Selling the bitter EMR pill (HIMSS meeting)

At a major health technology meeting, technology advocates, hospitals and others put their heads together to see how to get physicians to embrace health IT.

By Pamela Lewis Dolan — Posted April 7, 2008

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A few days after the University of California Medical Center in Irvine went live with its new electronic medical record system, a letter arrived on the desk of the hospital administrator.

"I think the person who chose the [EMR] system should be shot first and then fired," the note read.

Pamela Griffith, RN, director of applications for the UC Medical Center, displayed the note at the annual conference of the Health Information and Management Systems Society in Orlando, Fla., in late February, where a lot of discussion focused on how to get physicians to use technology.

Only a few years ago, many of the chief technology officers, vendors, hospital administrators and others who attended HIMSS thought that as technology became more pervasive, physicians would have no choice but to adapt. It turned out that assumption was false. Griffith presented the angry doctor's note as evidence of the backlash her hospital failed to anticipate.

She and others shared success stories, as well as lessons learned, of implementing new technology. The common thread was the realization that for major IT projects to be successful, physicians need to be on board, early and often. The solution, many found, was engaging doctors in leadership roles before implementation.

Sometimes it's the reluctant ones who make good leaders, said William McClatchey, MD, chief medical information officer of the Atlanta-based Piedmont Hospital system. He found involving physicians who are opposed to the technology gave the IT staff and hospital administrators a better sense of the backlash they could anticipate, and hopefully prevent, at go-live time.

"The unique voice that physicians share is the unique experience they have. The physician is the point person, and it gives them the perspective to provide the insight that organizations won't find from other professionals," said John Leviss, MD, vice president and chief medical officer for Sentillion, an Andover, Mass.-based health IT company.

Curtis Cole, MD, chief medical officer of Weill Cornell Medical College in New York, said physicians are an important part of the process since they can educate IT departments about the problems that need to be solved. And IT departments can show physicians how technology can solve those problems.

Engaging doctors

When Dr. McClatchey's hospital started implementing a computerized physician order entry system in 2000, he said physician involvement was "critical." During implementation, work flow changes are major, and having those changes driven by the physician and nursing staffs is what will make the difference, he said. Piedmont developed a team of 200 employees that included 25 to 30 physicians from a range of specialties. All were compensated for their efforts, he said.

But because most physicians have found few financial incentives to embrace IT, hospitals are learning that it takes more than the promise of streamlined processes and improved quality when asking doctors to put in extra hours and possibly lose revenue to help implement technology that doesn't deliver a return on investment.

Dr. McClatchey acknowledged that hospitals, for example, shouldn't tell doctors to embrace a system because it will make them more efficient and save them money, "because it won't." It can improve patient care, save the hospital money and make it more efficient, but only if physicians use the systems, he said. And as more hospitals link into regional health information exchanges, considered to be the backbone of a national HIE, it's crucial that doctors embrace the technology, experts say.

But Drs. Leviss and Cole warn that finding the right physician to lead a project can be difficult.

Dr. Cole said it's important to find a balance between doctors who are interested because they are "computer nerds" and those who like gadgets but aren't all that tech savvy. "Just because that [tech-savvy] physician will put up with the frustrations of the new technology, that doesn't mean all will," he said. Some hospitals have found that the best doctors to fill leadership roles are ones who are afraid of or are opposed to the new technology.

Hospitals also should not assume that all solutions developed by the IT department will be useful to every physician. "If you don't know where the ICU doctor is struggling ... you're not going to come up with the right solutions," Dr. Leviss said.

Facilities are even using their own marketing departments to educate physicians as to how the IT department can help them. Steven Bennett, vice president of Snelling Executive Search in Altamonte Springs, Fla., said some hospital CIOs are tapping into their in-house marketing resources, creating IT slogans, blogs, brochures and newsletters all aimed at selling the services that IT offers to the rest of the hospital.

Apart from finding a physician leader, the other big decision is whether to make using technology mandatory.

Dr. McClatchey said Piedmont's decision not to make its system mandatory was risky, but it produced 100% compliance after incremental changes were made.

Nancy E. Dunlap, MD, chief of staff and chief operating officer of the Kirkland Clinic at the University of Alabama at Birmingham, said that, based on her experience of rolling out an electronic scheduling system to 900 physicians at Kirkland, "A mandate that everyone's going to do it is very important." Because of the mandate, she said, those who protested "forgot very quickly how to do it the old way."

Wider implementation?

Although it may seem that exposing doctors to technology at hospitals might be the path to wider EMR adoption in practices, that hasn't exactly been the case. To be sure, almost every hospital, after a big technology implementation, has a story to tell about doctors who were opposed to the technology then later find they can't live without it.

The reality is that much of the available medical technology is still financially out of reach for many physicians. But there also are just as many who wouldn't use it if you gave it to them because of the way it impacts their practice flow.

"A free EMR that makes you see less patients is not free," said Jonathan Bush, CEO of Athenahealth, a Watertown, Mass.-based technology vendor. "We don't make 7-Eleven serve sushi even though it would be better than slushies," he said.

That theory has been proven in many states that experimented with free e-prescribing systems, according to Barbara Drury, president of Pricare Inc., a Larkspur, Colo.-based consulting firm.

