Gregory R. Wise
Clinical IT systems show tremendous promise for reducing costs and improving the consistency of health care across the nation-but these systems only work when all clinicians actively participate.
At a Glance
Suggestions for gaining active participation of clinicians in the design and implementation of a clinical IT system include:
- Selecting open and easy-to-use systems
- Gaining organizationwide buy in
- Successfully articulating the benefits of these technologies for both patients and the organization
Paperless records that can easily be read and universally accessed are widely regarded as vital tools for advances in patient safety, cost-effectiveness, efficiency, and accountability in health care. These systems put a wealth of information at physicians' fingertips, and stories of the successful implementation of computerized provider order entry (CPOE) and electronic medical record (EMR) systems abound.
So why aren't these systems ubiquitous in the nation's physician offices, hospitals, long-term care facilities, and elsewhere?
For one, the process of selecting the right technologies and ensuring a smooth implementation is risky. There are many technology options available, and it can be a challenge to figure out which ones will best meet the organization's long-term needs.
CPOE and EMR systems are capital investments that an organization could live with for the next 10 to 20 years. The cost of switching technologies is extremely high, and many EMR vendors have made it difficult for EMR products from one vendor to integrate with systems from another vendor. Trade-offs abound; often, one particular technology meets certain needs very well, but falls short in other areas. If chosen well, the technology can prove invaluable for the organization. If chosen poorly, the IT selection process could prove to be a costly and divisive failure. Given the high stakes and the still-emerging state of the industry, it is little wonder that many hospitals and healthcare systems are reluctant to wade into these waters.
The second primary reason for delays in universal adoption is culture. Physicians and others in health care are not known for their tech savvy-just a few years ago, questions lingered about whether physicians would use computers, let alone hand-held devices powered by cutting-edge clinical software. Although technology adoption has progressed in health care, some still eschew the time it takes to learn how to use new technologies, believing these technologies do not directly relate to the care and treatment of patients. Sometimes, it's difficult for clinicians to make the connection between installation of a new CPOE system and improved patient care due to reduced medical errors. Without understanding how new technologies will improve their day-to-day work or benefit patients, clinicians who need to embrace such changes could be slow to support new technologies.
Third, many hospital administrators focus on the bottom-line efficiency benefits of new technologies while failing to show clinicians how these technologies can also improve the overall patient experience. As difficult as it sometimes is for clinicians to see how installing IT systems can improve patient care, it can be even harder for them to see how such improvements can positively impact their organization's bottom line. As a result, one often hears of the need to establish the business case for the installation of such
clinical IT systems.
Additionally, the fragmented nature of our healthcare delivery systems does not lend itself to the rapid adoption of expensive IT systems. Often, the investor of capital and the beneficiary of the dividend are distinctly different entities. This is perhaps most perplexing in the outpatient setting, where many physician practices must decide if they are willing to invest their own funds in technologies that are likely to bring about tremendous efficiencies-such as reduced duplicative testing and improved coordination among providers-where benefits would likely be enjoyed more by consumers than by the physicians. Under our current system, physician investors often find they are economically rewarded by the inefficiencies these technologies are meant to improve.
To engage clinicians in supporting new technologies, hospitals should select open and easy-to-use systems, gain organizationwide buy in, and successfully articulate the benefits of these technologies for patients and the overall health of the organization. Healthcare organizations should consider a few key strategies.
Changing the Status Quo
Although moving from paper reporting to EMRs has a number of benefits for hospital administrators, clinicians, and patients, this process has its share of problems. For EMRs to be successfully implemented throughout an entire hospital system, the mindset-and, more important, the workflows-of staff must be changed at every level of the organization, from the front desk to administration. Given the disruption to the status quo, it is easy to understand why, despite the positive results, many organizations remain hesitant to adopt this technology.
As with any major change initiative, implementation can be time-consuming, and some just aren't willing to make the commitment to learn the new technology. Often, the key to success is to show the "quick win" benefits of adoption.
