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EHRs: Healthy Relationships, Not Health Records

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It’s been eleven years since my Intel colleague, John Sherry, and I first did some fieldwork studying physician practices and hospitals that were in the throes of choosing, installing, and/or experiencing EHRs (electronic health records) for the first time. Most interesting to me of these studies has been when we could get in to a practice in the earliest stages—something I have now witnessed in probably 20 different organizations—when, usually, a tech-savvy doctor or passionate clinical operations manager begins championing the EHR cause and trying to pull everyone else along, usually, kicking and screaming. Time and time again, I have seen the process become so bogged down in the minutia of databases, software features, interoperability, ontologies, and codes that the intrepid pioneers ran out of energy, capital, or political capital with their colleagues before getting anywhere near the Holy Nirvana that EHRs were supposed to deliver unto them.


Over the past few months, I’ve visited many states and practices who are experiencing this kind of culture shock in the midst of national carrot-and-stick health reform programs around investments in EHRs, meaningful use deadlines, and payment reforms. And I am left more than a little worried that in our zeal to create the internet for health—a goal I certainly believe in—we are becoming, once again, too focused on the minutia of health records, with too little attention focused on the healthy relationships among doctors, nurses, health workers, and families that we want this infrastructure to enable. I find myself even as the “tech company guy” asking these practices: What care models are you trying to enable? What problems are you trying to solve? What are the new kinds of relationships you are trying to prioritize in your practice? Too many of them can’t answer these basic questions…or they have so many answers that no one technology could ever hope to solve so many problems.


So here’s some “free advice” (remember that you get what you pay for!) based on the many EHR adoptions I have now witnessed:


1)     Relationship Maps: The clinical teams who have brought all stakeholders to the table (doctors, nurses, social workers, clinic managers, operations managers, IT specialists, finance managers, patients, etc.) in the beginning have a greater chance of success. Yes, you’d think this is “common sense,” but I too often see practices designing and optimizing EHRs only for and from the physician’s point-of-view, and then they are shocked when the system breaks down or other clinical staff resist and revolt. I work with teams to literally map out the relationships they want to have—what do they want to do differently with one another once the EHR is installed?—in easily understood scenarios for everyone to see. If everyone is clear about the value proposition and end-state the EHR is supposed to help them accomplish, then it’s far more likely they will get there…and that they will realize they have to change their behaviors along the way, not just the tools they are using to do care.


2)     Workflow Scenarios—Before and After:  Even more surprising to me is how few practices actually have ever stopped to evaluate their workflow today before ever trying to change that workflow significantly by adopting an EHR. Many of them have elegant (mostly unread) manuals about best practices, protocols, rules, and even formalized cultural expectations of their members, but it’s what actually happens in routine practice that really matters. The teams I have studied who either hire a firm or themselves do ethnographic and informatics analysis of their current workflow are much more successful at integrating EHRs into their future workflow. Again, step-by-step scenarios about who touches and acts upon what information, who actually lays hands on patients, who deals with hand-offs between departments, etc. are really required to do any process/culture change, whether through technology or not. The hard part is not the IT install…it’s the culture and process change for folks who have never been trained on how to do that!


3)     Adopt Coordination Tools First, Data Will Follow: I should probably have put this as the #1 recommendation in terms of importance, but sequentially in the EHR adoption process, it fits better here. Clinicians are already steeped in the lingo of their respective medical professions, so it’s no surprise that they don’t want to become fluent in EHR-ese and IT jargon, but I see implementation teams wasting lots of time trying to get everyone on board with “shared language.” In fact, most practices start with the most painful part of the process—agreeing on codes and terminologies for their databases (which often reveals the larger problem of how variable and un-evidence-based the ostensible “best practices” in the clinic really are!)—instead of adopting a tool that can deliver immediate value to everyone out of the gate. Again, this EHR system is ultimately about better care coordination and relationships amongst the stakeholders, so those who adopt the coordination tools first—things like secure messaging with one another, or “last touch” patient alerts, or e-consultations, or e-prescribing, or a simple shared demographic record with trace histories—tend to do better longer term with their EHR adoption. Once they have tools that allow them multiple ways to communicate and coordinate with one another, they then—surprise, surprise—start asking for those tools to be populated with actual patient data. But too often, we ask clinical teams to suffer through months, even years, of “infrastructure” and data entry without any tools or features that deliver immediate value (and thus, yield sustained buy-in and patience for the more difficult challenges that certainly lie ahead).


4)     Expectations Management Is Key: Finally, the teams I have seen who have done a great job managing collective expectations about EHRs end up being the ones who achieve the most meaningful use of the tools. That means not pitching EHRs as a “Holy Nirvana” in the first place (and definitely means not promising a “paperless office”!). That means giving the teams time to go through very natural and normal growing pains as they become accustomed both to the software and the workflow/relationships they are growing into. That means making the ROI expectations long enough for the tools to become well-learned and internalized into the culture to see results and value. And that means doing continuous, iterative observations and improvements of the workflow and relationship maps even once the system has “gone live.” In my experience, the slow, patient teams—with appropriate expectations out of the gate—win the race.


I remember well that very first practice I studied back in 1999. Within the first few weeks of turning on their EHR, they discovered, among many things, that their costs for very standard hip surgeries were all over the map. They had never previously noticed this to be a problem, nor did they have any idea why. But as they began to look at the EHR data—along with their financial data—they soon discovered the main culprit.


They were admitting patients to the hospital for surgery on Thursdays and Fridays. But OT and PT, who didn’t work on weekends (because no one had ever asked them to!), were required to sign off on all patient discharges. So an unnecessary weekend hospital stay was driving up costs and suffering for the patients. For a while, this clinic simply didn’t schedule hip surgeries later in the week. Eventually, they set up both a new discharge process (it’s about workflow!) and a new team-based approach to occupational and physical therapy that signed up some folks to work on weekends (it’s about relationships!) that made everyone happy with lowered costs and better quality outcomes for their hip surgeries. Oh, and the patients were much happier to go home earlier, too!


So amidst all the hype and hope of EHRs, I simply ask us to remember that it’s ultimately about healthy relationships, not health records. The verbs, the actions, the behaviors are the important part…not the nouns, the gadgets, the nomenclatures. That’s the spirit and intent behind “meaningful use” of EHRs, and if we find ourselves having lost the meaning of all of this, we simply need to go back and remember—or identify for the first time—the relationships we’re trying to build.


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