focus is on adding functionality not part of an EMR’s/EHR’s initial build. But the real breakthroughs have come at the process level, where EMR optimization has meant driving clinical use by optimization workflow and standardization of processes across the enterprise; and ultimately, at the “outcomes-driven” level, it will mean truly transforming all kinds of outcomes—patient care quality, clinician effectiveness, operational efficiency, and cost control/reduction—across a patient care organization.
Another key concept that Thompson introduced to his audience on Tuesday was that of “chokepoints”—situations and places where hospital organizations get “stuck” in their efforts to optimize their EMRs/EHRs. “The solutions to overcoming these chokepoints depend on the reasons you’ve gotten stuck,” he stressed. “As doctors would say, you need to diagnose before you prescribe.”
One example that Thompson offered his audience of a case study in success was at the pioneering patient care and health plan organization in the Seattle area, Group Health. “Group Health had just completed an EHR rollout, and had over 1,000 requests for changes,” he noted. “ Their intake process was typical. They had tried to add more staff, but that didn’t help, and clinicians were getting frustrated and angry, and IT staff morale was low. So they reviewed a sample of change requests and found that the way the process was designed was not actually how it worked, per the changes made to process. Clinicians and other end-users would e-mail IT staff directly, and IT staffers would develop work-arounds for them on an individual basis. All those things would impact productivity.”
As a result of thinking through their “chokepoint,” Thompson said, Group Health IT leaders “borrowed ideas from Lean and Agile, and limited their intake to what they could take accomplish within one quarter, referred to as a sprint. They assigned accountability. They used visual controls or Kanban. And doing so, they were able to reduce their backlog by 80 percent within one sprint, and were able to eliminate it altogether within six months.”
A second case study that Thompson presented was that of Fletcher Allen Healthcare in Burlington, Vermont. “After they had implemented their 40-plus ambulatory sites,” he reported, IT leaders had struggled with a traditional support model, but things weren’t improving, so they created an enhancement team of four to five people including a doctor and nurse; sent out a survey to the practices; and scheduled time to go onsite, scheduling them far enough in advance to get participation from doctors. Then they spent several days onsite at each site, configuring work screens, etc. Then the demand for this was so great that they had to had a second team. MD use improved dramatically, and doctors were much happier.”
As Thompson pointed out, a chokehold can be any number of things, including product limitation, screen design flaw, insufficiency of devices, poor integration, poor relations with clinical staff, etc. “Almost nobody gets through without chokepoints,” he said, “but you have to get through them or you’ll have months or even years of frustration. So you have to diagnose first!”
Above all, Thompson shared with his audience, leadership, innovation, and measurement will be key critical success factors in overcoming chokeholds and moving forward into genuine, robust optimization. “The CIO and IT staff of an organization can educate the CEO and c-suite,” he said. And he quickly added this: “To be clear, the right way to think about EMR optimization is that it’s the driver of strategic value. It can become a sustainable competitive advantage with three conditions—leadership, innovation, and measurement, which includes using timely data to drive rapid cycles of improvement in performance.”
Everything that Doug Thompson shared with our webinar audience this week accords with what we at HCI have been hearing from CIOs and other healthcare IT leaders for some time, but Doug presented all of this in a very cogent, succinct, high-level way that was both insightful and refreshing.
Above all, Doug’s distillation of the ins and outs of the phenomenon confirmed once again how complex and fraught the process of EMR/EHR optimization really is—and how strategically it must be led in hospital (and large medical group) organizations, going forward.