In 2014, health care record-keeping and communication are finally emerging from the Stone Age and entering the 21st century, moving away from the pen-and-paper processes abandoned by the rest of the modern world decades ago.
This revolution is driven primarily by the HITECH Act and accompanying meaningful use program. These initiatives drove greater adoption of electronic health records by doctors and hospitals in the last five years than in the previous 40. According to one estimate, EHR adoption by physician practices rose from 17% in 2008 to 48% in 2013 and hospital EHR adoption increased from 13% to 70% during the same time period. These EHRs will play a central role in the move to accountable care and population health management.
A principal HITECH objective was to improve patient care, but a number of recent publications challenge the program's success and EHRs' value -- from both the perspectives of physicians using EHRs and researchers who are decrying a high level of patient safety events across the industry. One article points out that a substantial minority of physicians are dissatisfied with the effect of the EHR on office operations; others suggest EHRs are failing to live up to their promise of reducing patient harm.
Should we be disappointed that this technological revolution hasn't yielded all the anticipated benefits? We think this would be premature. Here's why -- and who's doing it right.
Managing Expectations for the EHR
EHRs can facilitate patient care improvements through three basic mechanisms:
- Better information capture and documentation;
- Better sharing of information across settings; and
- Most importantly, application of computerized clinical decision support (CDS) and data analysis.
The early literature supporting the value of CDS -- on which the meaningful use criteria were largely based -- was derived mostly from a handful of academic institutions with custom-built EHRs that they had constructed and tuned over decades.
It is unreasonable to expect that the majority of organizations that have implemented commercial EHR products in recent years will achieve the kinds of care improvements in a short period of time (two to five years, or "overnight," in health care industry terms) that took the early academic centers many years to achieve.
While in recent years we have learned more about how to design and implement effective CDS, most organizations have neither the staff expertise nor the budgets to commit to drive changes of this magnitude in a short time. Commercial EHR products are equipped with many of the ingredients needed to support clinical workflows and build robust CDS, but they bring with them their own inherent constraints.
Perhaps more importantly, we know that driving rapid technologic and workflow change in organizations is both difficult and hazardous. One way hazards can manifest is through unintended consequences of computerization. Sometimes problems arise from improperly designed or coded software containing errors; however the great majority of unintended consequences arise from the gap between vision for the system as designed and the reality of the system as used. It is virtually impossible to anticipate the full spectrum of individual human and workflow interactions with the system and the resulting manner in which the system gets used.
Implementation Challenges
Problems may manifest during implementation -- for example, during the switch from manual to automated processes. In another common scenario, designers underestimate the amount of time required by physicians to complete their documentation and ordering tasks, resulting in increased physician workload. Quality of documentation may suffer through efforts to replace narrative text with structured templates. Workflows can be disrupted in dangerous ways and new kinds of errors can be introduced.
It takes painstaking planning and rapid response during and after implementation to avoid these problems and resolve those that inevitably occur. It usually takes years for organizations to overcome these challenges and settle into the routine use of a new EHR system. Only then is it possible to truly take advantage of the system's more sophisticated tools and capabilities to affect lasting improvements in patient care processes and patient safety.
So, Who Got It Right?
While success is less newsworthy than failure, an increasing number of organizations have weathered these trials and succeeded in demonstrating genuine benefits from computerization.
Sentara Healthcare
Sentara Healthcare in Virginia reported operational and financial benefits from EHR use, such as length of stay reductions, reduced IT maintenance costs, lower medical records staffing and lower paper costs. It also reported improvements in clinical processes, including faster order execution (e.g., 80% reduction in medication delivery times), increased nursing efficiency (e.g., one hour increase in direct patient care time per nurse, per shift) and more rapid patient transfer times (e.g., 40% reduction in the time it takes to transfer a patient from one unit to another).
Most significantly, it also reported substantial outcome improvements, such as a 50% reduction in hospital mortality ratios (actual/expected deaths) and a reduction of more than 100,000 potential medication errors annually.
Texas Health Resources
Texas Health Resources in Dallas reported EHR-related improvements in its compliance with its CMS Core Indicator bundles, increasing from 65% to 90% compliance to 90% to 95% compliance for all items in the bundle. The organization also achieved a more than 50% reduction in adverse drug event incidence at several targeted hospitals within one year of EHR implementation.
They measured more than 40 minutes of net time savings per nurse, per shift in three of four studied nursing units. And the average time from order writing to computer input for non-stat orders fell from 118 minutes to zero, resulting in more rapid order execution and the more timely delivery of needed care to patients.
Geisinger Medical Center
Geisinger Medical Center in Pennsylvania reduced average hospital length of stay for coronary artery bypass cases by 16% through its evidence-based care program. Geisinger's EHR system helps ensure that 40 critical steps are followed for every patient in the program through the use of checklists, default documentation templates, health maintenance gap reminders and automated order sets; the EHR identifies gaps in care so they can be completed in a timely manner (e.g., before surgery).
Geisinger's pre- and post-implementation analysis showed that 100% of program patients received all 40 care elements included in the bundle, compared with just 59% of those in the conventional care group. Average total hospital length of stay was 5.3 days in the program group, compared with 6.3 days in the conventional care group, and hospital readmission rates were substantially lower for the program patients.
EHRs Are 'Far From Perfect,' but 'Essential'
Today's EHRs are far from perfect. Physician documentation often requires more time than it used to, at least initially. And it takes time and expertise to build out the programmatic and application structures needed to realize significant benefits in safety and quality.
But EHRs are nonetheless essential, and we should thank the federal program that's forcing health care to finally join the 21st century. We are obligated to move forward -- to use modern tools to improve medical decision making, to document legibly and to share information quickly and accurately with our colleagues, as well as our patients. We cannot return to the Neolithic era.
Source: iHealthBeat, Tuesday, September 2, 2014
