On November 12^th, Senator max Baucus gave us some insight into where healthcare reform in this country will be headed under the new leadership.  He published a white paper, Call to Action Health Reform 2009. 

In this document he laid out a plan that had three main goals:  1)  Ensuring health coverage for all Americans; 2)  Improving health care quality and value; and 3)  Achieving greater efficiency and sustainable financing.  In the white paper he discusses that we may have reached a tipping point where the main stakeholders in the process – consumers, businesses, labor, providers, plans, manufacturers and state and local governments – cannot afford the cost increases and cost shifting any longer and are willing to engage in serious reform efforts. 

To achieve these goals he wants to set up insurance exchanges that allow all citizens to purchase insurance.  He would allow older citizens to “buy into” Medicare and lower eligibility to those seeking access to Medicaid.  This would increase the consumer volume for many of our clients. 

Key to his whole approach is an increased focus on quality of care delivered versus volume of care delivered.  I see payments in the near future tied to improving outcomes, or as it is known, pay for performance.  To achieve these measures he will increase incentives and investments in healthcare IT (something which President-elect Obama campaigned on).   In his press conference he discussed immediately allowing providers to be incentivized to implement electronic medical records by giving them the same 2% incentive that is now available to Medicare providers for using e-prescribing (see my blog e-prescribing incentives).

Obviously this is in the early stages of development, but I think the train has left the station.

Today I want to be less pedantic than I have been recently and have some fun. I've already written about John Kotter in my blog “A Sense of Urgency”. Now I have gone ahead and read his fable about change, Our Iceberg is Melting. It is about a penguin colony in Antarctica. A group of penguins live as they have for many years. Then one curious bird discovers a potentially devastating problem threatening their home. Initially hardly anyone listens. The fable tells about resistance to change and how dramatic change was successfully brought about. The characters are familiar in our own lives and work. You can even decide which character in the drama describes you best.

Kotter believes in the power of stories to communicate important ideas with emotional impact. Read this story. Share it with others on your team. Talk about his Eight Steps and how to accomplish them in your electronic health record implementation. There is even a website with more tips and, of course, materials for sale.

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.

The economy is capturing the headlines lately and has been a topic of our strategic planning as well.  We have been looking at where we see the economic downturn impacting our clients and what they are doing about it.   We recently had an executive symposium with the CEOs of our Florida clients (one of the worst hit states) to see how they were handling state budget cuts, and I just returned from California where I attended the SATVA member’s meeting where the economy was a topic of interest. 

The result of these discussions is a dichotomy.  On the one hand, the states are looking at huge budget deficits (approximately $50B this year, with rumors of $100B next year).  On the other, Medicaid dependent providers typically weather a downturn better than non-Medicaid providers.   Some states are raising eligibility requirements to try to manage their costs, but at the same time the Congress is working on a stimulus package that is rumored to contain an increase in the federal share of Medicaid dollars to pump money into the states which should benefit behavioral and public health providers.

In our Florida discussions we saw that progressive providers were looking at ways to help their state (and themselves) through the budget crisis.  They talked about finding areas where the state was having problems (for example in the prison population where they offered to provide services directly in the prison versus having to move the prisoner into an inpatient unit).   Several of them were affiliating with primary care providers or FQHCs to provide a medical home to the consumer while at the same time being able to contract their staff to the FQHC to share costs.   It was encouraging to see the creative strategies being developed.

I am interested in hearing what your agency may be seeing and/or doing about the economy so that we can share your best practices with other clients.

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.

Now that I have just advocated for EMR content customization, let’s return to content design. This is my favorite part of EMR implementation. I wrote earlier on educating the clinician members of your design team about databases. Next they need to understand the different data types available for capturing information and the implications of data type decisions. 

The most important distinction is between free text and dictionary-based data types. Everyone is already familiar with the notion of typing ongoing text. Similarly, most people have encountered check boxes on forms, e.g. medical histories attached to clipboards in doctor waiting rooms. Clinicians are comfortable with creating narratives as part of clinical histories and other documentation. Indeed I have seen several behavioral health EHR’s that consist entirely of textboxes for entering the organizations’ usual narrative content. Such EMR’s are essentially electronic paper, but what a waste! Among the advantages of an EMR are efficiency, standardization and aggregated reporting.  None of these is achieved using narrative textboxes.