The current "one-off" model of patient care also serves to maintain the status quo. Physicians often have been trained in this approach to focus on the patient in front of them and ask, "How efficiently and effectively can I see and treat this particular patient?" Few physicians are trained to think about the health system as a whole, taking a view of the entire process within the larger context of community health. Because it is often easier to understand the benefit that IT systems such as EMRs bring to care at the system level, physicians accustomed to the "one-off" approach to care are less likely to have any motivation to insist upon such technology.
We need not only a new way of doing things, but also a new and systemic way of thinking, with the primary focus remaining on providing high-quality patient care.
The Potential to Eliminate Harm and Waste
Clinical IT systems are providing safer, more reliable, and more efficient care while cutting down on waste at hospitals. Clinical IT systems that improve patient safety and help eliminate harm by improving efficiency and reducing the potential for error are good not only for patients, but also for hospital finances.
Clinical IT systems are also good for the staff. With clinical IT systems, scarce human resources can be retasked to the job of caring for patients rather than researching and abstracting patient records. With electronic records that are easy to archive and research, providers can get a quicker and broader view of the care process and outcomes, allowing clinicians to spend more time on what matters most-delivering care at the bedside.
At the same time, clinical IT systems have eliminated waste. When lab results are recorded in an electronic format, they are easier to find, making it less likely that patients will be subjected to repeated visits and redundant tests to document what is already known. The days of an expensive set of test results being overlooked, or even lost, in the paper record can be eliminated with EMRs. Every detail is documented, making care more efficient, thorough, and convenient.
A recent study found that IT systems in one of its member hospitals led to a 58 percent reduction in duplicate lab tests through alerts at the time of order (Currin, John. G., Jr., et al., Sustaining a Quality Culture and Engaging Physicians Through Clinical IT, Premier, Inc., June 2008). That equated to a savings of $9,100 a month and a potential savings of $109,200 annually.
With today's health insurers paying less for expensive procedures, pinpointing areas of redundancy and eliminating costly medical errors is a win-win for patients, physicians, payers, and the larger community.
The Impact on Patient Safety
Consider the effect of clinical IT pharmacy systems on patient safety. With clinical IT systems, it is possible to dispense drugs with multiple digital checks to ensure safety-a process that enhances human capabilities with computer systems that double-check for allergy histories, potentially deadly interactions, or the potential for overdose due to kidney or liver compromise. Considering that the average Medicare patient takes 12 to 14 different medications during a hospital stay, having an automated checkpoint can be a much-welcomed additional layer of safety.
In fact, a study published in the Nov. 24, 2008, issue of Archives of Internal Medicine shows the use of EMRs has an impact not just on safety, but also on malpractice settlements. According to the survey, facilities that use EMRs paid reduced malpractice settlements for physicians-yet another cost-saving benefit of these clinical IT systems (Virapongse, A., et al., "Electronic Health Records and Malpractice Claims in Office Practice").
Digitized information also has allowed for a better understanding of the linkage between care and outcomes, one of the more significant benefits of clinical IT systems. Hospitals and clinicians can improve care and outcomes if they analyze how care that was provided during and after a patient's visit relates to improved or worsened outcomes. Feedback is essential to improvement. Beyond retrospective analysis of data, some systems now utilize real-time data, such as automated infection surveillance, to provide feedback on a time scale that allows active intervention by the clinician. Taking a close look at these data provides opportunities to develop new protocols and to examine all aspects of care to determine what can be done differently to improve safety.
Health IT Is Needed to Remain Competitive
Most consumers prefer to choose providers that give them the best quality of care with the shortest wait times and the most responsive staff. More and more, clinical IT systems are helping providers differentiate themselves from the competition.
Nothing motivates change like competition. Comparative data repositories that show performance relative to peer hospitals can be a powerful incentive for change. No one wants to lose patients because the organization they represent is at the bottom of the comparative list. Peer comparative databases are a great help to providers in this regard. These systems can be mined to develop a wide range of clinical comparisons that help fuel competition for the betterment of all involved. They can cause institutions to review processes and assess what they can do better to improve quality for patients.
