The eHealth Initiative recently released its Fifth Annual Survey of Health Information Exchanges at the State and Local levels.   In this survey we are starting to see the clinical benefit of interoperable clinical systems.    More than 130 HIE initiatives are in progress with 42 of them reporting to be operational. 

The biggest reported reasons for implementing an HIE are improving quality (97%) and patient safety (90%) with the biggest challenge being developing a sustainable business model. 

The big news in this survey is the positive clinical and financial benefits being reported by the users of the system.  69% of the fully operational exchanges reported a reduction in health care costs.  The savings were attributable to reduced staff time, reduced redundant tests and decreased cost of care for chronic patients.  More than half of the exchanges reported positive impact on the delivery of health care.   Major benefits were increased access to lab results, improved compliance with chronic care and prevention guidelines, reduced prescribing errors and more rapid identification of disease outbreaks – something critical to our public health clients. 

The bottom line was that 69% of the operational exchanges reported a positive ROI.  This is the first survey in which a majority of the participants reported a positive ROI.

When designing the content of your electronic health record, you have lots to think about. I've just written about data format decisions with some examples.  Databases also permit you to place rule-based controls around Clinician use of options and fields in the EMR. These tools protect data integrity by preventing unauthorized input and protecting content from modification. They help ensure that Clinicians are capturing the same sorts of information and that you are getting the information your organization must have. An effective controls strategy enforces desired content while minimizing the inclusion of inappropriate and unnecessary data. The type and extent of controls also implement your organization's goals and policies.

In other words, they are a very useful set of functions in your design toolkit. Now, what do I mean by Controls?  Here is a list of some with examples:

·    Define access to options and fields as for input or "read only"– Denying input access to finalized forms protects the integrity of the content and of accountability. Denying access to (disabling) a time field that auto-fills with the current time prevents fudging the time vital signs were recorded.

·    Make fields required or optional for filing. Required fields ensure completeness and consistency. Optional fields invite the addition of relevant information in consistent formats.

·   Use event logic e.g., "If this response is selected, then this will happen." If the required item “Pain Present Y/N” is clicked “No,” then the initially disabled fields for Intensity and Location remain disabled, preventing extraneous data. If  “Yes” is selected, then the Intensity and Location fields become enabled and required, ensuring compliance with organizational policies about assessing pain in all patients.

Hopefully I am giving you the idea. This document shows more examples of Controls with Avatar screen shots.

I realize that I jumped right in writing about EMR design. Without thinking, I just assumed that you would choose to develop content for your EMR that was customized by and for your organization. Obviously, you can opt for using an Off the Shelf solution. Let’s back-up a step and look at the pros and cons of content customization.

First the cons: these boil down to time and money. As I wrote earlier, content design is a team effort. It takes many meetings of a diverse staff group to develop a good design. (At UBHC the design workgroup had 29 members who met for a 1/2 day per week for three months.) The staff time costs money. There is no way around that. Also the time involved may extend your implementation schedule. Though this extension is not inevitable if you start the design task early. You can begin even before you select the Electronic Health Record application.

The pros boil down to facilitating staff buy-in and getting a better EHR, one that really reflects the information needs, workflows, clinical culture and policies of your organization. These issues are especially relevant to behavioral health organizations where humanistic values are high and industry standardization is low relative to physical health.

In my experience, leaders of EMR implementations define their greatest concern to be staff buy-in; so why pass-up the primary opportunity to engage clinical staff. I also have seen that those organizations, which began with an Off the Shelf approach, were invariably dissatisfied down the road. They turned to customization and then had to face the more difficult task of retrofitting their new information flows to accommodate what they already had in place. At UBHC the initial design remains sound eight years after the implementation.

So, is customization worth the effort? Clearly, I think it is.

As you already know from a previous blog, I favor defining firm, challenging timelines in an EMR implementation.  These create intensity, momentum and discipline.

In his latest management book, John P. Kotter describes the paramount importance of people within an organization having "A Sense of Urgency." (Check out below a brief presentation of his concepts.) In part of the book, he focuses on the importance of engaging employees emotionally in a change project.  He cautions that a well-devised plan arouses little urgency in an organization. He goes on to explain that human brains are programmed much more for stories than for abstract ideas. He tells of using stories to create an mind/emotion understanding of the risks to the company and the employees should they not move forward.  

In my psychodynamic therapist hat, I know that intellectual insight alone does not bring about change. The mind content needs to be directly linked to an emotional experience for an "Ah Hah!" to happen.


I’m going to revisit my presentations to try for less PowerPoint and more stories.

When planning an EMR implementation, don’t be afraid to set brisk timelines and be sure that deadlines are known to be firm.

Peter F. Drucker, the greatest (in my opinion) of business management gurus, wrote that to do their best work people must have an optimum amount of challenge. There should be enough challenge so they must push themselves and can then feel pleased with their accomplishment, but not so much as to overwhelm and demoralize them.

In my experience of a very challenging EHR implementation timeline without any wiggle room, the pressure of the deadlines focused the efforts of all involved.  In the large, inclusive workgroups there was no time for old rivalries and territoriality. Compromises had to be made, so decisions could be reached and the process could keep moving. Tight deadlines permitted the building of momentum and of enthusiasm for the tasks.  In the context of group process under the watchful eye of top management, no one wanted to be identified as an obstructionist. At the same time the process itself must be open and creative as well as disciplined. There are always legitimate competing interests and needs. The issues must be wrestled with until good enough solutions are found.  Keep in mind that an EMR is not a final masterpiece. If anything it is a living entity in that it will be made to grow and change building on the experience of the uses. 

By the way, we met our deadline to the day, and I still feel proud of it years later.

