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.

I have to admit...I somewhat expected this to happen...Medicare has extended the date on the banning of computer-generated faxed prescriptions for several years. While I know it's a relief for many prescribers, I have to say, I was somewhat looking forward to it. I thought it would be a great way for many prescribers to "take the plunge" and begin sending more prescriptions electronically. Of course, I'm a huge fan of e-prescribging.

So what is Medicare doing? CMS has extended its deadline for banning faxed prescriptions by three years, moving the Jan. 1, 2009, deadline to Jan. 1, 2012. The deadline change is included in the 2009 Medicare Physician Fee Schedule final rule announced by CMS on Oct. 30. According to a CMS press release, the agency reversed its position "in the interest of patient care and safety and to encourage prescribers and dispensers to adopt e-prescribing."

It's not surprising that several health organizations supported changing the deadline. For example, Steven Waldren, MD, director of AAFPs Center for Health Information Technology stated, “The Academy’s position was that the 2009 deadline would force some physicians to move backwards in their efforts to accomplish e-prescribing.” He stated that many EHRs have e-prescribing systems that fax prescriptions instead of sending them electronically.  Dr. Waldren went on to state, “…those physicians would have reverted back to paper-based prescriptions” if the deadline remained the beginning of next year.

The Pharmacy Health Information Exchange, operated by SureScripts-RxHub, maintains that sending prescriptions electronically versus fax is a much safer and more efficient way of sending prescriptions. E-prescribing offers proven benefits to physicians, including reductions in medication errors, reduced calls from pharmacies, electronic access to formulary information and external medication histories. In an effort to get prescribers to send prescriptions electronically, Medicare is offering its prescribers a 2% financial incentive beginning in 2009. If, however, by 2012, prescribers are not using e-prescribing, they will face a 2% pay decrease.

The entire 2009 Medicare Physician Fee Schedule final rule will appear in the Nov. 19 Federal Register.

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. 

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.

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.

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.

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.   

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.

External Connected Care

In my last blog entry I discussed Internal connected care.  To truly have connected care, internal connected care is the enabling technology to facilitate external connected care.  External connected care is the ability to share clinical data between disparate providers.  It allows a discharge summary to arrive at another provider before the consumer arrives to give the agency the consumer's diagnosis, active medications, reason for referral, demographic data and much more.  We call this new product CareConnect, and are using the evolving national standard called a Continuity of Care Document (CCD) transfer information between Avatar, MIS and Insight systems.  

Many behavioral health and public health agencies do not have the resources to Develop and maintain interfaces to various RHIOs and other providers.  The Netsmart CareConnect system will allow them to make a single connection to CareConnect and have Netsmart manage the interfaces to other providers and RHIOs.  Connecting care in this fashion will provide better service to the consumer by reducting potential medication errors and by reducing inpatient admissions by emergency rooms by providing the clinicians with the information they need when they need it.

We are continuing to define and extend the CCD to add behavioral and public health extensions.  At Connections a few weeks ago we had some discussions about these extensions.  Some preliminary ideas were to add components of a substance abuse assessment, a risk assessment and a suicide assessment.  What are your thoughts?

I recently had two useful pieces of information come to me that illustrate my thoughts on achieving user buy-in to an electronic health record.

 

One was a tip on blogging from our blog host. It introduced me to the acronym WIIFM. The tip reminded us that readers search for and look at blogs, asking, “What’s in it for me?”

 

The other information was told to me by a nurse turned techie/implementer in a large system with over 10 institutions. She described the implementations in two of their facilities. In one, the implementation focused on creating reports for the needs of the top managers. In the other, the implementation team created reports designed to meet the needs of the clinical staff. For example, they created a shift change document for nurses and a report showing treatment permissions coming up for renewal. She described that in the first facility, the implementation had a difficult time winning over clinicians. In the second facility, the clinicians had a much more positive attitude and the implementation went much more smoothly.