Sometimes the improvements involve something as simple as changing coding practice. Sometimes processes of care improve, thanks to data gleaned from these systems. Often, the data can uncover areas with large opportunity for improvement that might have gone undetected without a comprehensive, systemwide method to assess relative performance. With new information, physicians and hospital administrators have the tools they need to change and improve. By providing objective information to physicians and hospitals that allows them to assess whether they are indeed as good as they think they are, clinical information systems have become a powerful motivator for providers.
Additional Areas of Consideration
In its recent report Healthcare at the Crossroads: Guiding Principals for the Development of the Hospital of the Future, the Joint Commission stated that clinical information technologies are key to a hospital's vitality. In the Health Data Management 2008 CIO survey, 45 percent of respondents whose hospitals plan to increase their IT budgets in the next fiscal year said their organizations were doing so to improve access to information for clinicians. Twenty percent reported they were doing so to reduce medical errors and improve quality, while 16 percent cited competitive pressures in their particular regions. With all the evidence to support it, what are some of the hidden concerns that need to be addressed prior to clinical IT implementation?
Making wise decisions on the purchase of these systems is critical. There are significant capital and time investments associated with implementation, and a mistake could cost millions of dollars. Whittling down multiple vendors and costs associated with upkeep once a system is in place is challenging-and administration's desires don't always match those of physicians. Different departments have different needs. Emergency department physicians may not want the system supported by surgeons in the operating rooms. Each department's wish to select best-of-breed software for its own needs may be sacrificing the larger system's need for connectivity and integration. Functionality remains a key issue, driven largely by time constraints.
Second, a lack of uniformity in existing clinical systems makes it harder to sell the value of an EMR system. With little standardization in these systems, there are instances where there is no cohesive flow within an institution, let alone outside of it. Vendors have no incentive to make systems compatible, as competition remains high for medical dollars. But lack of standardization among IT platforms is counterproductive to the good that clinical IT systems can offer. Physicians who can't access a patient's medical records are right back where they were without the technology.
If clinical IT systems are to live up to the benefits they promise, standardization is essential, and should be driven by the healthcare provider community. Systems must be open, compatible platforms to ensure scalability and reach beyond the hospital walls to other healthcare facilities. With so many systems already in the marketplace, and few incentives for providing integration among competing systems, it may take government intervention to bring them together at this point.
The Joint Commission report stresses that during the implementation phase, clinical IT systems must be embraced by staff and designed to enhance workflow and care process design. Otherwise, already broken or defective care processes will only worsen. Everyone in the organization-from front desk personnel to bedside nurses, physicians, and laboratory technicians-must be involved.
For physicians whose practices are split across two or three hospitals, efficiency is a must. The physicians should be shown that EMR systems can streamline a process. For example, an orthopedic surgeon who might ordinarily have to physically sign his name a dozen times during a visit to a hospital will find that his signature is needed just once-for an electronic signature-when the hospital implements an EMR system. Simple time-saving elements, if they can be found, will help bring those physicians who might be hesitant to change into the fold. They must believe the system can work for them.
There is no doubt clinical IT has cut down on unnecessary or duplicate tests. It has prevented human errors, including dosages mistakes, and saved patient lives. It is allowing physicians to track progress and practice more effective preventive medicine through evidence-based care.
But work remains to be done. Functionality, cost, and the ability to communicate beyond hospital walls must be addressed for EMR systems to live up to their true potential.
The Veterans Administration and its Care Coordination Program has solved this problem with a comprehensive EMR system that is standard across VA healthcare delivery sites. The rest of us have not. Perhaps the question is, What is government's proper role in this? What needs to take place for our healthcare system to reach the point where a transparent flow of patient information is possible no matter where you are, no matter what time of day or night, no matter what hospital you wind up in? EMR systems already have done so much to improve the way we practice medicine. Imagine how much more medicine will improve as these systems are embraced, integrated, and put to use for the good of everyone involved.
Gregory R. Wise, MD, is vice president, medical affairs, Kettering Medical Center, Kettering, Ohio, and associate professor of medicine, Wright State University, Dayton, Ohio (Greg.Wise@khnetwork.org).
Richard Bankowitz, MD, is vice president and medical director, healthcare informatics, Premier, Inc., Charlotte, N.C. (Richard_Bankowitz@PremierInc.com).
Publication Date: Sunday, March 01, 2009