October 6, 2020
EHR implementation: a guide to overcoming roadblocks
Introducing monetary incentives for adopting EHR systems and penalizing for their absence, the HITECH Act of 2009 defined the future of electronic health records—sooner or later, EHRs had to become an integral part of providers’ digital mix.
Time passed, and now in 2020 we clearly see that it worked, as adoption rates have hit about 90% at regular and critical access hospitals in the US:
Still, there are other statistics that provide some food for thought. According to Statista, the EHR market will continue a steady growth to reach $40bn by 2024:
But how is this possible if over 90% of practices have already resorted to healthcare app development and deployed EHR systems? We’ll explore the matter in detail.
Often perceived as a free pass to healthcare interoperability, EHRs aren’t universally so simple and benign.
First of all, EHRs are rarely convenient for their prime users—medical professionals. According to the 2019 study by Definitive Healthcare and Vocera, about 77% of clinicians believe that having to deal with EHRs is one of the major burnout contributors as they cause cognitive overload. As a result, medical professionals are not too fond of EHRs regardless of the benefits:
Right now, it feels like physicians are a slave to their EHRs. There's a high amount of burnout—emotional burnout, depersonalization, and a low sense of professional accomplishment.
Dr. Alain Chaoui
MD, Congenial Healthcare
What’s more, EHRs distract practitioners from their patients as the former have to pay much attention to correct data entering. As a result, clinicians spend more time on “desktop medicine” and less on face-to-face conversations with their patients. This lack of focus may worsen the quality of care and patient experience.
At the same time, EHRs’ usability is far from intuitive. A 2019 research by Mayo Clinic and the American Medical Association discovered that this parameter was rated with a discouraging “F” by the majority of the 5,000 participating clinicians.
EHRs are widely commended as a fine source of clinical data on each patient, which can be used for driving insights with healthcare BI. Sadly, the quality of this data is often questioned, as about 18% of digital health records are duplicates. This signals problems with patient matching, which is often done manually. As a result, patients risk to get irrelevant treatments, which may damage their health.
One more issue revealed itself vividly during the pandemic—interoperability. Before, doctors argued that EHR systems were not that interoperable, and that patient data transfer from one system to another still had to be manual. But during the COVID-19 crisis, doctors simply have no extra time to invest in such tasks. At the same time, tracking symptoms and outcomes in large patient populations with the help of EHR and healthcare big data analytics is critical. This made vendors look for some EHR redesign options.
But what’s in it for providers? Do they need to acquire other expensive EHR software? It’s not a good choice. Providers try hard to reduce their expenses by implementing a range of budget-friendly initiatives (healthcare automation, for example). Obviously, they prefer to make the standing EHR solution more relevant. And here comes EHR optimization, a common ground that brings together the interests of health IT experts and providers. It allows both parties to avoid hefty investments in new product and concentrate on improving the existing solution. But is it possible to meet the challenges above without much hassle? Luckily, it is.
As we can see, EHRs, be they out-of-the-box or custom-built, have some issues hindering clinicians’ work. To minimize these hindrances to a tolerable minimum and avoid potential pitfalls, providers need to take only one step—to get into the development process. Sounds crazy? We don’t mean clinicians need to drop stethoscopes and rush to some programming courses. They just need to monitor the development and combat the natural resistance to change to facilitate EHR adoption. Surprisingly, though, clinicians rarely take part in EHR development.
Dr. Andrew Pecora from Regional Cancer Care Associates (NJ, USA) visited some large EHR vendors and was surprised to discover they didn’t involve clinicians in their product development:
Computer scientists are great people, but they're not physicians, they don't think like physicians…and yet they made the EHRs. I think, [they] have to get physicians way more involved. The note, the use of the EHR, the flow of the content should be intuitive to the specialty and the care that needs to be provided at that point in time for that particular patient.
Dr. Andrew Pecora
MD, Regional Cancer Care Associates
So is it correct that doctors just need to barge in and exclude the EHR features they believe to be irrelevant? Not really. It’s not about disrupting the work of software engineers but rather about helping them create EHRs with the actual clinical workflows and specifics in mind. There are other steps providers need to make to ensure a smooth transition to EHR and its efficiency.
Introducing EHRs is not only about the digitalization of paper documents. With these tools, some well-established clinical processes and workflows may become obsolete. However, realizing the need for change and making it work may take time and another round of inefficient care provision. So it’s better to take a look at the processes while the EHR is still under development and map the existing workflows.
