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.

A recent article reports findings that uncertainty about Return on Investment (ROI) is a significant barrier to the adoption of Electronic Health Records. In my last blog, I introduced a monograph, “Measuring the Business Value of IT Investment,” by Craig Symons. He believes that financial measures are not enough when making decisions about IT investment.  In that blog, I presented his view about the lack of precision inherent in the financial measures.

Symons further describes that IT investments often provide intangible benefits which are hard to measure and so are left out of financial measures. Let’s think from the clinician’s perspective: No more trips to the record room; no more searching through pages of lab results for the crucial information or struggling to read months even years of hand-written progress notes to get the big picture of what is going on with a patient. (FYI I worked mostly with schizophrenic people who had long often-complex histories.) Confider that such delving into a difficult case would likely not occur at all with a paper chart because the process is so cumbersome and time-consuming. A well-designed EHR also provides decision support tools and links to the universe of knowledge on the Internet.

Symons also notes that IT investments produce not only immediate benefits but also provide opportunities for future benefits.  Consider the benefits to quality and cost of care in the potential for communicating with other providers. There is also the exciting opportunity to bring web-based interactivity to the patient-provider relationship.

Seems that the intangible and potential benefits truly deserve a place when thinking about an EHR implementation. 

Yet another look at the article on Electronic Health Record implementation from the New England Journal of Medicine. It presents a survey of nearly 3000 physicians in outpatient medical practices nationwide. The results showed 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 moving from paper to an electronic health record. The second most frequent response after cost was uncertainty about return on investment (ROI).

ROI is a commonly used formula-based numeric measure, but it is not as straightforward as one might think. Sure maybe you can project a definite positive ROI before the fact. The EHR implementation I managed at UBHC was in the black after the first two years thanks to bringing all billing in-house and discontinuing all transcription services. But such initial cost-saving opportunities may not be available to your organization. Your situation may be unclear. Time to pause and think about the place of ROI in IT decision-making.

Using ROI as a factor in decisions about an EHR is problematic. As Craig Symons states in his monograph “Measuring the Business Value of IT Investment,” purely financial measures such as ROI imply a precision that does not exist. He describes that the calculations used in the measures are based on estimates of benefit, which in turn are based on assumptions. So the accuracy of the calculated ROI is only a good as the underlying assumptions. He presents other shortcomings of purely financial measures, which I’ll touch on soon.

Symons presents several alternative approaches to evaluating IT projects. Have a look.

These are exciting times for electronic prescribing. We have definitely entered and are playing in the political arena’s sandbox. And so far, everyone seems to be playing well together. As I mentioned in an earlier blog, on July 9, 2008 the Senate approved a Medicare bill that, among other things, will provide financial incentives for physicians to use electronic prescribing. The bill is called the Medicare Improvements for Patients and Providers Act of 2008 (HR 6331). According to the bill, physicians who use electronic prescribing for their Medicare patients will be eligible for incentive payments of 2% in 2009 and 2010, 1% in 2011 and 2012, and 0.5% in 2013. Doctors who do not use electronic prescribing by 2012 will see a pay cut of 2%.

 

A major part of the bill was a halt to a scheduled pay cut of 10.6% to Medicare physicians. The President vetoed the bill stating that he supported rescinding the pay cut, but objected to the way lawmakers would finance the plan, largely by reducing spending on private health plans serving the elderly and disabled. However, the Senate voted 70-26 to override a presidential veto of the bill and the House voted 383-41 to override it.

 

To listen to a podcast discussing the Medicare e-prescribing incentives and what e-prescribing is all about, go to http://prwebpodcast.com/releases/pod1105664.htm.

Have you heard?! On Wednesday (July 9, 2008) the Senate approved a Medicare bill that, among other things, will provide financial incentives for physicians to use electronic prescribing. The bill is called the Medicare Improvements for Patients and Providers Act of 2008 (HR 6331). According to the bill, physicians who use electronic prescribing for their Medicare patients will be eligible for incentive payments of 2% in 2009 and 2010, 1% in 2011 and 2012, and 0.5% in 2013. Doctors who do not use electronic prescribing by 2012 will see a pay cut of 2%.

 

Another part of the bill halts a scheduled 10.6% Medicare physician pay cut. Although the President has threatened to veto the bill, it was passed with enough votes to override a veto, paving the way for it to become law.

 

For the electronic prescribing community, I think this is the best thing since sliced bread. I think it’s great the government is providing incentives for using technology rather than punishment for not.

 

For those still not convinced of the return on investment of using an e-prescribing system, these incentives certainly should help.

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.

As we discussed at the Executive Symposium at Netsmart Connections, Netsmart has been working hard in Washington with several other groups to get Congress to provide incentives to providers to adopt e-Prescribing.  Last night our efforts were rewarded when Congress passed legislation as part of the Medicare bill.  

This legislation provides a 2% incentive for physicans who use e-prescribing.  For those of you using InfoScriber already please review this legislation to make sure you are prepared to capture the extra revenue.  For more information take a look at the story at HealthCare IT News.   For those of you considering it, this helps increase the ROI of integrating it with your Avatar, MIS or Insight electronic health records.

As many of you may have heard, there is a new Medicare/Medicaid law that is scheduled to go into effect January 1, 2009. (Actually, it’s an existing law that has been deferred until now.) The law states that prescriptions cannot be faxed directly from any e-prescribing application (like InfoScriber) to a pharmacy’s fax machine. Rather, if the prescriber wants to fax a prescription to a pharmacy, he must first print it and then manually fax it to the pharmacy. If you’re scratching your head at this point in disbelief, join the gang. It seems like a step backwards. The intent of Medicare is to get prescribers to send more prescriptions via eRx and not by fax. This intent, I believe, while noble, is impractical.

