Two Regenstrief Institute and U.S. Department of Veterans Affairs researchers were co-editors of a recent special supplement to the Journal of General Internal Medicine designed to help address issues around health systems’ transitions to new electronic health record systems. One of those researchers, Michael Weiner, M.D., M.P.H., recently spoke with Healthcare Innovation, about their findings.
Along with Regenstrief Institute’s David Haggstrom, M.D., and two other guest editors, Weiner led a team looking at a range of EHR system topics including data integrity, security and patient care.
In addition to his role as a research scientist with the William M. Tierney Center for Health Services Research at Regenstrief Institute, Weiner is an investigator at the VA Health Services Research and Development’s Center for Health Information and Communication at the Richard L. Roudebush VA Medical Center, and a professor of medicine at Indiana University School of Medicine.
Healthcare Innovation: Could you explain why you and your colleagues thought EHR transition was an important topic to research now?
Weiner: Absolutely. If you look across the country, you'll find that most healthcare institutions are now using electronic health records, and these systems are primarily commercially developed. There's a big need to understand how those systems work, what their limitations may be, and what their impact is for patients and for the healthcare enterprise. They're extremely expensive systems and they do so many complex activities. Institutions invest millions or billions of dollars in purchasing a system. Many institutions have switched from one system to another due to consolidation of the enterprise or due to needs to standardize or optimize their care delivery or due to requirements from their stakeholders. What we really need to figure out is: what are these systems doing for patient care? Are there things we need to change or improve and, if so, what are those things and how do we do it?
HCI: The introduction to the special supplement describes this as a socio-technical challenge. What does that term imply about the project management issues around implementing a new system?
Weiner: These are socio-technical challenges, for sure. What that means is they are targeting many of the complex interplays of sociological issues within the healthcare setting or the patient setting and technical issues together. These new information technology systems affect how people work with each other; they affect how work is done; they affect communication, not just within healthcare teams, but between patients and those different teams.
When you introduce a new system, the workflow for accomplishing any given task can change dramatically and therefore it requires, in some cases, new types of work to be done, new roles to be defined, new ways of actually coordinating that care. We need to work to streamline those operations and maximize efficiency. There are also issues with the user interface, the software that's on the screen and how to make those interfaces as safe and efficient as possible. There are ways to design interfaces that cause errors to actually occur because they promote poor decision-making or they promote misinterpretation of what one is seeing. Those are things we obviously need to avoid.
HCI: The introduction also mentions that despite there being so many issues and so much money involved here, there has been relatively little research on this topic so far. Why do you think that is?
Weiner: Well, the number of institutions that have undergone electronic health record transitions is not very large at this time. There are several institutions around the country that have now done it. The Department of Veterans Affairs, where I work, is in the process of doing it. That's a very long process.
The other reason is that doing this type of research on such a transition requires a tremendous amount of planning to measure what should be measured — to capture the various socio-technical outcomes that are important and of interest, to look at multiple dimensions such as the perspectives and experiences of the users, the costs, the outcomes, the process of implementation, the culture change and the training.
HCI: When we talk about a learning health system approach, maybe people who are doing a transition to Epic think that they are never going to do it again, so why focus on lessons from the transition?
Weiner: I think that is part of it. It's a monumental event for a large institution, but, like you said, it's also a rare event for an individual institution. So the motivation for any one place to do this work might be limited, but the benefit is that it helps our whole medical community to do this well. The other reality is that institutions are not isolated. They all interconnect with other institutions beyond themselves. So the impact of the transition in one place is going to have ripples in other places that connect with that institution. So it's really broadly important.
HCI: I understand that this supplement examines both VA and non-VA facilities across diverse organizations in geographical settings, but does it delve into some of the issues that the VA has run into with this current transition? And if so, can you talk about a few of those? Is part of the problem just the scale of the VA system making this more complex than it would be for a regional health system switching over to a new EHR?
Weiner: Yes, the scale at the VA has mattered. It makes the enterprise-wide execution more complex, involve more people and be more expensive. The other thing is that each site within an institution tends to have some of its own local practices that might differ from the other sites within the same institution. And that's the case in the VA, as it is in other places. One has to then reconcile local practice with what is now intended to become an enterprise-wide standardization of practice to a large degree. So the bigger the institution is, the more difficult that standardization can be, and that has been true for the VA.
The special issue of the Journal of General Internal Medicine on this topic does address many of the actual experiences in the VA transition to a commercial system. For example, professional roles that need to be assessed and sometimes adjusted so that they are aligned with their access to the computer system. That's one of the things that has been a challenge in in the implementation of the system in the VA. Another is looking at referral templates. The templates are the forms that are standardized and used to complete a referral request and then ultimately, lead to the consultation. With the new commercial system comes a whole new set of referral forms that are a part of that information technology product. And so there's been a need to examine all of those forms.That's a difficult undertaking. It has required changes to some of the referral templates, and to some of the processes that are used in actually sending that referral from its origin to its destination.
The governance is another big issue that has been examined and reported on in this special issue, because there's a need to manage and administer the system, to have an organized way to report problems and to then address those problems that come up with how the system is performing.
HCI: The VA and Oracle Cerner are now pausing the system implementation and doing a course correction. So they're probably touching on several those things you mentioned such as the governance issues to make sure they're addressed.
Weiner: That’s correct. The VA, in partnership with Oracle Cerner, is addressing those challenges that came up in the first five go-lives or implementations. They are committed to sufficiently resolving those issues before proceeding with the remaining implementations at the other sites. I think that's a wise decision to ensure that we are not risking patient safety or other kinds of problems. The other kinds of issues that have come up are things like how do we work with trainees in the system, so that trainees have adequate training and access to the system during their training, rotations and activities? And how do patients actually access this system effectively and learn to do so for their own health care?
HCI: I am setting up an interview with an executive at the Indian Health Service, because they are about to launch an EHR modernization effort similar to the VA’s. So maybe they can learn some lessons from what's happened in the VA.
Weiner: Absolutely, the Indian Health Service has a number of parallels to the VA system — both are public sector kind of organizations with a very large footprint that invest a lot in this work. I think not only the Indian Health Service, but many other institutions should look at the VA's experience and learn from it, so that these challenges don't have to be repeated.
HCI: Was there anything else in the in the research studies that surprised you or concerned you?
Weiner: Yes. An important undertaking has been measuring errors in tasks and also the time to complete tasks using the new system. And there are mixed results about those measures. One thing we have found in a few instances is that when we actually measure errors and task time, we can see improvement with the new system. But when we go to the clinical users and ask them about their experience, they sometimes report negatively about their experience with things like task time, so we need to dive into why there are sometimes opposing measures of the same kind of attribute or factor. We don't completely understand that yet. But I think I'd say there's great potential for these new systems to actually streamline and improve many aspects of care.
HCI: Maybe that flows out of initial skepticism about the transition. Even if you can measure that they are doing something more efficiently, they still may have an overall impression that the transition has been painful or they don't like the new system.
Weiner: You're completely right. And I'd say two things to that. The first is these transitions are always difficult. They're always challenging. I would even say they often don't go well initially, because of the complexity of the job. The second thing is that we often do see a big learning curve, a drop in user experience, satisfaction, performance and outcomes, and then there's an improvement after a period of time. That time might be a few months or it actually might be a couple of years. But that's part of why studying this is difficult, too, because we can't just study what happens overnight. We have to look at it over an extended period of time because what is actually happening changes during that period.