 

I believe WIIFM is an absolutely legitimate attitude for a CEO, a supervisor, or a clinician using an EMR. After all we’re talking about the relationship of a user to an electronic health record system It may be long-term but it is not an intimate relationship.  WIIFM is OK. So, implementers, ignore it at your peril!

 

I’d love to hear more stories about where WIIFM fits into your implementation.

Intenal Connected Care

When I think of Connected Care I think of it in three parts:  Internal Connected Care, External Connected Care and Consumer Connected Care.  Today I want to discuss Internal Connected Care.  When I talk about internal connected care I am talking about connecting what were previously independent silos of information in a healthcare organization.   For example, If you can integrate your schedulers, with your front desk, with your clinical staff and finally with your billing department you will make your organization more efficient.  If your system can connect the clinical process with the financial (i.e. require the correct progress note before a service is billed) you will reduce internal overhead.  We have heard repeated stories from clients who have increased their revenues significantly after implementation of an EHR because they were now cpaturing services, and billing for them, that had fallen through the cracks previously.

Yet internal connected care does not stop there.  As we strive to improve the efficacy and outcomes of the treatment provided, implementing electronic medication mamangement systems like e-prescribing and computerized physician order entry (CPOE) allows the clinician to check for adverse drug interactions and to reduce clinical errors caused by transcription or handwriting errors between the physician and the pharmacist. When you add document scanning and management to the mix, you allow the clinical staff to have the best quality information when they need it. 

Internal connected care is designed to increase communication internally to an organization, to remove friction from the process and to allow for the provisioin of the highest level of clinical care possible in the most efficient manner.

I would like to hear your views of internal connected care and how you have implemented systems that help provide higher quality care.

Computer Fluency of Users

Do designated users of the e-Prescribing application have basic computer knowledge? Experience has shown that users familiar with using a computer, whether at home or at work, tend to learn the application at a faster rate than those who do not. To accommodate staff members that are not computer-savvy, your e-Prescribing application should have an intuitive, user-friendly interface, and should offer as much consumer-specific data as is possible to the prescribing physician.

 

Nursing Staff

How many nursing staff will be using the system? What is their receptivity to adopting electronic prescribing? Nurses should be made aware that organizational efficiency may not immediately rise at the point of transition, but over time, e-Prescribing can greatly assist them in a variety of areas, including reducing the number of call-backs from pharmacies, eliminating the need to transcribe medication orders, and improving risk management efforts.

 

Hardware Setup

Does your organization have adequate computer and printing resources for the project to be successful? There should be a computer available for each prescriber to use during appointments. Computer monitors should be positioned so that it is not necessary for the prescriber to turn his/her back on the consumer to issue a prescription. Also, a printer must be stationed nearby to instantly produce prescriptions or collateral information. Experience tells us that the first thing users will complain about during the introduction of new applications is the hardware (e.g., “The printer doesn’t have ink in it so I can’t use the new program”).

 

IT Support

Do your information technology leaders and staff endorse the project? Are your IT specialists working on other projects concurrently? The effort required to implement new systems should not be underestimated, especially in a setting that will bring technology to the desktops of all clinic staff. Assignment of adequate internal IT resources is mandatory to assure project success. 

 

Current Consumers on Medications

How many of your active consumers are on medications? A typical estimate is 60-70% of active charts. Your organization will need to determine the most efficient way to input consumers’ current paper-based medication information into the new system. Many organizations use data entry to do this; but keep in mind that it takes an average of three minutes to enter each consumer’s current medication information.

 

Pharmacy Communication

Have you let all routinely-used community pharmacies know your organization will begin e-Prescribing?  Notifying pharmacies in advance will reduce the number of phone calls that may originate from inquiries regarding the new prescription formats (e.g., confirming authenticity).

