E-Health – It All Depends on How It’s Used

Technology isn’t a quick fix. Just ask General Motors. In the 1980s, the auto giant spent $50 billion to automate and computerize its plants in an effort to compete with Toyota. Today, GM is emerging from bankruptcy while Toyota still leads in producing high quality, fuel-efficient vehicles.

What happened? “The Japanese have a great way of describing the error that General Motors made,” said Thomas Kochan, co-director of the Institute for Work and Employment Research at the Massachusetts Institute of Technology Sloan School of Management. “It’s workers who give wisdom to these machines.”

Will the Obama administration’s $20 billion push to flood the nation’s physician offices and hospitals with electronic medical records (EMRs) suffer a similar fate? The July/August cover story in the Washington Monthly by Phillip Longman pointed to one possible stumbling block on the road to widespread diffusion of EMRs – self-interested software firms pushing proprietary systems that can’t talk to each other.

But there may be an even greater danger. The people who actually deliver care will fail to achieve the potential health benefits of having every patient’s EMR at their fingertips.

That was the reality facing Kaiser Permanente’s Colorado medical group in Denver five years ago.  The health maintenance organization, touted as an exemplar of quality care, was an early adapter of EMRs. And what those records told local managers when it came to controlling blood pressure — a major goal — was troubling. Despite annual free checkups and prescribing lots of blood pressure pills, only 59 percent of patients had achieved control in follow-up visits. “Putting a blue sticker on a piece of paper that says you have high blood pressure wasn’t working,” said Sean Riley, the medical director of the group.

Since Kaiser is a unified health system with salaried physicians, it had a direct stake in raising compliance. Greater blood pressure control would almost immediately translate into fewer heart attacks, fewer hospitalizations and lower costs. But how could office-based medical groups reach into patients’ homes and lives to get them to change behavior?

Kaiser’s top managers took a page from Toyota’s production system: organize the office staff throughout its system into unit-based teams and throw the problem to them. They relied on what they believed was every health care worker’s inherent desire to deliver high quality care. “When we started, nobody wanted to buy in,” said Dominique Spain, a medical assistant in the Denver group. “But when they realized it wasn’t about just taking on one more task, it became doable.” The EMRs became a benchmark for a team motivated to get its numbers up.

The Denver unit-based team adopted a holistic approach to treating patients with hypertension. Nurses would hand out literature and give a short talk outlining the long-term health effects of uncontrolled hypertension. Medical assistants began making follow-up phone calls to non-compliant patients. They scheduled additional office visits for patients simply to see a nurse to get their blood pressure checked. Some patients were given kits for taking their blood pressure at home.

Less than three years after starting the program, blood pressure control is up to 70 percent of patients. Kaiser officials estimate that translates into 350 people leading healthier lives, which will prevent 12 deaths and $500,000 in additional medical costs by preventing heart attacks and strokes.

“Technology doesn’t change lives,” Riley said. “It’s the process around the technology that brings results.”

Kaiser’s team-based approach for using EMRs to improve patient care for its 8.6 million beneficiaries was facilitated by a union-management partnership that’s been in place since 1997. About 104,000 of Kaiser’s 165,000 employees are unionized.

“The evidence is very clear that improving patient care requires the coordination of nurses, service employees, doctors and technicians working together in a coordinated fashion,” said MIT’s Kochan, who studies union-management partnerships around the country. “You cannot get sustained teamwork in an adversarial relationship.”

It’s a lesson reform advocates in Washington ought to keep in mind as they craft legislation. Getting health improvements and lower costs from EMRs is not a given. It will require creating workplace environments that know how to make the best use of those records.

“To demonstrate higher quality and become more affordable, we had to take a systemic approach that required a hundred percent engagement strategy,” said Barbara Grimm, a senior vice president at Kaiser Permanente. “Health care needs to be a continuously evolving process.”

The Japanese called their strategy kaizen or continuous improvement. EMRs, like statistical process controls in a manufacturing setting, are only a tool for generating information. It takes people changing the way they work to actually improve quality and lower costs.

More on health IT:

15 replies »

