Feature Story
Tangled in Technology
Clinics that have made the switch from paper to electronic health records have much to say about how to ease the transition.
By Howard Bell
Richard Adair, M.D., believes electronic health records (EHRs) are good for medicine. The 66-year-old internist who practices at Abbott Northwestern Hospital in Minneapolis says the hospital’s 2-year-old EHR system vastly improves the care he can offer his patients. “It makes tons of clinical data available with a keystroke, with filters that give you only the information you need,” he says. “In internal medicine, we deal with complex, sometimes elusive problems that require us to synthesize lots of information. Instead of searching for pieces of paper and flipping endlessly through a paper chart, it’s all right there in front of you.”
Doing It Right
When electronic health records (EHRs) are properly planned for—and used to their fullest—chances are good they will reduce cost, enhance quality, and standardize care closer to best practices. Minnesota clinics that have already been through the process offer this advice on how to minimize the pain of implementation and maximize the benefits.
Planning
Don’t skimp on planning time. Sue Severson, director of health information technology services at Bloomington-based Stratis Health, which helps clinics and hospitals go electronic, recommends spending at least a year assessing your needs and selecting a vendor, then taking another year to implement the system and go live. “The size of your clinic doesn’t matter. If you don’t invest time in planning, you’ll suffer for it,” she says.
Like many Minnesota clinics, Hutchinson Medical Center, which went live with its EHR 18 months ago, got help with planning and implementation by using the CMS Doctor’s Office Quality–Information Technology (DOQ-IT) program, a resource offered by Stratis Health. DOQ-IT walks clinics through a formal readiness assessment and helps them with preparing RFPs, getting staff buy-in, interviewing vendors, and building templates. “It helped us make sure we did all the prep work and did it properly,” says Hutchinson administrator Jim Lyons.
Get buy-in from all physicians and staff early in the planning process and set realistic expectations for what an EHR can do. “We made sure our staff knew that it won’t make your coffee or wash your car,” Lyons says. He explains that staff at all levels helped map out workflow processes and sequences and discussed how they wanted to customize the EHR. For example, at Hutchinson Medical Center they customized the EHR so that if physicians don’t want to type in every little note, they don’t have to.
Designate a project manager with strong IT skills who can serve as the point person with vendors and staff. Cindy Seidl, support services director at Central Lakes Medical Clinic in Crosby, suggests identifying “physician champions” who can analyze functionality needs, evaluate competing products, help train other physicians, and lead the organization in going live with the system. Some studies show that without physician support and commitment, EHRs can be a financial drain and offer few, if any, patient care benefits.
Selecting an EHR
Take price off the table when deciding which EHR is best for you. “We didn’t want sticker shock to influence our decision,” Lyons says. “We looked at functionality—how well it would work for us—then looked at price.”
Spending more money doesn’t mean you’re getting a product that will work better for your clinic, according to Severson. “You can get fantastic results from a mid-level product if the functionality is right for you and you use it properly.”
Do not pick a product because it’s easy to use. “We’ve had clinics tell us they like a system because it looks easy; but easy should not be a criterion for selection. Functionality is what you’re shopping for,” Severson says.
Do all of your homework before inviting vendors to visit. When it’s time to evaluate a product, create a team that includes someone from each department to analyze how well the software will do the specific things that department needs it to do, Severson says. When analyzing functionality, it’s crucial that physicians, nurses, and support staff participate.
Make sure the vendor contract spells out in detail what you’re getting for your money. Seidl says the agreement should include how much IT support you’re getting and for how long and when installment payments are due. “You have to understand vendor terminology,” she says, “so you’re all on the same page.”
Implementing Your Plan
Spend your training dollars long before going live. “Identify early on those who need basic training in keyboarding and navigating,” says Kaye Schroeder, EHR project manager at Central Lakes. Getting everyone comfortable with computers is one way to reduce what Rachael Nyenhuis, director of network development for the Northstar Physicians Network, says is the biggest barrier of all—fear of change. “Especially for nurses and support staff,” Nyenhuis says, “it’s hard to ask them to learn a new way of doing something when the paper way was working OK and they don’t necessarily see an immediate benefit to changing.”
Find ways to ease the pain. Careful planning topped with humor worked for Hutchinson. “We have some creative people on staff who kept us loose and feeling good about going live,” Lyons says. Among other morale-maintaining activities, staff passed out T-shirts that said “EHR/HMC” and cans of pop labeled “EHR Elixer.” “We made every employee feel they were part of the process, that they weren’t alone, and that someone was always there to help,” Lyons says.
During the first 10 days, Hutchinson provided at-the-elbow support for all staff. Physicians helped each other, and the IT staff at Hutchinson’s “command center” were available to answer questions.
