EHRs: Why one size doesn’t fit all

Jan. 1, 2011

HITECH Act regulations should not be adopted in isolation, but rather customized to organizations and their practitioners.

Dr. Geeta Nayyar

When Congress passed the Health Information Technology for Economic and Clinical Health (HITECH) Act last year, government made enormous strides in advancing technology adoption in healthcare. By providing incentives to organizations that successfully implement electronic health records (EHRs), the regulations will ultimately help hospitals and physicians improve quality of patient care, better manage the health of populations and reduce costs.

In the rush to implement EHR solutions and receive financial incentives, however, many organizations overlook the importance of customizing the technologies and incorporating physicians' inputs in the process. Hospitals have unique workflows, clinical concerns and challenges, and it's essential that decision makers consider each of these aspects to ensure that they're engaging with the appropriate technology, rather than selecting a one-size-fits-all solution. Additionally, leaders should consider the clinician's workflow and viewpoint to effectively move an organization forward. As the primary users of EHRs, physicians have an insider's perspective on the clinical workflow of an organization and can provide insights to help best customize a solution.

Going beyond HITECH

The drivers that should motivate your organization to implement health technologies should be the desire to achieve both the HITECH Act's incentives and to improve clinical care and practice. To make the smartest decision and gain the most long-term value, leaders should have a 360-degree view of their organizations and needs. An important part of increasing provider engagement and EHR adoption is understanding your IT system and how that system integrates within its environment. Hospitals have multiple systems that must integrate. These include: lab management systems, billing and administrative functions, pharmacy systems, radiology and imaging systems along with an admission/registration function. Long term you may also want to integrate your system into a personal health record (PHR). EHRs are not designed to operate in isolation. They actually function at their full potential when they are sharing and combining information from disparate sources. Because of this, hospitals should approach EHR adoption with a broad focus that extends beyond government HITECH incentives — they should also consider how it will add value to their clinical workflows and improve quality of care to ensure they are making the most valuable long- and short-term investments.

Full integration will ensure that the right connections are made around the EHR your organization has chosen. Having an understanding of the enterprise architecture needed for your organization will help determine what level of customization might be needed in a particular product. Your organization should assume it will need some degree of customization and then budget for it. This will likely be inevitable for most organizations and should not come as a surprise late in the development of an implementation strategy.

Where IT and clinical practice intersect

EHRs hold a great deal of promise for healthcare organizations that want to achieve better quality and clinical care outcomes. These objectives will only be completely realized when the technology and healthcare industries are able to fully integrate. Electronic health records need to be designed and aligned with a clinician's workflow and viewpoint in order to be wholly effective and move an organization forward.

Current EHR systems are sometimes built with limited clinical inputs, resulting in systems built with an emphasis on documentation and billing when clinicians need more decision-making and logical documentation tools. Clinicians would prefer to harness these technologies in ways that would allow them to better achieve clinical care outcomes than to simply use these technologies for billing and medical documentation purposes.

I've seen this disconnect between IT and clinical practice cause significant disruptions in my own experience as a physician. Without the marriage between IT and clinical practice, new technology initiatives can inadvertently hamper clinical care instead of enhancing it. For example, the ambulatory care clinic where I practice medicine recently made electronic lab order entry mandatory. To order a lab electronically through our EHR, a provider must link the labs requested to a diagnosis on the chart. This linkage forces providers to keep an updated problem list in the patient chart in order to satisfy meaningful-use criteria. The problem with this function is that as a physician, I often order labs to help me make a diagnosis. The EHR function instead demands that I make a diagnosis prior to having lab results. Forcing diagnosis before lab results encourages providers to document a hypothetical diagnosis that will support the command to order lab tests. This can be harmful to the patient, because a vague, unsubstantiated diagnosis listed in the chart will be viewed by other providers, thus influencing their clinical decision making around a patient's symptoms. Additionally, providers have to wait for lab results to return and then actively update a diagnosis from the patient's problem list in the chart. From a clinical perspective, this is a lot of imposed work and extra steps required just to order lab tests. More importantly, these imposed steps could actually lead to medical errors instead of preventing them.

As this example demonstrates, if EHRs are not adopted with an insider's perspective in mind, workflows can experience serious issues. Unlike its original intent, this seemingly simple criterion for meaningful use is surprisingly complex for both clinicians and patients. The regulations set forth in the HITECH Act should not be adopted in isolation, but rather customized and tailored to organizations and their practitioners. It is through this understanding that disruptions in clinical workflow will be avoided and patients can be seen in a timely, efficient and “meaningful” way. Hospitals must have a strong understanding of their clinicians and how they provide patient care in order to truly achieve meaningful use of these technology systems.

As I continue to practice medicine, I remain an advocate for both better patient care and the use of information technology tools, such as EHRs, to advance that mission. Ultimately, this is about healthcare, not technology, and what matters most is improving the lives of the patients and families I treat every day. Now is an exciting time for healthcare technologies, but organizations must take a broader look at their unique situations and seek physician input when selecting a new system. Fully embracing these technologies with the right motivations and advisors will prove incredibly beneficial to both patients and healthcare organizations if done correctly. Finding the right technology partner that can bridge the gap between technology and healthcare delivery — using clinical know-how and the ability to employ a disciplined lifecycle to adoption — is pivotal to success.

Dr. Geeta Nayyar is principal medical officer, Vangent.

For more information on Vangent solutions:

Committees can champion tailored systems

To better engage with clinical staff, organizations should be knowledgeable about the latest health regulations and should be able to educate employees about how those could affect both business and clinical practice. One way to involve physicians is to encourage them to serve on an internal HIT committee. Many hospital systems are finding it important to have clinical committees comprised of provider champions to test out EHRs or give feedback on existing systems that can be improved from a clinical vantage point. These groups serve as a bridge between the organization's IT and clinical staff. Increasingly, this need exists within hospital systems, and hospitals are hiring full-time chief medical informatics officers (CMIOs) to play this clinical translational role.

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