Remember: Technology is but a Tool

Yesterday, Chilmark Research participated in the CRG conference, Driving Change Through Managed Care IT from Provider Payments to Quality, which was held in New York City. Despite having a title that no one will be able to remember, the overall theme of the event and presentations therein gave one a bird’s eye view into what payers are thinking as we march forward with healthcare reform and the digitization of the healthcare sector.

A common theme that repeated itself numerous times over the course of the day was the lack of business process maturity in the healthcare sector. Meg McCarthy, EVP of Innovation at Aetna was the first to make this statement citing this issue as arguably the number one challenge for this industry sector to overcome. (McCarthy provided some interesting details on the Medicity acquisition but we’ll save that for a later date.)

Later that day, Jessica Zabbo, Provider Technology Supervisor at RI-BCBS gave a very detailed presentation on her company’s experiences working with providers on the adoption and use of EHRs. Over the last several years RI-BCBS has done a couple of small pilots. In both cases a defining parameter of success was business process maturity. For example, the company did a Patient Centered Medical Home (PCMH) pilot that coupled pay for performance metrics (P4P) with EHR use. Basically P4P measurements were to be recorded and reported through the EHR. One of the key lessons learned was that P4P program success was highly dependent on the EHR being fully implemented and physicians comfortable with its use (process maturity). But in a Catch-22, to successfully incorporate P4P metrics into the EHR requires a very deep understanding of practice focus and workflow. Without that understanding, failure of the P4P program is almost certain.

Thus, it is with some dismay that when one goes to the HHS site to view the recently released ONC Strategic Plan for HIT adoption one sees the figure below:

What’s the problem you ask?

Where is “Process?”

Nowhere in this figure is there any mentioned of business process/workflow. Technology is but a tool. The proceses by which clinicians collect and securely share health information is where the focus needs to be with technology in the backseat, not in the driver’s seat. But this figure goes beyond just flipping the equation, it completely ignores “process” altogether putting technology squarely at the beginning, at the start to all things grand and possible if only clinicians would simply go adopt and use the technology. (Despite some wishful thinking and pronouncements, e.g. “the era of EHRs is upon us” providers are not necessarily chomping at the meaningful use bit.)

Now to ONC’s credit, they are in a bit of a bind here for to admit that business processes and change thereof need to be taken into account would most assuredly require a major rethink of what is truly possible in the next several years as ONC tries to empty the HITECH coffers of its billions and demonstrate to Congress that this program is indeed a success and is creating jobs (remember, this was passed as part of the Stimulus Act and creating jobs was priority numero uno). Unfortunately, being a job creation bill is not conducive to providing the time necessary to create and implement new business processes that are supported by IT. Business process change takes a tremendous amount of forethought before any contract is signed for any EHR, but HITECH works counter to that with aggressive adoption and reimbursement schedules leaving very little time for thoughtfulness in re-architecting processes.

In a prescient way, Chilmark predicted that the issue of process re-engineering would be one of the greatest challenges in adoption and use of EHRs and recommended to ONC in our 2009 comments that ONC consider relaxing the schedule to allow to allow sufficient time for process re-engineering. Unfortunately, it appears that it remains full-speed ahead with HIT driving a weaving HITECH truck down a narrow and winding road.

John Moore is an IT Analyst at Chilmark Research, where this post was first published.

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8 replies »

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  2. I was an industrial engineer for many years and come from the school of thought that there is no business/practice too small to improve. My clients include small businesses and small medical practices. I cringe every time I hear them say that there is nothing that can be improved especially when moving from a paper-based environment to an EHR. I point them to this link before my initial visits. http://www.emrapproved.com/hit109.php

  3. Don’t be harsh on them, Bobby. If a primary care solo practice managed to survive and stay open so far, chances are their “workflow” is pretty decent already. Besides, there aren’t too many flow choices when you have 3 or 4 people in a clinic and everybody does two or three jobs anyway.
    They know how to see patients, but have no idea how to Click for Cash (C4C) 🙂 and they do need the money. You’re doing a good thing.

  4. I have to admit that in my REC client solo/small outpatient clinics, the eyes glaze over at the mention of “workflow.” They just want “Clicking For Cash” help. Which, honestly, given our increasing workload, is about all we’re gonna have time for, at least ’til likely about mid 2012.

  5. “Unfortunately, it appears that it remains full-speed ahead with HIT driving a weaving HITECH truck down a narrow and winding road.”

    …and PCAST is suggesting that the current full-speed is not nearly enough. Got to go faster….

    My personal opinion on process and workflow redesign is that the term is meaningful in a hospital or large organization. For a small, or solo, practice it is meaningless, or at least highly overrated.

  6. “Nowhere in this figure is there any mentioned of business process/workflow.”

    Maybe not in that graphic, but the Strategic Plan itself addresses workflow issues (including HIT “usability”) in numerous places, e.g., pp. 9, 11, 14, 22, 24, 35, 41, and 53. Now, I have been critical of ONC for only now getting around to focusing on EHR usability, but the RECs have been working on workflow assessment and redesign issues, tools, and tactics since day one of HITECH last year. There’s an entire CoP (Community of Practice) within the ONC HITRC (comprised of staff from all 62 RECs) that meets regularly (I am a member of it) to focus on workflow issues. We are quite of aware of the importance of effective alignment of information flow with broader process workflow and have been all along.

    I might also add that workflow issues are addressed within pages 61, 74, 75, 89, 91, 92, 103, 111, 144, 146, 168, 178, 192, 220, 517, 559, and 592-594 of the Meaningful Use Final Rule (CMS-0033-F), with much of that dialogue generated in response to the myriad stakeholder/interested party public comments. Given that this Strategic Plan is now in its own public review and comment period, I would urge anyone with an interest to submit your ideas and concerns.

  7. Dr. Tim Jahn, the chief quality officer of the eastern Wisconsin division of Hospital Sisters Health System addressed this issue in a commentary in Modern Healthcare a couple of weeks ago. It was entitled, “Fix Processes First: Add an EHR only after freeing clinicians through efficient care protocols.”

    In it he states, “without optimizing processes first, the EHR becomes “digital cement” that keeps hospitals inefficient.”

    Not sure if it is behind the pay wall, but it is a good read.