 

To make matters worse, in response to this upcoming law, it appears that some major pharmacy chains like are beginning to change their fax lines to tie into their main telephone switchboard lines and require users to press a button to choose to fax. What this does is prevents electronic prescribing applications to fax directly to a fax machine (i.e., it will now require human intervention to know what number to press based on each pharmacy’s menu options).

 

If you are using an electronic prescribing application that currently faxes directly to fax machines, you may begin experiencing increased fax failures.

 

In response to these changes, we encourage you to send your prescriptions electronically whenever possible and avoid faxing. When you do have to fax (eg, controlled substances, etc.), it may be necessary to print out the prescription and manually fax (depending on the pharmacies to which you are sending).

Some exciting news came out today that will positively affect our world of e-prescribing. The nation’s retail pharmacies and leading pharmacy benefit managers (PBMs) today announced a merger of the country’s two leading health information networks.

 

The groups have merged two organizations: RxHub, founded in 2001 by the nation’s three largest PBMs – CVS Caremark Corporation, Express Scripts, Inc. and Medco Health Solutions, Inc.; and SureScripts, also formed in 2001 by the National Association of Chain Drug Stores (NACDS) and the National Community Pharmacists Association (NCPA).

 

Their press release states that the organizations will consolidate their operations, forming a single, secure, nationwide network for e-prescriptions and the exchange of health information.

 

RxHub’s expertise in patient identification and delivering drug benefit information to the physician at the point of care complements SureScripts’ focus on electronic prescription routing from the physician’s office to the pharmacy. The merger combines these strengths with a shared focus on more access to patient medication history to form a single suite of comprehensive services. Among other things this merger will allow prescribers to transmit electronic prescriptions and renewal requests to both retail and mail-order pharmacies. E-prescribing is on the move!

While there has been much discussion in healthcare policy and political circles as well as media buzz about Electronic Health Records, the actual implementation of EHR’s in the U.S. remains low.  An article in the June 18 New England Journal of Medicine cites a survey done in late 2007 and early 2008 of nearly 3000 physicians in outpatient offices nationwide. The results show that just 4% had extensive electronic records systems in their practices, and 13% had basic systems.

There are lots of details in the article. Here are some highlights regarding usage. There were higher levels of EHR use by younger physicians and those who worked in primary care or large group settings. Interestingly,  providers serving higher proportions of minority, uninsured or Medicaid patients were not significantly different in their EHR adoption than other physicians. Also adoption was higher in the Western section of the country.

Happily, a large majority of the physician users were satisfied with their systems – 93% for fully functional system users and 88% for basic system users.

Among the 83% of respondents who did not have electronic health records, 16% reported that their practice had purchased but not yet implemented such a system at the time of the survey. An additional 26% of respondents said that their practice intended to purchase an electronic record system within the next 2 years. So, many practitioners are on the path to implementing an EHR. It is not too late to be a leader in your field and in your community by joining this group.

Supporting NCCBH in Washington

Last week I attended the NCCBH Hill day in Washington, D.C. to lobby on Capitol Hill for legislation that supports the mental health community.  We addressed many issues effecting the industry (a list of the agenda we addressed can be found at the National Council for Community Mental Health website), but I particularly focused on one that effects the users of our Electronic Medical Record systems:  The Support the Community Mental Health Services Act (H.R 5176/S. 2182).  

This act addresses the need to provide funding to co-locate primary care/chronic care services at CMHCs; to integrate treatment for co-occuring mental heath and substance abuse disorders; to provide funding for workforce recritment and retention; to enhance behavioral health eduction and training; to provide funding for telepsychiatry and patient education; and finally one that directly impact users of electronic health records, psychiatric software, and medication management systems.  This final measure would require the Secretary of HHS to collaborate with the Office of the national coordinator to develop a plan to ensure that components of the National Health Information Infrastructure address the needs of behavioral and substance abuse providers.  

I met with Senator Hilary Clinton, Senator Charles Schumer and Congressman Steve Israel and got very good response from all offices.  We requested that they co-sponsor the legislation and endorse it.  I recommend that each of you communicate with your local legislators and request the same.  It is easier than you think.   

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. 

When/Will Consumer Directed Healthcare Impact Behavioral Health?

At Netsmart Connections we spent time talking about the trend toward consumer centric care and involving the consumer in the care process.  We discusssed consumer portals that provide consumers with access to their electronic health record and medication histories.   

As part of that discussion we looked at how the cost of healthcare is impacting the US economy and several changes to the system that are being proposed to address the problem.  Yesterday I had a conversation with Ryan Daniels from William Blair, Netsmart's investment banker.  I have attached two of Ryan's market analyses (his 2007 and 2008 updates on the CDHC impacts to the healthcare provider markets) in which he looks at how Consumer Directed Healthcare (CDHC) is or will be affecting the primary care marketplace.  Although these reports look at primary care primarily, he does speak about how some behavioral healthcare providers are well positioned going forward because they are less dependent on government funding.  This does not apply directly to many of you, but is a trend worth following as we often see funding approaches that are first tried on the primay care market work thier way into the behavioral health markets.

The question to be discussed is if and/or when this trend will impact behavioral health and public health.  I have had several discussions down in Washington as to how these trends will impact the medicaid and indigent populations and I have gotten several different answers:  1) it wont; 2) they will be treated differently; 3) thier HSAs will be managed by someone for them.   It is not clear where this is going, but it is a trend very much worth watching. 

If anyone has any input please contribute to the group.