Part I: Setting Expectations Works For GPS, Why Not EMRs Under Meaningful Use?

Dec. 20, 2011
I work with a team of very talented and dedicated people. We spend much of our time evolving and enhancing our EMR based upon a combination of advances in the technology, user-defined input, and anticipated user needs moving forward. One of the most important goals we have is to evolve the system in ways that make physician adoption and use easier by developing EMR capabilities that create real value for improving patient care and safety.
I work with a team of very talented and dedicated people. We spend much of our time evolving and enhancing our EMR based upon a combination of advances in the technology, user-defined input, and anticipated user needs moving forward. One of the most important goals we have is to evolve the system in ways that make physician adoption and use easier by developing EMR capabilities that create real value for improving patient care and safety.Occasionally, I find that stepping back from these challenges, to look at them from a different, often less complicated viewpoint, helps me gain a clearer perspective of what needs to be accomplished. It’s this thinking that led me to write the blog that follows.I see numerous similarities between the effective use of GPS assisted navigation while driving and physician adoption of electronic medical records under Meaningful Use. To me, it’s a matter of setting the proper expectations.Getting instructions from a GPS can be a little frustrating and even dangerous at times. For instance, while driving at highway speeds, with stressors like heavy traffic, or unfamiliar routes. Even getting directions when driving at 25 mph can present special challenges, such as when those directions conflict with your expectations, common sense, signage or your spouse's recommendations.Those of us who use GPS on a regular basis know that the directions it provides are not always correct. Therefore, we set our expectations based upon this knowledge, and temper the results based upon our experience, the use of additional tools, and sometimes, intuition.I’ve heard many reasons not to use GPS . . . it’s distracting, it’s too complicated, it’s time consuming, it pesters me constantly; if it’s not always right, I don’t need it, I know where I’m going, why use it? This is getting even more interesting as GPS assisted navigation has become more sophisticated in recent years, with Internet connectivity and with it, integrated access to up-to-the-moment traffic, nearby services, and communication. My conclusion is that in almost every instance, the right expectations were not set with detractors, so the technology was not accepted as beneficial. The GPS capabilities either under adopted or not adopted. And per the title graphic above, that may be a safety issue.I find the same is true when it comes to EMRs. GPS does not make decisions for you. It provides decision support to help you make more informed decisions, and beyond what any one human user can know . . . just like an EMR.Too big of a leap to relate GPS to EMR? Let’s take a closer look. First, a basic framing of their definitions. GPS is a technology that defines a driver’s current location and helps them find a path to their desired final destination, or at least as close as possible.An EMR is technology that helps a clinician determine “the location” of the patient in terms of their available vitals, labs, and other inputs such as radiology reports, which in turn help to select a path to the desired final destination. That destination being curing the problem or coming as close to doing so as possible.The technologies for GPS and the EMR have been evolving for decades. In recent years, both have been vastly improved, transcending merely creating clarity on the current location, to helping their users get to where they’re trying to go. Both now have the capability to guide, that is, point out an available course and its specifics. With GPS, that may be turn-by-turn directions. With the EMR, that may be a care pathway, articulated as an order set or sequence of order sets. And with both, each step may have additional details available, such as the traffic on a particular highway segment, or a clinical contradiction to a medication order.So, is it too big a leap to relate the service of a GPS to an EMR? I don’t think so. When I take a step back from what’s being asked of clinical users in the era of Meaningful Use, the guidance needed at many discrete steps of a clinical process becomes even more recognizable as similar to the guidance provided by the modern GPS. As with all new technologies, there is some initial resistance by intended users. It was true with GPS, and it’s true with the EMR. But as these technologies evolve to create more perceived value, with expectations are properly defined, adoption increases.This brings us to the challenge of how to drive physician adoption under the criteria of Meaningful Use; a relatively new challenge. It involves " problem-based and problem-list-basedworkflow" to ensure that appropriate order sets are used, the documentation templates and guidelines are available, quality measures are explicitly available in context, and complete handoff documentation is produced. The hand-off documentation refers to both clinical summaries for patients (an electronic copy of health information in MU context), as well as documents for subsequent clinical professionals to assure seamlessly coordinated care.One of the interesting, albeit odd twists in all of this has been clinical decision support, and specifically alert fatigue and alert overload. Essentially, a provider organization needs only to include one clinical decision support rule in Stage One MU. In reality, however, problem-based workflow will increase the degree of passive prompting to ensure a faster, easier, and safer end-user experience than the alternative.For example, if I open a patient's chart and add heart failure to their problem list, it will be faster, easier and safer if the system facilitates my results review and my ordering dialogue in that context. Otherwise, I will certainly need to use a lot more clicks to get to those results (such as cardiac ejection fractions) and orders (such as heart failure medications). And, of course, I probably won’t get to the results and orders I might not have thought of, or been able to find due to the complexity of the process.Again, it’s about setting the proper expectations to ensure physician adoption. Setting expectations is not simply a matter of educating about the limits of EMR technology. It’s a process that combines making physicians keenly aware that their clinical knowledge and interpretive skills are invaluable and not being undermined. The EMR is a tool that aides in raising the bar for patient safety and quality care. It provides decision support, but the final decision still rests with the physician.What do you think so far? While I’m working on the second installment of this blog, I invite your comments. (Part II continues here: http://bit.ly/GPSandEMR2 )

Joe Bormel, M.D., MPH
CMO & VP, QuadraMed

This post: http://bit.ly/GPSandEMR Previous post: http://bit.ly/MUKayak

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