 

In Conclusion

More and more behavioral health providers are adopting e-Prescribing as technological advancements and government regulations drive the healthcare industry towards wholly automated processes. Early experience indicates that the benefits of e-Prescribing are real, and by far outweigh the risks and costs of implementation. Transitioning to an electronic prescribing system requires a dedicated investment of your organization’s time, money and resources. Good planning and proactive communication with all internal and external stakeholders will help assure a successful implementation, which, in turn, will result in higher quality care for your consumers.

At a workshop a couple of years ago, a behavioral health executive contemplating an EHR implementation asked me, “How can I get my clinicians excited about this implementation?” My short answers are “Be realistic” and “It depends.”

Clinicians have different needs for information and a different relationship to an EHR than executives. Managers need information to lead the organization. I would also add that they do very little of the direct data input, so they get the benefit of the reports without much personal effort.  Not so for the clinicians who, along with support staff, are the main sources of the content being entered into the EHR. So what might get a busy clinician excited about an EMR implementation? Let’s think about this question from the point of view of salaried clinicians in a behavioral health organization.

Such clinicians are not much interested in organization finances, compliance and other executive concerns.  They too want information, but of a very different sort. They want an efficient method to capture relevant client history.  They would appreciate tools that could help them define the treatment and track progress. They need to communicate with themselves and with other staff treating the client both currently and in the future. Approaching these needs will be experienced as helping them do their core job, providing the best care they can for their patients. So far, so good.  Clinicians further need to capture data and document their work to satisfy all the various data masters of the universe, eg payers and accrediting entities. This is experienced as extraneous to their core job. (They feel grumpy about doing it and will feel grumpy about the EHR that ensures they do it.)  And, of course, they want EHR content to be easy to access and navigate.

If you are an implementer, don’t set yourself up for disappointment by expecting clinicians to be excited about the EHR implementation itself. Moving from paper to computer involves lots of changes for clinicians. A well-executed implementation is critical in getting the EHR off on the right foot. Do understand, though, that the long-term success of the EHR you are implementing depends on how well the system you deploy serves the work the clinicians are doing.  It depends on their having ready access to a computer, on the functionality of the software you have chosen, the design of the content, the usefulness of the outputs, the adequacy of the supports.  None of this is magic. Digging down into the details and finding good solutions at the level of the clinicians at their jobs is the work of the implementation.

I’ll write about my experiences and thoughts on these challenges in future blogs.

Is Your Organization Ready for e-Prescribing? Part I

 

The past several years have witnessed an explosion in the automation of healthcare practices and medicine. And while the adoption of electronic prescribing will undoubtedly yield a variety of benefits to physicians, consumers and payers, there are several organizational factors you must consider before implementing a system of this nature.

 

For e-Prescribing to provide significant value, your staff must utilize the system and, in turn, the e-Prescribing system must deliver the functions desired and required by your organization. The purpose of this article is to provide a framework for the knowledgeable consideration and implementation of an electronic prescribing system. Over the next two blogs I will present a few important elements to think about when faced with the question, ‘What factors do I need to consider ensuring a successful implementation of an electronic prescribing application?”

 

Current Practice Management System

What practice management system is your organization currently using? Does the system have the ability to export a variety of consumer information to the eprescribing system, thus eliminating duplicate entry? If your staff needs to do duplicate consumer demographic entry into an e-Prescribing application, it could hinder adoption and efficiency of the system.

 

Prescriber Adoption and Training

How many prescribers will be using the system? What is their attitude about adopting e-Prescribing technology? Will their schedules allow for necessary training? If a large number of prescribers will use the system, training will likely need to be grouped. Doctors must schedule time to attend the training without overburdening their schedules, and adequate training facilities will be required to accommodate Web-based training for large groups of people.

 

Leadership in the Organization

Is there a clear message from the top leadership of the organization supporting the adoption of electronic prescribing? There must be a strong statement of support for the project from the executive management team, from both organizational and technology perspectives. If your leaders give the impression that e-Prescribing is optional, adoption will be spotty at best.  

Stay tuned for Part II...