Scan only those paper records you absolutely need into the EHR. “Scanning was the biggest job during the transition,” Lyons says. Before going live, Hutchinson collected everything in patient charts that needed to be scanned, including patient data coming in from other sources, then had medical records do the scanning. “A good scanning plan greatly streamlines the transition and gets you off paper quicker,” Lyons says. Central Lakes saved money and time by being conservative about how much paper it scanned into the EHR. “We learned from other organizations that they scanned more than they needed to,” Seidl says.
Getting the Most Benefit
Finally, no tool will deliver the benefits promised unless it’s used properly and to its full extent. “Most of the complaints we hear are not failures in the software,” Severson says. “Everyone likes to blame the product, but many failures are instead caused by inadequate planning, inadequate analysis and redesign of workflow, and inadequately preparing staff to use the EHR. An EHR in the hands of someone well-trained can improve patient care.”—H.B.
|
Meanwhile, George Schoephoerster, M.D., is frustrated with EHRs. The 56-year-old geriatrician and family physician has struggled for two years with the EHR at the CentraCare clinic where he works in St. Cloud. “They don’t save me time—they cost me time,” he says. “They make finding patient information harder for me, not easier. I’ve been using it for two years now, and I still have a harder time finding things than I used to with a paper chart. On nights and weekends, I’m still doing charts trying to catch up. I still see fewer patients than I used to, so my income has taken a big hit.”
When it comes to EHRs, it seems, physicians either swear by them—or at them. At their best, they streamline workflow, improve quality of care, and save money by connecting scheduling, medical records, laboratory, radiology, prescription ordering, and billing functions. Yet mastering an EHR involves learning an incredibly complicated software system and changing work habits and processes. Not surprising, implementation is notoriously stressful for everyone involved. “We’ve heard from physicians who say they’ve been through one implementation, and one is enough,” says Sue Severson, director of health information services at Bloomington-based Stratis Health, which has helped more than 100 health care organizations go digital.
Minnesota physicians who aren’t already using an EHR will likely encounter one in the coming years. A state law requires all Minnesota health care facilities to have an interoperable EHR in place by January 1, 2015. Sixty-two percent of Minnesota adult primary care clinics already have or are implementing an EHR, and 87 percent plan to have one up and running by late 2009, according to a Stratis survey of 600 such facilities in the state.
Severson says most Minnesota physicians will make the shift from paper charts to EHRs. “They know electronic health records can increase efficiency and quality of care, and they’re motivated to do this,” she says.
Productivity Takes a Hit
Still, physicians need to know that staff productivity plummets during implementation. During the first six weeks of using an EHR, Schoephoerster says his productivity dropped 50 percent. Two years later, it’s still down 25 percent. Productivity took a hit at Abbott Northwestern Hospital in Minneapolis, too, according to Richard Sturgeon, M.D., an internist and just-retired vice president of operations who served as a physician leader during the hospital’s EHR implementation. “Every step in the care process takes longer when physicians are learning how to enter the information,” he says. “I had one GI doc complain it took him longer to chart a colonoscopy electronically than it did to do the colonoscopy.”
The productivity decline at Abbott during the first year required the addition of 150 more staff at all levels. Although leaders were pleased when productivity went back up a year later, it was a sad and regretful moment, according to Sturgeon, when they had to let those additional people go.
Income went down for all the partners at Hutchinson Medical Center when it “went live” with its EHR 18 months ago, according to Jim Lyons, administrator of the 22-physician clinic. “We knew it was coming,” he says, “so during week 1 of go-live, we cut everyone’s patient load to 50 percent of normal.” During week 2, it climbed to 75 percent of normal, then was back to 100 percent during week 3.
Physicians at Hutchinson are still seeing on average one less patient per day than they did before going live, according to Lyons. But he says there has been a bump in the quality of the care they offer. “We’re doing better documentation and catching more things like drug interactions. And we’re seeing more complex patients. Both of these contribute to the slight drop in productivity,” he says. Lyons believes that within three to five years, physician incomes should be higher than they were before implementation of the EHR because the clinic will need fewer support staff.
Sturgeon speculates that productivity for “some of my gray-haired colleagues” may never fully recover. “They developed short cuts and delegation strategies over the years that allowed them to offload duties and increase their efficiency,” he says. The EHR required them to do many of those duties, such as medication reconciliation between admission and discharge, that someone else used to do. Likewise, Schoephoerster says he now spends more time doing routine sign-offs that support staff used to do.
Severson says there are ways clinics can minimize the temporary drop in productivity. Some may not be very popular. For example, she says, some clinics have had physicians work longer hours in order to learn the system and maintain their patient schedule. Abbott allowed its physicians to use the EHR until they felt swamped, then switch back to paper. The hospital has slowly been phasing out paper as physicians become more proficient with the EHR.