But deeper issues lie beneath the type or click choice. Clinicians think of the clinical history as the patient’s story. I heartily agree with this. Effective treatment is grounded in understanding the story of the person’s problems and suffering. At the same time, the story includes numerous individual pieces of information, for example, past substance abuse, the presence of a firearm in the house, sexual abuse by a family member rather than a stranger and a parent who committed suicide. Such salient features of client stories, alone or in combination, can serve to trigger alerts about individual risk. They can help supervisors and administrators identify and monitor the care of clients with a defined set of problems. Aggregated, they can guide managers to unmet service needs.

Likewise, a case summary can be a text formulation and/or lists and measurement scales. The former presses the clinician to integrate an explanatory narrative that justifies an approach to treatment. The latter asks the clinician to abstract specific problems and strengths, to assign a diagnosis and to quantify patient attributes in various domains. The narrative facilitates reflection and understanding. The lists and scales sharpen focus and enable accountability. Aggregated lists and scales can help address important questions including about outcomes, efficacy and best use of resources.

Likewise with progress notes and so on. Now what of the original question – to type or to click? The answer is to do both in artful, disciplined combinations. In my next blog, I’ll give some examples of such combinations, which I hope will be artful and disciplined or at least useful. 

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.

So often when I am giving demonstrations of our e-prescribing software, I am asked questions like “can it do this,” “can it do that?” Many times the question goes something like this, “If my patient is a 29 year old female with brown hair and long fingernails and I am considering prescribing a medication that will turn her hair purple, will it tell me that the patient doesn’t like purple hair because she can’t find purple nail polish?” My response: “Um…er…hmmm…well…no. It won’t do that.” Then I go on to ask “How do you know that now, that your client doesn’t like purple hair?” They respond, “Well, I have to ask her.”

Okay, so I’m being a bit outrageous, but I hope you see my point. Technology is wonderful and it can do many, many things. However, there is a point where clinicians need to be clinicians and use their training and skills. It takes many years of education and training to become a physician or other type of prescriber. If technology could do everything, including think and made clinical judgments on behalf of the physician, I suspect more people would become physicians.

Society has always had and continues to have great respect for physicians for their expertise in keeping us well. I doubt we’ll ever have (or want to have) that much respect for a computer application.

The content of an EMR captures data to serve many masters. These include payors, regulators, accrediting entities, researchers and the organization’s managers. Most of all, however, it must serve the work between client and clinician. In my previous blog, I wrote about the need to recruit a workgroup of clinicians with a broad array of clinical skills and homes. Then what? Well, the next step is to educate them about the technical underpinnings of the project, namely about databases.

In my experience the early leadership in software implementations comes from IT professionals. So, since you are reading this blog about electronic medical record implementation, I assume that you are probably pretty computer savvy and technically informed.  But let me plead with you to assume that the clinicians on the design workgroup are neither. Sure they email, write documents, Google and shop online, but most likely they do not understand what a database is. Since clinical documents are one of the main EMR outputs, they think that the EMR is some sort of giant MS Word document.  Thus they make comments such as “Why can’t you spell-check the whole thing at once?” and they expect to read the clinical information that has been entered by accessing the inputs screens rather than by viewing a report.

When considering data capture and, especially, information flow it is essential for the designers to grasp the database basics: that information is captured in various data types in input screens and stored in columns and rows in tables and that reports pull the information from any available table.  

I have shown many clinicians this simple database schematic. The frequent responses have been as if it were a revelation. They told me that now they “got it;” that they felt enlightened and empowered; and that they were eager to get going on the design task. And all it took was about half an hour. 

As I wrote last time, when you are designing the content of an EMR you have to consider the dimensions of clinical culture, information flow, specific data capture and the use of controls. Good design also means finding solutions to meet the often competing needs of clinicians, management and, yes, the software.  It’s a complex process. I don’t claim to have all the answers, but over the past eight years as EMR implementation manager and then consultant for Netsmart Technologies, I have struggled extensively with the issues. 

First and most importantly, as the project manager for the implementation at UBHC, I did not struggle alone. We cast a wide net to recruit a workgroup of 30 members. The members were supervisors and line clinicians from all disciplines and levels of care as well as the leaders of all stakeholder departments. Here is a list of the participants if you want more details. Our charge was to design the structure and content of our electronic health record. We met for half a day a week for three months. The learning curve was steep. (more on workgroup education next time) The process was intense. The turf issues and, shall I call it, specialty narcissism were very much present. Together they created the major threat of “Content Creep.” This is a situation in which Staff want the details of their specific domains included and in their customary formats. The back-and-forth process eventually made it clear that to accommodate this range of domains would result in content that was too lengthy and complex. The phrase: “That item means 100,000 clicks per year…Is it worth it?” became a regular refrain.

