Last week I had two separate, but close to identical, conversations with software companies that claim to have found the solution to the problem of getting physicians to use the EMR. But in neither case did they perceive the problem to be exactly what I think it is. I don’t think the problem is the cost of the software, or the lack of ROI, or even the functionality of the current tools. I think the problem is the "switch". And trawling around the web today I found an interesting article on COPE in HealthImaging which basically makes my point.
John Fitzpatrick, MD, director of medical informatics at Forrest General Hospital (FGH) says the biggest barrier the hospital first encountered with CPOE was that it took too long to use and was not intuitive for physicians.<snip>…Fitzpatrick recommends that healthcare providers in private hospitals find a CPOE system that physicians can enter the orders in as fast as doctors can hand write them or else the chances of success will be slim. "If the system can be made faster than on paper, all you have to do is incentivise the doctors through the learning curve," says Fitzpatrick.
"We are paying the pilot physicians for a limited time frame for their efforts acknowledging that at least initially it takes more time than on paper," he continues. "However, as they become more comfortable with the system, they get faster and faster at entering orders. Our original incentive plan was structured based on an incremental target for percentage of orders entered spread out over six months. However, most of the physicians are entering more than 95 percent of their orders from day one, and are probably reaching paper neutrality within six weeks."
So "time breakeven" on the switch to CPOE is 6 weeks or about one eighth of a year. Unfortunately translated into private practice that means that moving to an EMR will cost a physician some considerable chunk of one-eighth of their income in lost productivity. Let’s say that number is 30% of their productivity for that time period and lets say that the average doc’s annual revenue is about $500K, and for the sake of easy math let’s say it’s a 5.2 week period of lost productivity. That translates into a $15,000 loss in practice income, ignoring the cost of the software and hardware. And there are no corresponding costs to be cut, so the upshot is that the average small practice doc is looking at taking $15K that as income loss.
And there alone is a good reason not to do this…which is why some kind of
bribery incentive is required.
I may be mixed up on this, but didn’t the VA have to write off an ungodly amount of money last year because their EMR system didn’t work, forcing them to start over? I’m working from a really vague memory here, so someone who actively tracks these issues please correct me if I’m wrong.
Frankly I think the only way that EMR are going to really work is if an entity with huge clout (like CMS) mandates/incentivises/standardizes the use of them. Especially with the CMS increasing the amount of payments based on risk scores/risk adjustment data there could be a real motivation for them to get behind it. I’m not sure that there is any other player with the motivation. A defacto standard would make this enormously easier. I understand that the VA has developed an EMR system that seems to work for them – why is no one talking about using that? It really doesn’t make much sense for everyone to be reinventing the wheel here?
Or we can find a way around physician incentivize-me-or-else. For instance, why not give a way for tech savvy patients to enter their own information before the appointment?
The poster above makes a great point about the need for learning-centric education.
On the other hand, what universal educational process is, in the final analysis, anything but compulsory? I think it’s going to be very difficult to keep providers happy, and that might not be the best model for us to use.
There’s something else, too. Successful CPOE and EMR implementation efforts usually include rigorous documentation of care processes.
In addition to being annoying and exhausting, this process is extremely unpleasant–the folks in charge of documentation spend all day finding out that people have routinized care in incredibly ass-backward ways.
And they are presented with a choice: hardwire these stupid ways of doing things by building an IT protocol to support them, or change the routines and suffer the extreme rage and loathing of everyone involved? Mix and match?
Ad a group, doctors are incredibly resistant to inconveniencing themselves intentionally. I mean, they don’t even wash their hands, even though it’s incredibly important for patient safety. I remain extremely skeptical that any process that depends on physician vonunteerism will be effective.
At the end of the day, I think we should spend less time designing a better product, and more time figuring out more efficient ways to coerce physicians.
Forgot to add an important point. Since technology tends to boil down to it’s functionality, vendors (and turf-conscious internal tech leaders) deliberately add “proprietary” concepts and language to separate their product from the pack. This adds to the learning curve.
There’s an interesting thing about the learning curve: EMR propagandists think of learning in terms of training rather than acknowledging damage done – i.e., the negative lessons are still lessons, and sometimes indelible. One of the lessons is that technology changes rapidly, so a big investment in training is easily wasted. At Kaiser, a big effort was put into training physicians for the CIS EMR (which was utterly non-intuitive), and then Halvorson pulled the switch for Epic. What if Kaiser decides it doesn’t like it’s business relationship with Epic?
Moreover, what I observed is that at Kaiser there are a ton of technology projects, and it’s the project managers who are responsible for getting “buy in” from physicians, “champions”, and bigwigs with clout – and the project manager needs to succeed for the sake of their own job. Medical center administrators are supposed to figure out how to schedule all this in, and they have to draft in their own personnel to fit this “project” into their regular jobs. There is tremendous pressure to embrace technology, and when I left Kaiser, there were actually physician “tsars” for each medical center. These people had to get their medical center on board with the “vision”.
I assisted with the training for one system, and I wrote the case study of a training roll out for another. That’s right – there are scads of little systems that physicians get training in, and those can be switched at any time. Even the big EMR is made of lots of little modules. You would not believe how many technology “projects” can be imagined for a medical center setting. The doctors train on these during lunch. Every time they invest the time in something like this, the system may be gone five minutes later. A lot of technology at Kaiser is considered “transitional”, a stopgap measure while something else is rolling out.
When I went to my doctor for an appointment, he spent more time with the computer than with me. Think about it: appointments are scheduled for 15 or 20 minutes. After a patient waits a month for an appointment, filled with concerns about whether they are sick or whether the doctor will blow off their symptoms in a patronizing way or whether they will be eligible for some government service…and the doctor spends that 15 minute struggling with the Technology Boondoggle of the Week.
One of the things that would help is attending to the rational delivery of training and making training learner-centric. Right now, the technology division can be just as patronizing toward “stubborn” and “stupid” doctors as doctors can be toward their layman patients. To be frank, one of the problems is that HR tends to hire for technology training experience, and people with that experience tend to have acquired it in ad hoc ways. HR often deliberately excludes people who are “too technical”, too, – so they end up with people who don’t understand what they are teaching, and they suck at teaching, too. Kaiser would be better off hiring people with both a degree in Education and technical interests.
Here is an account of the training chaos at Kaiser from the Medical Center perspective. It came from an internal employee conference on Creating a Learning Community:
This boils down to: Stop the Madness!