Another way to lessen the hit to productivity is to go live slowly by having a small number of physicians “roll in” to the system at one time. Central Lakes Medical Clinic, a multispecialty clinic in Crosby, divided its 25 physicians into groups of three to four. Every two weeks a new group would go live. “For us, that worked best,” says Cindy Seidl, support services director. “It’s more of a cash flow crunch to go live all at once.”
Severson says ultimately each clinic must decide what pace works best for rolling out their EHR. “Diving in all at once isn’t necessarily bad, but if you don’t prepare, it could be a very uncomfortable situation,” she says, adding that vendors may push a clinic to fully implement quickly so they can go on to the next job. “We encourage clinics to set their own timelines.”
Computer Comfort
George Schoephoerster admits he’s never felt at home with computers and that’s one reason he struggles with the EHR. “Computers to me are like cars,” he says. “I don’t care how they work as long as they get me from here to there. Yesterday, I called the techies three times for something I just didn’t understand, and some of the time they didn’t even have the answer.”
Trained in an analog age in the architecture of the medical note, some physicians think better and work better on paper than on a computer. At Hutchinson, those who were comfortable with computers had an easier time adjusting, according to Lyons. But he says age had nothing to do with comfort level. Severson agrees. “We’ve worked with older physicians who are so good with computers they served as physician champions and teachers at their clinics.”
Maybe so, but Sturgeon says younger physicians at Abbott generally tolerated the stressful first months with the new EHR better than those of his generation. “Early in implementation,” he says, “a cadre of residents and younger hospitalists did more of the heavy lifting of patient care while the rest of us learned the system. About five years ago, we reached a point where residents could keyboard faster than they could write, so it was easier for them to make the switch.” Many older Abbott physicians had poor keyboarding skills and were initially allowed to dictate their notes. Then someone would enter their dictation into the EHR for them. Nearly all of those physicians now make their own entries into the EHR.
The Cost Question
Cost is the No. 1 reason clinics delay getting an EHR, according to results of a national survey of physicians published in the New England Journal of Medicine in July. The good news is that EHRs are less expensive than they used to be. In 2004, the U.S. Department of Veterans Affairs, which developed its own EHR in the 1980s, made its VISTA source code available to anyone who wants it. That prompted several software vendors to use the code to develop competing brands. “Right now, there’s great competition among ambulatory care products because so many products are out there,” says Sue Severson, director of health information technology services at Stratis Health in Bloomington. Still, it’s an investment. According to a Stratis survey of more than 600 Minnesota adult primary care clinics, 58 percent spent $50,000 or less per physician to buy and implement their EHRs. Forty-two percent spent more than $50,000 per physician.
Experts say there are a number of ways to shave expenses. Northstar Physicians Network clinics saved “a significant amount” on software by negotiating with vendors as a group of 100 instead of separately, according to Rachael Nyenhuis, director of network development. The clinics also house their separate databases on a single server, which is maintained off-site by SISU Medical Solutions, a Duluth IT firm. “Sharing a server cut costs tremendously,” Nyenhuis says. So did choosing a Web-based EHR that did not require expensive T-1 lines, which aren’t available in all rural areas.
Three of the clinics reduced their costs by using their local hospitals’ EHR. Others took out conventional bank loans or dug deep into their pockets to purchase systems, Nyenhuis says. “Our physicians felt strongly this is something we need to do, and clinic size has not been an insurmountable barrier. We have a solo practice that went live last September, and he’s never looked back. He has no medical records department and only two support staff.”
Northstar clinics reduced their costs further by jointly training their physicians and staff to use the EHR. “As a bonus,” says Nyenhuis, “joint training created wonderful opportunities for physicians and staff to share ideas and come up with creative solutions for templates.”
As a rule of thumb, clinics that break even on their initial EHR purchase within five years have made a good investment, according to Severson, who says some clinics do it in only two-and-a-half years. “It’ll take longer,” she says, “if the clinic is already thinly staffed and has efficient processes.”
How much a clinic will save or spend long term will depend on how well the clinic planned for and implemented their EHR, how good the coding is, and how well they use the system. “Over time, clinics will likely reduce clerical staff through attrition and reassignment to other jobs,” Severson says. “But they will need more computer hardware and IT staff, which are costs they must factor in.”
A number of federal and state programs are designed to help ease the financial pain, especially for small and/or rural providers. The Minnesota Department of Health offers grants and revolving loans, which recently have ranged from $15,000 to $500,000, to help pay for readiness assessment, planning, and implementation. The Department of Health also offers six-year, no-interest revolving loans of up to $1.5 million for EHR implementation.—H.B.
|
To lessen the stress of switching to an EHR, Severson says it’s crucial to do plenty of rehearsal and training well before going live. “Physicians need a room where they can practice entering data without any pressure,” she says. Abbott set up 10 workstations in the physicians’ lounge. During the first year, a physician “super-user” of the EHR was there to answer questions. “One-on-one training with physicians helping each other can be extremely effective,” Severson says.