By the time we were done, the participants had had the opportunity to understand the needs and concerns of wide range of functional areas and all LOC.  They were then able to make recommendations based on detailed knowledge of the information needs in balance with the realities of staff time and the software. The focused group process was powerful in setting the stage for the necessary compromises. Patience and determination were essential to discovering the solutions.

 So get your clinical leaders and line clinician “best minds” together and jump in. You don’t have to wait until vendor selection is complete. You can begin the content analysis and struggle now. They are generic.

So far I’ve written mostly about reasons and motivations for implementing an EMR. I’m feeling restless to get going with doing it, so I’m going to skip ahead to thinking about the design of your EMR.  I picked design because of the challenging article by Drs. Pamela Hartzband and Jerome Groopman I wrote about in my last blog.  In the article they described the risks of clinicians going brain dead (my word) while filling in standardized forms and templates.  They ardently support what they call “Thinking” medicine and called for the EMR to work for the clinician and not the other way around.  So do I. It is the main reason I decided to morph from practicing psychiatrist to EMR implementer.

The challenge for the content designers is that they themselves not go brain dead. This would look like them just assembling items and pick-lists based on requirements of payors, accrediting entities, states, their own management and so forth. Of course, these various data-masters must be satisfied.  But the designers must also think deeply about how to use the technology to help the clinician capture the essential story behind the patient’s presenting problem(s) and then abstract a formulation that leads to a plan.

There are several dimensions to consider in the design process, including clinical culture, information flow, specific data capture and the use of controls. There are irreducible tensions among the needs of clinicians, management and, yes, the software.  The trick is to find a sensible balance with support of the clinical work as the highest value. I’ll write more about finding the way in upcoming blogs.

Design is as complex as it sounds, but do not be intimidated. The very good news is that software development is never completed. It evolves as you learn from experience and user feedback and as new functionalities become available. Also it is great FUN to be a creator of software and not just a consumer.

I recently wrote about the concern of clinicians facing an EMR implementation of losing their professional autonomy. This concern came to mind as I read an article entitled “Off the Record -  Avoiding the Pitfalls of Going Electronic” co-authored by Drs. Pamela Hartzband and Jerome Groopman.  In the article, the authors rightly worry that the capacity to manipulate the EMR make it far too easy for trainees to avoid taking their own histories and come to their own conclusions about what is wrong with the patient. (This slippery slope, of course, applies to physicians in independent practice as well.) For me the exploitation of these capacities also speaks of the temptation for professionals to take shortcuts and thus to collude with the economic pressures of the current healthcare environment and abdicate their professional obligations to their patients.

The authors cite the glut of raw data not digested into relevant information; the practice of clinicians copy and pasting (essentially plagiarizing) from others and from their own previous content. They cite their experience that templates invite voluminous, unfocused notes, which may be efficient but not conducive for creative clinical thinking. As they note, writing forces us to think and formulate our ideas.

They observe that EMR’s can become a vehicle for perpetuating erroneous information that gains momentum when passed on electronically. In my 25 years practicing psychiatry, I often saw the written chart do the same disservice as clinicians uncritically accepted previous diagnostic formulations. Though the accessibility and interoperability will amplify this woeful practice.

They believe that the most disturbing effect of the technology is that it diverts attention from the patient during the 15 minute clinic visit. Surely the EMR is not the primary culprit here. Consider the time constraint itself plus the payor’s documentation requirements and possibly an inadequately trained and inexperienced user.

My overall and, admittedly somewhat defensive, response is that an EMR is neither an ethics auditor nor a supervisor. Nor can the technology be blamed for inadequate content design. I too am ardently concerned with the trends towards protocol driven, time-compressed, technology focused healthcare. However, I view the poor use and outright misuse of the EMR more as an enabling result than a cause.

In conclusion Drs. Hartzband and Groopman write “Practicing ‘thinking’ medicine takes time and electronic records will not change that. We need to make this technology work for us rather than allowing ourselves to work for it.”  Yes, indeed.

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.

