How’s that working out for you?
For a large percentage of you, whether or not you admit it, not so well. What you bought needs some serious tweaks, re-engineering, re-thinking, re-vamping.
For an even larger percentage, maybe most of you, the best advice is: Junk it. Throw it out and start over.
Poorly designed and poorly implemented information systems are worse than useless, worse than a waste of those millions and billions of dollars. As we go through rapid, serious changes in health care, poor information systems will strangle your every strategy, hobble your clinicians, kill patients and actually threaten the viability of your organization.
A lot of health care executives dismiss the complaints about the new systems as the carping of stubborn technophobic doctors and nurses who should just get with the program. If you are tempted to do that, you need to take a step back. You need to get real. The complaints and concerns are too widespread, too deep and indeed too frightening for that kind of blithe denial. And they are not just coming from disgruntled docs.
Dr. Clem McDonald of the National Institutes of Health, a true pioneer in pushing for electronic medical records (EMRs) over the last 35 years, has called the current implementations a “disappointment,” even a “tragedy.” He is far from alone in this assessment.
In the rush to digitize and automate, we’ve made a botch of it across much of health care. What was supposed to be a new fast track of efficiency and effectiveness has become a hemorrhage of money, efficiency, personnel and the most important of all management tools: trust. You must deal with this, you must deal with it fast, you must deal with it effectively. The future of your organization is on the line.
Questions to Ask
Ask these questions about your electronic health record (EHR). Don’t just ask your IT people, and certainly don’t ask your vendor. Ask the users.
Does it slow clinicians’ workflow?
- • Is it transaction based, rather than patient based? If a patient, for instance, is admitted from the emergency department (ED), is the ED information in a different record? If the patient is coding and your intensivist wants to know what the blood pressure variation was in the ED, does she have to close one record and go hunting for the other one?
A Medical Economics survey published last February showed that over 70 percent of physicians would not buy their current information system, if they had the chance to make that choice again, because they hate the way it works. Nearly 70 percent have seen no improvement in care coordination with the hospitals. And 45 percent believe it has actually hurt patient care.
Were clinicians involved in its design?
- • Did anybody ask them what they needed in the major tool that runs their entire work life?
In a recent Black Book survey, 98 percent of 13,650 registered nurses polled said nurses in their facility were never asked to help design the system; it was just imposed on them. As a result, 85 percent say the system is flawed and gets in their way, 94 percent feel that it has not improved communication among the care team, and 90 percent feel that it has damaged communication with the patient.
Do you worry about recruiting and retaining skilled, experienced nurses? In the same survey, 79 percent of RNs put the reputation of the information system among the top three reasons they would choose to work at — or avoid — a particular institution.
Does it require more work, rather than less, from your clinicians?
- • Does it allow billing codes to be derived directly from the medical record, or does it make coding a separate activity — which often means a “coding assistant” hired just for that?
- • Does it ask your clinicians to do more documentation?
The best estimate is that, on average, documentation demands have doubled in the last decade — and much more of those demands fall on clinicians rather than on transcriptionists and assistants.
A study by Woolhandler and Himmelstein in the International Journal of Health Services reported the following: “Although proponents of electronic medical records have long promised a reduction in doctors’ paperwork, we found the reverse is true. Doctors with fully electronic medical records spent more time on administration than those using all paper records.”
Similarly, Dr. McDonald has just released a survey that estimates these new systems add a full 48 minutes of work to each doctor’s day — at a time when physician services are becoming a more and more scarce and precious commodity.
Does it hide critical information?
- • Does it, like most EHRs, have a “flat” structure, in which the salient data is mixed in with tons of data that is not important for the clinical moment? While your clinician, in his head, is rapidly structuring the diagnostic information and going through his decision tree, is the information presented in a way that helps him, or in a way that fights him every step of the way?
- • Is there a way for a clinician to flag, on the presenting page, in neon lights, an unusual but highly important piece of information — for instance, a patient’s recent travel history from West Africa and his exposure to Ebola?
- • Is it easy to get lost in the system, entering data in the wrong patient record or putting information in the wrong field?
- • Do your clinicians feel that the software increases or decreases the possibility of “never events” and medical misadventure? Does it increase or decrease the clinician’s and the system’s exposure to malpractice suits?
UI — the user interface — is an art, and it is a big deal in medical information. Bad UI kills patients and lands you in court. CRICO, the patient safety and medical malpractice company for the Harvard medical community, recently released a study that identified 147 cases, costing more than $61 million, related to EMR mistakes — incompatible information systems, faulty routing on test results, faulty data entry and mistakes in “copy and paste.” That’s one year, one medical community, one insurer.
How opaque is it?
- • Does it maintain different records for the same patient even within your system?