That proved to be the case at Hutchinson, according to Lyons, where for the first six months after they went live, lunchtime sessions brought together doctors who had questions with those who had answers. “Docs were learning from docs,” says Lyons, “not from a trainer in a classroom. We had an open-and-free exchange of ideas.”
Two weeks before going live, Hutchinson had physicians do evening “dry runs,” during which the physician practiced filling in templates while talking to and examining a volunteer playing the patient. “That reduced the fear of using the system with real patients,” Lyons says.
Adequately training all staff while still seeing patients was such a challenge at one of the clinics in the Northstar Physicians Network, a coalition of independent practices in northern Minnesota and northwestern Wisconsin, they closed the clinic for one day so that everyone could be trained at once. “They had an easier go-live because of it,” says Rachael Nyenhuis, director of network development for Northstar. “Fragmented training can make the go-live process a bit rougher. If you can’t close, pick a Saturday for all-staff training.”
At Central Lakes Medical Clinic, super-user test pilots that included two physicians, IT staff, and four department directors worked through the bugs and did trouble-shooting before anyone else went live. Those super-users and the clinic’s two physician champions provided group training sessions and one-on-one “at-the-elbow” support. They also introduced staff to the easiest EHR functions first, gradually building competence and confidence in their ability to use the system.
New Ways to Work
Perhaps the biggest changes physicians must adjust to are the ways EHRs change the way they do patient care. Learning to navigate the EHR was only 20 percent of the challenge for physicians at Abbott, according to Sturgeon. “Eighty percent of the challenge,” he says, “was learning all the new workflow processes and sequences. Suddenly, all the work you do is done differently than you’ve been doing it for years. Prescription pads are gone. No more dictating. All the information you need is in a different location. Communication between doctor and nurse is more visual instead of verbal.”
Electronic health records automatically flag potentially dangerous drug interactions and allergies. They prompt physicians to schedule screenings and track and analyze health trends for individual patients and entire populations. They also automatically place lab and radiology results in the patient’s chart, provide access online to clinical decision-making protocols, and change the way physicians communicate with other providers and departments.
In addition, EHRs change the way physicians communicate with patients. “Nobody ever talked to us about how an EHR would change exam room interaction between doctor and patient,” Schoephoerster says. “I’ve had patients complain that some of my colleagues always have their nose in the computer screen.”
Sturgeon has heard similar reports. “One patient was heard to say, ‘Doctor, I’m talking to you. Would you at least look at me?’”
Nyenhuis says the trick is to find a balance. “You can’t lose yourself in the computer,” she says, “but you can’t ignore it either.” She says the Northstar clinics told their patients that they were in the process of switching to the new system and asked them to be patient during the transition.
At Hutchinson, physicians turn the screen so that patients can see what they are doing. “We encourage them to do things like print out a graph of the patient’s lipid profiles while they’re talking about it,” says Lyons. “It’s three clicks away and gives the doctor a quick win with the patient while keeping the patient part of the process.”
Lingering Concerns
Like any tool used in medicine, it’s important that the EHR works for the doctor and not, as Schoephoerster worries, that the doctor works for it. “EHRs track outcomes and adherence to guidelines,” he says. “But somebody needs to make sure the so-called ‘standardized care’ is good care—customized care for individual patients.”
In a New England Journal of Medicine article published in April, two Harvard physicians warned that EHRs potentially compromise care by fostering a generic approach to diagnosis and treatment. In a digital age, physicians must still practice “thinking medicine,” not “data entry medicine,” they warn. Cutting and pasting another physician’s notes into your notes may be appropriate in some cases, but not when the physician’s own creative clinical thinking is sacrificed for the sake of efficiency.
Schoephoerster, who wants to see major changes in how health care is provided, worries that EHRs solidify the status quo and thus make it harder to fundamentally change how physicians care for patients. “The current productivity-based system,” he says, “is designed to maximize physician income by seeing as many patients as you can in a day. It’s designed around the doctor, not the patient. EHRs digitalize this status quo, which may make it harder to change things. We seem to have a lot of workers building the information highway, but nobody’s designing it.”
Despite some apparent design flaws, that highway will be home to nearly all Minnesota physicians in the next few years. Wary first-time travelers might take comfort in knowing the ride gets smoother over time. “After the initial learning period, most physicians appreciate the value of the EHR,” says Stratis’ Severson. “They don’t want to go back to paper.” MM
Howard Bell is a medical writer in Onalaska, Wisconsin.