Drury said many states that assumed e-prescribing would be the gateway to EMR adoption were disappointed. For example, the state of New Jersey offered 4,661 physicians free e-prescribing systems, but only 1,706 doctors signed up. Finally, only 283 ended up using them.

There was no formal follow-up into the low response. But consultants at HIMSS speculated doctors might have resisted because they felt they were being coerced, or because the technology simply didn't work for them.

Bush said many times technology is made available in order to "engage" the physician. But "from a physician's standpoint, engaging sounds like bullying."

He said physicians accept technology when the benefits are proven. "Anything that benefits physicians will be adopted by physicians." It's just up to the vendors to make the technology financially feasible and useful.

E-prescribing can stand alone, Drury said, but more benefits are realized when it's part of an EMR.

But one area to watch, Dr. Leviss said, is the relaxation of Stark laws that now provide safe havens for hospitals to donate health IT.

"Vendors aren't stupid," he said. They have been targeting the hospitals as opposed to practices since that's where the money's been.

There has been more discussion about hospitals providing the technology to physician practices, especially as more become involved with regional health information exchanges. But "No one is doing anything right now," he said. As soon as a handful jump in and do it and can show others how it's done, there may be more movement, he said.

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Some shift in priorities; money still top barrier

Current IT priorities (within 12 months) 2007 2008
Inpatient clinical information systems 48% 40%
Reduction of medical errors/patient safety promotion 54% 39%
Implementation of an EMR 48% 38%
Connection of hospital with remote environments 33% 30%
Business continuity and disaster recovery 35% 27%
Integration of systems in a multi-vendor environment 34% 26%
Upgrade of network infrastructure 25% 26%
Implementation of an ambulatory care system 23% 24%
Most significant IT barriers
Lack of financial support 20% 26%
Lack of staffing resources 16% 13%
Vendors' inability to deliver product effectively 15% 12%
Lack of time from clinicians 10% 9%
Lack of strategic IT plan 8% 8%
Provision of IT quantifiable benefits/ROI 6% 5%
Difficulty achieving end-user acceptance 5% 5%
Lack of clinical leadership 4% 5%

Source: The 19th Annual 2008 HIMSS Leadership Survey, conducted between Nov. 20, 2007, and Jan. 20 on the Web. The results represent 307 usable survey responses, which represented 261 unique health care organizations and more than 700 hospitals throughout the U.S.

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Social support crucial for health information exchanges

Long-term sustainability for health information exchanges will come only through the building of relationships with hospitals and physicians, said John Mellin, program manager for the eHealth Initiative, a nonprofit group aimed at improving quality and efficiency in health care through technology. Mellin spoke to attendees at the HIMSS 2008 annual conference.

Once the social capital has been built, the money will follow, he said. "People will support what they help create," he said.

Much focus has been placed on the long-term sustainability of regional health information organizations after several notable RHIOs ran out of money last year and shut their doors. RHIOs are considered the foundation for a national health information exchange.

Mellin said many of the RHIOs that failed made the mistake of accepting large grants to get projects up and running without first building support for the projects from the people who would be using the exchanges and contributing to their long-term financial success. "Money can't buy you social capital, but it can trick you into thinking you don't need it," he said.

In another address, Kelly Cronin, director of programs for the Dept. of Health and Human Services' Office of the National Coordinator for Health Information Technology, said 91% of RHIO operators said having a sustainable business model is a major challenge, up from 88% in 2006.

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IT's unintended consequences

For all the stories about the paper-based doctor opposed to technology who later became a fan, there are just as many doctors who become so dependent on new technology that they are unable to do their jobs the old way, even during times of outages.

Experts brought together at the HIMSS 2008 conference in Orlando, Fla., in February say overdependence on technology is just one "unintended consequence" of adopting new technology.

While new technologies come with the promise of streamlined care and improved quality, few who adopt them are truly prepared for the disruption to work flow, the negative emotions from staff or the glitches that come with not fully understanding how the technology works.

Lyle Berkowitz, MD, director of clinical information systems at Northwestern University's Feinberg School of Medicine in Chicago, said that after a successful implementation, his practice soon learned that because of the broad range of categories in which data could be filed, it was nearly impossible for physicians to search for specific information related to past patient visits. After several months, the practice had to revamp its system to create several, more specific, data categories.

For Pamela Griffith, RN, director of application systems for the University of California, Irvine Medical Center, the power struggle that followed that hospital's EMR implementation was an unintended consequence she wasn't prepared for.

She said the system's ability to track productivity by department resulted in departments comparing their productivity to that of their counterparts in other departments. The nurse staff also refused to write back orders after outages, insisting that it was the doctors' job.

Blackford Middleton, MD, MPH, who heads clinical informatics research and development for Partners Healthcare in Boston, in his HIMSS address cited a September/October 2006 Journal of the American Medical Informatics Assn. article regarding the most common unintended consequences of information technology:

  • Extra work for clinicians.
  • Unfavorable work-flow issues.
  • Never-ending system demands.
  • Problems related to paper persistence.
  • Untoward changes in communication patterns and practices.
  • Negative emotions.
  • Generation of new kinds of errors.
  • Unexpected changes in the power structure.
  • Overdependence on the technology.

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