- • Can other providers read the records from your system?
- • Can your partners in any accountable care organization (ACO) read each other’s patient records? Can they use the system to actually coordinate care? Or do they have use work-arounds — faxes and Post-It notes?
In the Black Book survey, 67 percent of the nurses said they have to use work-arounds to make up for the flaws in the system.
Is it secure?
- • Can it be hacked? How easily? How do you know?
A survey by the Identity Theft Resource Center showed that medical records were the leading route for identity theft, accounting for 43 percent of all cases. This does more than bother your customers and cost them money. When the thief is actually stealing health care by posing as someone else, it can lead to harming patients when new false information is added to their medical records.
Is it impermeable to data-mining?
- • Are the vast amounts of data about your system available to you to help you analyze, for instance, where the outliers in expense are, or how much a given procedure actually costs?
- • Can the software help you characterize all inputs and costs for any given procedure or class of procedures to assist activity-based cost accounting and lean efforts?
Care coordination is the whole idea behind accountable care organizations. Can ACOs actually coordinate care? In September, Premier’s eHealth Initiative published a survey of 62 ACOs. How many of them reported difficulty getting data from external organizations? Every single one. How many reported difficulty integrating data from different sources within the ACO? 88 percent. How about difficulty going beyond data to actual interoperability across the ACO? 95 percent. This is a huge roadblock in the way of any real, serious care coordination.
According to eHealth Initiative’s CEO, Jennifer Covich Bordenick, “The cost of interoperability can be prohibitive for many organizations.”
Why? Let’s be clear about this: Interoperability and the secure, reliable, accountable exchange of data is not some kind of wild, impossible fantasy that vendors are struggling to make real. It is in fact the norm in electronic communication today. It’s why you can put apps from thousands of different vendors on your iPhone or Android tablet and they can all read the same data and talk to each other. And if you want to make your communications secure, and available only to the appropriate person, you can do that with free, off-the-shelf applications.
Imagine what the financial world would look like if their IT vendors had convinced each bank and brokerage to build software that would not talk to anybody else’s. Interconnectivity is normal. The reason it’s not normal in health care is that some or most of the vendors don’t want it to be normal.
Building good software on an enterprise scale for something as complex as health care is extremely hard. But this is not the hard part. You can design the software to produce data to industry standards, with entry ports built in so that other systems can read it, just as my Mac produces .pdfs and .xml files and .wav files that can be read by machines running Windows or Linux or Unix. Or you can make a different design decision, using proprietary coding that cannot be read by any other company’s software.
Why would they make that decision? Because they want you to stay in their walled garden, buying only their products. They do it for market share, that’s all.
The idea that interoperability is difficult or impossible is a con. In a classic case of an industry driving government decisions, neither the HiTech Act, nor the Affordable Care Act, nor the regulations implementing “meaningful use” have disallowed the con and demanded true interoperability.
We, as an industry, have largely fallen for the con. Some of us have been running our own con, trying use a lack of interoperability to build our own “walled gardens” and gain market share. In a world of ACOs, population health management, and shifting partnerships and affiliations, that attitude is frustrating our doctors, hobbling our strategies and killing patients.
Zane Burke, the president of Cerner (which just bought Siemens), made a strong point about interoperability in a recent interview with H&HN Daily’s Matthew Weinstock:
“We all owe it to the country … to really perform true interoperability and create openness…. You need platforms that don’t just open up your APIs [application programming interfaces] but actually create ecosystems for other players … to perform well. We can’t use the operating system at the EHR lever as a competitive advantage. It just can’t be that way.
“The industry community shouldn’t compete on the platform layers. And we need our provider community to not compete based on connectivity of their organizations, even where they compete in their market. We need our provider community to come together and say we need patient identifiers, interconnectivity, and interoperability to be ubiquitous across the U.S.”
It’s not like this is new. It’s not like we didn’t see this coming. I have been writing about and advocating for the digitization of health care for 30 years, as have many others. I have to tell you: We knew back then that interconnectivity through industry standards — and smart user interfaces that assist clinicians in their normal workflow rather than hinder them — were hard problems that needed solving.
It never occurred to me or anyone else who was writing about it at the time that the industry and its vendors would deliberately turn away from smart, clean, highly usable, highly interconnected design simply because of a fruitless quest for the lowest bid and a greed for market share. We did not imagine it because this deliberate turn away would be so manifestly stupid, so wasteful of our money, of the time and talent of our clinicians, and of the lives and suffering of our patients.
It cost us millions to billions to get into this mess. It will cost as much, maybe more, to get out of it. It’s time to quit digging the hole we are in, toss what does not work, start in again and do it right.
First published November 20, 2014 in the American Hospital Association’s Hospitals & Health Networks Daily.