          The case for implementing an EHR depends on your point of view.  In this blog, I want us to consider the question from a CEO’s perspective. CEOs spend much of their time monitoring enterprise performance and preparing for and making decisions. This is as true for executives in health care as for those in automobiles and banking. Volumes have been written about these high level tasks and, for sure, I don’t have new insights to add to that body of knowledge. What I want to highlight is the crucial contribution information makes to CEO oversight and decision-making. Courtesy of Wikipedia, I define Information to be "the result of processing, manipulating and organizing data in a way that adds to the knowledge of the receiver." In the domain of health care, information must include data captured through an electronic health record (EHR).  Here’s how this played out at my home organization, University Behavioral HealthCare (UBHC). 

In the mid 1990’s UBHC faced the surging managed care environment with its demands for effective care at lower prices, its requirements for accountability for documentation and outcomes and its focus on customer satisfaction. Our CEO recognized that in order to succeed in this environment the organization needed to use information to:       

• Establish and monitor care and productivity standards
• Optimize and monitor billing 
•  Identify service supply and demand trends  
•  Measure treatment efficacy and patient satisfaction

He further recognized that to accomplish these tasks, he needed the data to be comprehensive, detailed, high quality, and current. Relevant data from all functions of the enterprise had to be captured electronically for executive management control and reporting purposes. For our CEO this case for implementing an Electronic Health Record System was compelling. 

          By July 2000, an enterprise-wide EHR has been implemented. All staff - 500 clinical and 400 support - worked primarily in the EHR. By 2003, more than 1,000 managerial, fiscal, control, QI and clinical reports were in use. Outsourced billing and transcription costs were eliminated, saving $1.4 m per year. Successful billing was increased 10% through monitoring the billing process for problems which would have previously resulted in denials such as a missing Diagnosis or Progress Note. Gross revenues per clinician FTE increased 50% due to the ability to schedule more efficiently, to track work being done and to assist documentation compliance with reminders and to do lists.
          His commitment to the EHR implementation paid off almost immediately. In a recent conversation with him, he told me that he could not imagine trying to lead and manage the organization without the benefits of the EHR.

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.

 

But long term visions seldom motivate people to undertake the demanding sort of change involved in an EMR implementation. To achieve buy-in, leadership needs to define goals that address immediate challenges facing the organization. This requires thinking clearly about the organization’s environment, mission and resources. I’ll write about defining these goals in upcoming blogs.

The person leading an Electronic Medical Record (EMR) implementation must know both the clinical and IT terrains. Since these two sets of knowledge don't ordinarily come in the same individual, who is best prepared to lead the EMR implementation effort, a clinician or a techie? I vote firmly for a clinician. Here's why.

 

At its heart, an EMR implementation should be a clinical and business processes undertaking, not an IT project. While an EMR crucially depends on technology, the ultimate purpose is to advance the quality and efficiency of care provided by people for people. The essential  knowledge underpinning an EMR is an intuitive grasp of the flow of the clinical enterprise: how to think, what to ask, how to decide, how to plan, execute and document. Next in line of importance is understanding the requirements of the complex business environment of health care. Then comes technical knowledge: how to exploit the rich computer systems toolkit to capture and enhance the flow and requirements.

 

This is NOT to say that technical knowledge is unimportant. It is essential for an EHR implementer to grasp the core concepts of networks, client-server, databases and reporting. When I began my transition from practicing psychiatrist to EMR implementer, I identified my computer naïveté to be a serious deficiency. So I promptly  enrolled in the introductory computer science course at a local college. I learned about hardware, networks, operating systems, reporting… I even became competent at very basic programming. On my own, I studied databases and taught myself MS ACCESS. I participated in many IT meetings. With focused effort, I learned enough to be an effective member of our IT team. To my surprise I found that computers are great fun – and very useful.  

I have talked with many people embarking on an EHR implementation. I routinely ask, “ Is it easier to teach a clinician the technical side or a techie the clinical side?” The answer is always, “It’s easier to teach the clinician.” What's your vote?