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.

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

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

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

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

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

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

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

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

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

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

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

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.

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.

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.