First of all, it’s necessary to examine the clinic’s processes and how EHRs can be used to improve them. As a rule, the workflows that involve several clinicians or teams make top candidates for redesign. When at it, clinicians shouldn’t use lengthy and wordy descriptions but instead go for easy-to-read flowcharts:
Workflow mapping usually involves five stages, from setting the start and end points to the analysis of the current situation and drafting routes for improvement. The most common measures here involve eliminating redundant steps, improving inventory management, reducing delays and queues, and more.
Providers can take some error prevention steps when their EHR system is still in development. This helps reduce the cost of rework and ensure a timely product release. We’ll consider some of these steps below.
Involving medical professionals in EHR development at early stages may help reduce the notorious usability issues. Of course, it doesn’t mean that every employee should get into usability testing, neglecting their actual responsibilities. Setting up focus groups representing each department is more reasonable.
These clinicians, who know their work specifics like the back of their hands, are more likely to detect flaws and potential issues, from time-consuming digital chores to potentially deadly situations like incorrect drug dosage due to mistyped units of measurement. When the inspection is over, clinicians submit their feedback to the development team.
Once the system is up and running, providers can have another look at its usability with the help of summative testing. These tests include expert review, performance testing, usability testing, and risk assessment. They can assist providers in evaluating the cognitive load, efficiency, effectiveness, time costs, and other EHR usability parameters.
For vendor-provided EHRs, there’s another way to assess usability—the system usability scale (SUS). Vendors prepare questionnaires that ask users to answer 10 questions about the product usability. The answers are then ranked using a 100-point scale, where 100 is the top grade. 68 points make an average benchmark response, according to a study.
It’s important to keep in mind that EHR usability is not a stable parameter, and deploying new EHR features may alter it. That’s why regular usability tests are necessary.
Patient record digitalization rarely goes smoothly. For medical professionals, this transition to paperless medicine signals the need to change their well-established workflows and practices and adapt to the new technology swiftly. To make the transition seamless and reduce the related stress, providers need to lend clinicians a hand and offer EHR training courses.
Using EHRs is all about sufficient computer skills. So in order to design a helpful training, providers need to evaluate the clinicians’ level of computer literacy first. Nowadays, there are numerous online tests that check basic skills, so there’s no need to develop custom questionnaires. The test will also help to select the most tech-savvy clinicians and assign them as mentors, which can speed up the training process.
When it comes to the training itself, it’s important to remember that you train basic users, not experts. So it’s vital to show them the most widely used commands and make sure they are able to activate them. When clinicians get comfortable with the basic EHR functions, they can move on to more complex tasks. This cumulative learning method proved efficient at St. Vincent’s Health in Indiana: this medium-sized network reduced the training time by 50%.
Pre-training has yet another benefit. As we know, personal health information often becomes the target of hacking attacks that cost healthcare providers billions of dollars. Luckily, some attacks are preventable, provided that clinicians know their enemy. Thus, increasing cybersecurity awareness can help prevent phishing and spoofing that have recently topped the list of threats, according to BakerHostetler’s 2020 Data Security Incident Response Report.
So your EHR system is successfully deployed, and the key users have overcome resistance and adopted it. Can you call it a day now? Not yet.
There are always some more promising improvements to explore and implement. Some of them, such as making EHRs telemedicine-ready, may help combat today’s challenges, like the COVID-19 pandemic. Other EHR improvements aim to alter the overall concept of this tool and make it work not only for patient record keeping but also for preventive care provision.
These new EHRs should deliver the overall picture of patients’ health and provide templates for creating personalized care plans. For patients, these next-gen EHRs mean they get holistic care plans with the measures addressing all of their health issues. What’s more, this type of EHR may solve the interoperability problem by granting access to cross-system data via a user’s private key, similar to the principles of blockchain in healthcare.
For now, though, the development of such systems is still a work in progress. So we’ll have to stick to the traditional EHR development and optimization for a little longer.
Be it a full-scale development or a feature optimization, EHR implementation is a complex process with a range of hurdles on the way. Luckily, there are some steps that providers can take to reduce the number and severity of these challenges. The key point here is to start at the right time.
As we know, EHR adoption is not only about digitalizing paper-based patient records. In many cases, ensuring EHR efficiency requires changes in clinical workflows, which needs to be done long before the deployment, as process redesign is rather effort-intensive.
The next step helps resolve a common EHR problem—a cumbersome interface. Inspecting the interface can go in parallel with software programming, as this will help IT specialists resolve the detected issues on the fly.
The final step, user training, starts when the system is already up and running. This step is time-consuming but critical: when done right, it will help clinicians to not only operate their EHR system successfully but also prevent malicious hacking attacks.
It’s also vital to remember that with time, all EHRs need an upgrade. To stay efficient, they need regular maintenance, new feature deployment, and system updates at the technology level.
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