  1. As a healthcare provider since 1972, I have seen many changes in the system. The biggest problem is that our elected public officials have created so many legal requirements and have created so much paper and electronics processing work just to get paid that I have gone to a cash and check payment only system. I no longer care for patients who want me to bill any third party payer. This means welfare, workers comps, auto accident insurance and HMO’s. If patients want my services they have to pay me following each office visit. They have to go through the hassle to get reimbursed by their third party payer on their own time and expense. However; I also gave up on auto accidents. Having to take time to process all the documents to prove that a patient needs my services and go to court to defend the patient and not get paid for my time, it is just easier to refer the patient out to another doctor who enjoys this headache.
    I recently asked a retired attorney what the process was to get a new bill created so that it can be voted on. He said that the elected politician has his aids draw up the bill and then he or she reviews it and then sends it off to a legal department where it is turned in to some legal text which no one can understand.
    In this process that bill can be altered by the aids and/or the legal department, so that the original intent of the bill is lost.
    Since AARP represents us senior Americans, I feel that AARP can get enough retired qualified volunteers to write a totally new bill and have it VOTE ready and put it in the hands of all our Politician.
    Now here is my solution for improving the healthcare system.
    The government should get out of being a third party payer insurer.
    The government should create the laws that would regulate a no-fault short and long term healthcare insurance program.
    All insurance companies & HMO would not be able to sell stock in their companies to the public. Policy holders could be classified as shareholders. This means that they should be classified as non-profit entities.
    The CEO’S of these companies salaries should be no more than twice that of the President of the United States.
    All residents in the United States would be mandated to have the no-fault insurance. If they can not afford the insurance then the state or federal government would assist them in paying for their coverage.
    The states and federal government are already getting revenues from Alcohol, Tobacco and Minnesota care tax on health care providers. This revenue would assist in paying for working low income citizens.
    Here are some pluses for a system like this: the healthcare portion of the auto, home owners, business liability, workers comp, welfare medicaid, medicare and other third party insurance premiums would be eliminated. The resident of the United States would only have one healthcare insurance premium to pay. This would save the US citizen a lot of money. This would reduce the paper processing expense by thirty to forty percent.
    Each health policy holder would be eligible for a complete physical including lab test so that they can work on their own personal healthcare and health maintenance program.
    The healthcare provider would only be paid for the actual time spent with the patient and for the materials used in treating the patient. Also for the time spent on process patient records. The no-fault non-profit insurance carrier will not be able to deny payment to the healthcare provider.
    To prevent fraud the healthcare provider and patient would punch a time card.
    Malpractice liability insurance current policies should addressed also. There is a small number of providers that repeatedly cause the malpractice law suites. These individuals should be required to be reeducated and rectified in that portion where the malpractice occurred.
    It is time to quit add ons to an old worn out vehicle.

  2. This is a very interesting posting I must say. I have read a lot about health reforms and electronic medical records and such other stuffs.

  3. The story referenced in in the Washington Monthly includes 2 institutions that implemented information technologies. I question the causality attributed to the successes vs. failure. The author attributed success to the use of open source software when it is likely that success was more likely related to the approach to implementation. Implementation has to start with the people and the process and then bring in the technology. It appears the institution that was less successful probably brought in big vendor and then attempted to change the people/process. There are many references in the literature that confirm that starting with the technology, rather than the healthcare delivery process itself leads to the use of health information technology in ways that have inferior outcomes, and actually harm patients. The degree of success in any implementation of proven software is more likely to be related to how well the local decision-makers understand the process rather than the choice of software and vendors.

  4. “EMRs, like statistical process controls in a manufacturing setting, are only a tool for generating information. It takes people changing the way they work to actually improve quality and lower costs.” Is that so?
    Statistical analysis of the accuracy of care provided via EMR and CPOE show that it often gives the wrong care to the wrong patient tardily. It forces work arounds that disrupt the way doctors work and think, resulting in poorer quality and higher costs.
    How many of you have taken your high colonics?

  5. As a practicing pharmacist, I saw both sides of this issue…
    On one hand, as the article so adeptly pointed out, we would see new technology introduced, cursory training would ensue and then we would be thrown into the same workflow models we had before. No effect would be seen at all on patient outcomes and cries “user error” and “why don’t they get it” would ensue from the powers on high.
    On the other hand, I attended numerous “efficiency programs” (some of which had the Toyota name liberally sprayed all over them) all with a focus on building out our ability to do more with less, create value, increase our throughput and potency as clinicians. We would then go back to our jobs, documenting our actions on scraps of paper so we could remember who we cared for and what we did the day before…
    Technology alone will never solve the problem. My dad always said (and I’m sure he wasn’t the first) “You can buy a fancy hammer, it sure as hell won’t build a house for you…” Work flow redesign and technology integration, when married together in a thoughtful way, can have huge positive impacts on patient care.
    Charles Westergard, BSPharm, MBA
    Seattle, WA

  6. Excellent Posting! EHRs are what us epidemiology types like to call necessary but not sufficient technology for quality. And “necessary” is stretching it a bit, but real improvement needs some sort of measurement of performance or outcome, and if EHRs are set-up and used properly they can provide that. Is quality improvement types, especially those who labor in the physicians’ offices, not the palaces we call hospitals, have known for a while that unless your primary charting system provides process/outcome measures, that sustainable improvement is hard to maintain.
    BUT as Sir Goozer observes, people are the key human factor that makes our healthcare system work well or not. Given tools and no plan not much happens, given a plan that energizes health workers to contribute as a team – tied together by a good clinical information system, then quality things start to happen that we all want. Of course there is a limit, and staff need enough time to do what needs to be done, but systems that provide the right care and information to the right patient at the right time can be pretty effective.

  7. I have read and read about healthcare reform, EMR, etc. Why has no one noted the example of the Church Health Center in Memphis, TN?? Clinic, optometry, dental, wellness, prevention – and for who THE working uninsured in our own community. No Government agency helps. Non-profit, hundereds of volunteer MDs. Check it out and start the same thing in YOU communities. The Center even teaches other how to do what they do. Over 55,000 patients of record, and they use EMR.

