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Paul Cerrato
Paul Cerrato
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What EHRs And Marriage Have In Common

IT needs to understand the logistical hurdles and the emotional ones for clinicians--and realize an EHR rollout is just the beginning of a long-term partnership.

I once worked with a person at a major media company, let's call him Mac. Mac was smart and conscientious, but whenever the IT department introduced a new application on our desktops, he would freak out.

Despite the fact that we were given detailed, in-person training and follow-up tech support, Mac was constantly on the phone asking for more help, constantly complaining about how hard the program was to use. I'm sure you know many clinicians like that. Their resistance to a new electronic health record (EHR) system is almost palpable.

How do you overcome this resistance, especially when the EHR you just installed disrupts their work routine? Challenges like this have to be approached with a two-pronged strategy. Call it the "psychotechnical" approach.

You first need to understand any legitimate logistical problems they face as they work with the new health IT (HIT) system. But you also want to address any emotional roadblocks to adapting the new program, what experts sometimes refer to as the psychology of resistance.

Zeroing In On Physicians' Woes

Dr. Carolyn Clancey, director of the Agency of Healthcare Research and Quality, summed up the logistics issue succinctly: "The main challenges are not technical; it's more about integrating HIT with workflow, making it work for patients and clinicians who don't necessarily think like the computer guys do."

A recent Healthcare Information and Management Systems Society survey confirms that many clinicians are in fact feeling the pain as they put EHRs in place. While most respondents said they're satisfied with their EHR, they list workflow problems as their No. 1 usability pain point, with 84% complaining about it. Among their specific concerns:

-- There are too many passwords to work through.

-- They waste our time on duplicated documentation.

-- There's inaccurate patient data.

-- They experience alert fatigue.

-- They need to view many different areas in the EHR to capture the patient's story.

-- The system identifies the same thing by different names.

The list goes on and on. What's the best way to address such concerns?

Dr. Marvin Harper, chief medical information officer at Children's Hospital Boston, notes that the complaint about confusing nomenclature is legitimate but not strictly speaking an EHR issue. "During our EHR implementation, it took months to get multidisciplinary groups to agree on common terminology--which did not exist with paper documentation," Dr. Harper told me in an email. Once accomplished, "this has helped tremendously in caring for patients," he said.

Dr. Dan Nigrin, senior VP for information services and CIO of the Boston hospital's division of endocrinology & informatics program, recommends a balanced approach when dealing with the clinical team. "We need to tweak the software so that it fits the clinician workflow better," Dr. Nigrin told me, "but also convince clinicians to adapt and change where possible. You definitely don't want to upset an established clinical workflow. It's that way for good reason ... But on the other hand, there are plenty of things in medicine that are done in certain ways simply because 'that's the way we've always done them.'"

Dr. Nigrin says it's critical to get clinicians involved in the EHR implementation teams. When clinicians understand that a new workflow can make their lives easier, they're usually willing to change. "But it's also important for those same clinicians to put their foot down every now and then when they see a potential change in process that could lead to patient harm, and to insist instead that the software be adapted," he said.

John Bosco, CIO at North Shore-Long Island Jewish Health System in New York, emphasizes that the EHR vendor or the hospital's IT department must let clinicians see that, once past their learning curve, there will be clear-cut efficiencies. Regarding that frequent complaint about alert fatigue, he recommends that when an EHR is first installed, the alerts be configured "lightly." That is, choose them carefully and put them in place gradually.

Bosco likes to use the wedding/marriage analogy when discussing EHR implementation. You and your fiancée spend months planning a wedding--just as the IT team and clinical staff spend months planning the EHR's installment. Then the big day arrives, you throw the switch, and the system goes live. But IT executives and doctors, just like man and wife, have to realize that this is only the beginning. The IT team and clinicians have to remain committed to a long-term relationship that involves hard work, compromises, and maturation.

Process Mapping

Of course, both groups have to do a great deal of prenuptial work for the marriage to work. Clinicians must do intense "process mapping" so that they understand how patient care and administrative services occur step-by-step in the paper world.

You want them to think through their work patterns as they document patient care--in painstaking detail: Which vital signs are recorded and which staff member records them? How are medical histories taken? What kind of post-visit documentation occurs, and who inputs that information? Many more process points must be mapped, either using flowchart software or pencil and paper, depending on the complexity of the process.

Only after the clinicians have a complete picture of their workflow process can you have an intelligent conversation about how that process will be disrupted--and improved--after the electronic system is in place. Clinicians who have a hard time seeing the many aspects of their current work process may benefit from an EHR primer like Electronic Health Records for Dummies, by Dr. Trenor Williams and Anita Samarth.

The News Is Not All Bad

All this talk of physician pain and compromise might suggest that EHRs are more trouble than they're worth. But myriad success stories demonstrate that EHRs and related electronic tools can have a profound transformative effect on patient care.

So why are many clinicians still hesitant to make the workflow changes needed to reap the benefits of EHRs and other electronic medical tools? Frederick Knoll from Stanford University once outlined five steps involved in accepting medical technology: horror, denunciation, skepticism, evaluation, and finally acceptance as the standard of care. Many clinicians are still stuck somewhere between denunciation and evaluation. One of your jobs as an IT executive/psychologist is to figure out where each clinical team fits on this continuum.

Another useful scale to help measure clinicians' resistance was outlined many years ago by Everett Rogers in Diffusion of Innovation, in which he described the innovators, early adopters, early and late majority adopters, and laggards, who often require a direct order from their superiors to act.

It's almost a cliché to say laggards fear change; still, it helps to understand what's behind such fear. Some docs fear being embarrassed by their inability to speak the language of technology. I remember working with an older academic physician who couldn't locate desperately needed research articles on the Web and had his secretary handle most of his email. He was clearly uncomfortable admitting his ignorance.

For other clinicians, the problem is abundant self-confidence. When physicians have spent a quarter of a century running a lucrative practice using paper and pencil, they have good reason to believe in the status quo. When a group of young technologists suddenly suggests they're dinosaurs--well, you get picture.

Using well-reasoned arguments, positive case examples--and your best bedside manner--will go a long way toward winning over resistant clinicians.

The Healthcare IT Leadership Forum is a day-long venue where senior IT leaders in healthcare come together to discuss how they're using technology to improve clinical care. It happens in New York City on July 12. Find out more.

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