Let’s look again at the article on EHR implementation in the July 3rd issue of the New England Journal of Medicine. It presents a survey done in late 2007 and early 2008 of nearly 3000 physicians in outpatient medical practices nationwide. I discussed in my last blog the results showing that just 4% had extensive electronic records systems in their practices, and 13% had basic systems.

The survey asked respondents to identify the barriers to their moving from paper to an electronic health record. Unsurprisingly, the most frequently mentioned barriers were financial, namely the amount of capital needed and uncertainly about return on investment. The size of the capital investment is a straight up problem. Governmental policy makers, insurers and vendors are all exploring solutions in various brews of requirements and inducements as fit their areas of authority and self-interests. For example,legislation was recently proposed calling for a national inter-operable electronic health record (EHR) system. Some sources consider the proposed legislation could be used as a back door approach to force doctors and hospitals to implement EHRs.

Since you are looking at this blog, I assume you or your organization are at least thinking about implementing an EHR. If funding is currently an insurmountable barrier, you can still begin preparing. Learn more about the benefits others have gotten from EHRs. Think about the areas of greatest inefficiency or communication failures in your organization and how the problems could be addressed by improved processes assisted by an EHR infrastructure. Think about the impact on the organization and the barriers and resistances.

It's not too early. A successful EHR implementation begins in the minds of the leaders.

As to Return on Investment, I'm going to write some thoughts on that one in the next blog.

We’ve looked at three groups of clinicians, their attitudes and needs and potential motivation for moving to an EMR, but what about the managers?  They too are not a unitary group.  Top-level managers are presumably willing, as they have made the initial decision.  Hopefully they will have grounded their decision in an important strategic goal of the organization, rather than in response to external pressures or popular trends. They are probably eager for the greatly improved operational control managerial reports can provide.  Even better for them, they likely won’t be entering any of the data on which the managerial information is based.  They will, however, have to accept the scope of the task.  They will have to budget the funding, confront the resistances and allocate the resources for the implementation.  They will have to be open to the recommended changes which should result from the content design and workflow revision stage. They will have to be patient with stumbles and protests, but not too patient – more on this on this last later when I write about the crucial role of top leadership.

Mid and lower level managers may or may not be willing.  They too have to face the resistances while being closer to the resisters and to figure out how to accommodate the demands of the implementation on their local resources.  An effective EMR implementation involves clinical staff in content design and in training. In my experience the clinical program managers feel the most pressed regarding the time it takes to accomplish these tasks well.  They may want to reduce the time of the training sessions or suggest that staff be trained informally on the job. They must be engaged around the value of line clinician input and thorough preparation.  Also top managers must support line managers and clinicians by considering the necessary training time when reviewing productivity standards during the implementation.

Managers at all levels must work together to create an workable balance between the ongoing needs of the operation and the requirements of a well-executed implementation.  It calls for flexibility, discipline, imagination, fortitude and a sense of humor – the list could go on, but you get the idea. This all may sound rather dreary. It is certainly a challenge, but I found it to be energizing and with a good team it was even fun.  

In my last two blogs I’ve presented my ideas about implementing an EMR with three groupings of clinicians in mind. First we covered the “Excited” but impatient, then the “Willing” but concerned and skeptical.  Now let’s focus on the “Frightened” and again ask:

·       who they are?

·       what is their attitude to computers?

·       what does their motivation look like?

These clinicians are definitely mature. They have no kids at home and are less likely to have embraced new technology. They’ve had long professional careers and been at their organization for years. They are settled into established roles and methods in their work.  They may be eying their pensions and counting the years to retirement.  They are the elders of the community whose wisdom and experience bring such value to a clinical team.  They are computer naïve, intimidated.

When faced with the move from paper to computer, their initial response will probably be resistance, as they share the Willing group’s concerns about computerization diminishing the work and disrupting functional routines.  They may also present as grumpy.  Beneath these reactions, they are mostly worried they will look dumb and feel embarrassed as they learn. Some will fear they will never be able to master the machine.

These organization elders must be approached with great respect and sensitivity.  They must be extravagantly supported.  One-to-one on site tutoring is a frequent plan.  Training in a peer group setting by a peer rather than a whippersnapper preserves dignity and creates support. Use your ingenuity to help these clinicians become less anxious about giving the EMR a try.  My favorite success vignette is of a psychiatric elder who in the beginning protested mightily about computerization. After personalized training, he was so delighted and energized by his mastery of the software that he evolved into an enthusiastic local champion.  So rewarding for both of us.

Please share any tips and happy outcome stories you may have. 

During this electrifying political season, there is a flurry of attention being given to Electronic Health Records. Nationwide implementation of  EHR’s is a core component of candidate plans to reform the American health care system. The main reasons put forth include to save money, reduce medical errors, avoid redundant testing, identify previously ineffective treatment,  and provide access to current medications from any point of care.   The media is high profiling phrases such as “interoperability,” “RHIO’s” and “Personal Health Record (PHR).”

Adding to the intensity of the EHR discussion, the federal government is proposing penalties for EMR non-adopters. Our largest technology companies, namely Microsoft and Google, are charging into competition to capture the hot property of the PHR.

Some of the enabling technology for these high level goals is in place. Some crucial components are not. What are the providers of healthcare to do? More particularly, how can those contemplating software for behavioral health, addictions, MRDD and public health approach the question of why should they embark on such an undertaking? Here is my thought. To borrow a saying:

Plan globally and for the future………Act locally and for the present

An organization’s top planners must be aware of the national vision and policy trends concerning EHRs. They must be informed about technology trends. Only then can they define their own plans and make decisions. For example, they should not cast their lot with a vendor which cannot demonstrate its ability to lead or at least keep up with technical developments over the long haul.