  8. I hope this is not waste of money. In many other countries, the health care is totally free and you don’t have to make appointment to see doctor and you don’t have to pay ER fee. The doctors here often keep you waiting even you have a real appointment and try to get you more appointments even you are not sick, so they can make money off you.

  9. We are getting exactly the type health care we have decided to pay for.
    We pay for lumbar laminectomies for non-radicular back pain, and for cardiac caths for atypical chest pain. Subsequently, the highly sophisticated tools used to maximize the number of those procedures performed have been developed.
    We do not pay for long term management of chronic disease over time, and therefore the tools to accomplish that have not been developed or are not being used.
    I don’t see how EHRs and population management tools can be effective if we won’t pay the primary care docs for using them.
    We’ve put the cart before the horse. Instead, let’s decide on what results we want and are willing to pay for; the necessary tools and support will be created spontaneously.

  10. The example of Kaiser Permanente emphasizes one important point: a paradigm shift to patient-centric care is required. Otherwise, use of EHR systems will remain just another regulatory rule for providers to comply with. This is what healthcare reform must be about, as far as the supply side of the equation is concerned.

  11. It is all about culture change and changes to processes and workflow. This type of change is generally hard for all industries and will be especially hard for the healthcare industry.
    There is simply no silver bullet. Anyone that says different has been drinking the kool aid for too long. I am all for the movement to EHRs and healthcare reform in general, but the road to the promise land will be filled with more potholes than proponents are willing to admit (or they simply have no idea).
    This amount of change is unprecedented in any industry perhaps with the exception of when manufacturing first moved to the electric grid (i.e. as opposed to using their own sources of electricity). We will get there, but it will be a “long unwinding road.”

  12. This is an excellent article, because it reinforces the all important fact that we need to establish efficiency models if we are going to achieve methods to control health costs that are racing far ahead of other costs. We simply cannot economically endure cost increases at the present pace. One important approach is that we must reform the system and create a new spectrum of delivery in models of efficiency and measurability. Professor Clayton Christensen at the Harvard Business School, along with two eminent physicians, has written “The Innovator’s Prescription”, which describes just these reformations. EMR/EHR will be the tie that binds this all together – if we can eliminate all of the special interest purveyors. Since we work with doctors as advisors, I can tell you that the pessimism out there is rampant – most eschew EMR out of a fear that after all of the time and costs necessary to implement, something will happen to make it obsolete. The only consistent yardstick that has been laid down is the HITECH legislation, but that doesn’t seem to solve the concerns we’ve heard.

  13. Thanks Merrill- YUP-Like any other tool EHR/HIT is indeed JUST a tool which if not used properly- built on a values based platform- is as likely to harm as do good.
    Also constant user involvement and feedback from the ground up must prevail.
    Dr. Rick Lippin

  14. I agree with Merrill 100%, and would like to extend his the ideas he’s proposed just a bit if I may.
    In a full-blown kaizen-based management system, managers empower front-line workers to work “on” the system, rather than merely functioning “in” the system. This includes, as Merrill points out, reorganizing workflows and daily activities to assure improved results.
    But it also includes working on the EHR technology which is so central to health care processes. If the EHR is flexible enough, that is–if updates and new versions of the EHR can be released quickly enough–health care workers (particularly physicians) can provide feedback that will be incorporated into the EHR design, a powerful way to enhance the efficacy of the care process.
    This approach is impossible with the legacy client-server based EHRs that are present in many health care organizations today. The vendors of such systems labor to update their systems and have difficulties releasing new versions and training folks to make the switch.
    Web based EMRs, which are relatively new to the marketplace, support the very rapid release of updates and improvements. Indeed we release new versions of our EHR once or twice every month.
    In the case of Practice Fusion’s Web-based EMR, this flexibility has encouraged our physician users to submit suggestions for improving workflow, documentation and so forth…We get dozens of valuable suggestions every week.
    When their suggested changes appear in the system, physicians who contributed them become motivated users, and are eager to continue helping us improve our system.
    Web-based EHRs allow health care workers become active participants in the continuous improvement of everything they do.
    Glenn Laffel, MD, PhD
    Sr. VP, Clinical Affairs
    Practice Fusion
    Free, Web-based EHR

  15. I told that day one…that it is a waste of money. You need to have working processes before you make them faster. I might add not just working but efficient.
    I have now over 15 yrs of experience in Lean, Six Sigma, and Design for Six Sigma and one might say with pretty good track record in using it to deliver performance. The comment “ONLY TOOL FOR GENERATING INFORMATION” is absolutely not true. It is a method not a tool that can be used to provide solution. There are lots of people who were a six sigma/lean hat…but there is nothing beyond the hat….
    Agree on the comment about people. A business is a set of processes that people execute to deliver a product using system and structure (platform). What HIT is the platform. if you do not have process and people, platform has no meaning.