The short answer to the title question is: everywhere. One definition of corporate culture is "How we do things around here.” It is the collective behavior of people using common corporate vision, goals, shared values, beliefs, habits, working language, systems, and symbols. It is interwoven with processes, technologies, and learning. A successful EMR implementation necessarily impacts all these domains.

In the late 90’s my home organization, UBHC, was being transformed from a community mental health center to a managed care oriented corporation. This meant a dramatic change in corporate culture. An electronic health record was at the heart of this transformation. Here are some examples. Professional identity would be challenged as appointment schedules became centralized and electronic. Clinical information would become more standardized and monitored. Communication would move away from face-to-face, often group settings to electronic methods. There was new attention given to productivity and efficiency. The financial needs of the organization were now a necessary and valid priority, which required all staff’s participation.  Fiscal staff needed to respect the work of the clinician as the source of revenues and clinical staff needed to contribute in the effort to successfully bill services.

The EHR implementation itself became the main vehicle of this cultural change.  Leadership and inclusive process were the key elements. These will be the focus of future blogs.

Also among the clinicians an apt, tongue-in-cheek phrase emerged: “Psychotherapy begins at home.” By this they meant that the frequent psychotherapy themes of recognizing and adapting to change had now become their own challenge. It told a truth that was clarifying, but uncomfortable. 

An effective electronic health record implementation requires oodles of collaboration among every slice and silo of the organization. Ideally such collaboration would be a given. But all staff members are human beings who tend to develop identities and loyalties based in shared relationships and experiences. In other words, locally. Enter turf as a perennial resistance to the change that comes with the move to an EHR.

At the time of our EMR implementation, my home organization had been in operation for more than 25 years. Many of the staff had been there for > 10 years. Place and people already had a long history together.

Factional divisions were plentiful; blaming the other was usual.  Many staff groups believed that their function was the crucial operation and that other functions existed to service their operation's needs.  There were adversarial relationships between programs.  For example, Inpatient staff thought a hospitalization was central to the treatment and that they could more properly diagnose and treat a patient based on their 24/7 observation. Outpatient staff, meanwhile, believed a hospitalization was a disruption in care and that they better understood the patient because of long-term contact in the natural setting.  Then there were fiscal staff who thought clinicians were too lazy to do correct documentation for billing, while clinical staff saw fiscal staff as lacking compassion. … and on and on. I’m sure there are 100’s of choice examples out there.

So what to do?  My condensed answer is to get them in a room together, give them a task and a strict timeline and tell them they must be successful.  Details to follow.

A recent article in the New England Journal of Medicine surveyed 3000 outpatient medical practices on their use of an electronic health record.  Among the many results was the finding that nearly 400 of the practices had already purchased an EHR system, but had not yet implemented it. There are many possible explanations for this. I want to use the finding to segue to talk about motivation and the implementation leadership. (The leadership may be one or several people.  Both configurations can work, and these thoughts pertain to both situations.)

There are many, many elements necessary for a successful EHR implementation (or I wouldn’t have material for an ongoing blog), but the implementers’ determination and energy are the primary forces driving an implementation through to its completion.

The organization’s implementers have to face the resistance of staff, the scope of the task and the personal effort level involved. They will probably develop feelings, such as anxiety, anger, frustration and their own resistance, which may look like procrastination, over planning, even letting themselves be persuaded that an EMR just cannot work in their setting.

The implementation leaders need to discern a personally important mission in the EHR project to support the deep and steadfast commitment that is necessary. As I wrote here in an early blog, for me the mission was to make the electronic health record serve the clinical work. The passion for this mission still energizes me.  

I’d like to hear other people’s thoughts, feelings and ideas about the mission for EMR implementers.

E-prescribing is gaining more momentum than ever! I’m happy to report that the DEA has published a set of proposed rules for electronic prescribing.

On June 27, 2008 the DEA released its proposed rules for electronically prescribing controlled substances. Specifically, the document is titled “21 CFR Parts 1300, 1304, et al. Electronic Prescribing for Controlled Substances; Proposed Rule.” (http://edocket.access.gpo.gov/2008/pdf/E8-14405.pdf) This rule affects prescribers, e-prescribing systems, intermediaries, and pharmacies. When you look at the rule, you will see it is rather long and complex. However, a nice summary is found on page 36751 and the actual proposed rule starts around page 36769.

The DEA has established a comment period that ends on 9/25/08. I encourage everyone to take a look at the rule and participate in commenting. This is a rule that is going to affect us individually and collectively and we want to make sure our voices are heard.