The Painful Side Effects of Deploying Electronic Health Records

According to a recent study by Massachusetts General Hospital and George Washington University, less than 25 percent of all U.S. doctors use some form of electronic health records (EHRs) in their practices. Far fewer—only around 10 percent—have fully operational health information systems that collect patient health data, manage information such as orders for lab tests and prescriptions, and provide decision support.

Meanwhile, many of those healthcare facilities that are deploying EHR systems are having difficulty making the systems work. In November, an internal report by Kaiser Foundation Hospitals that was leaked to the press detailed hundreds of technical problems with the $4 billion enterprisewide EHR system supplied by the vendor Epic Systems. By 2009, the project, called HealthConnect, is supposed to provide doctors access to records for all 8.6 million Kaiser patients. But the system has suffered from excessive downtime, according to the report. In addition, users experienced problems accessing certain applications that allegedly did not scale well to Kaiser’s vast network. Three days after the report became public, Kaiser CIO Cliff Dodd resigned, although the company won’t comment on any connection with the troubled project.

Yet health policy experts say EHRs are what’s needed to reduce the 225,000 deaths a year due to medical errors and adverse effects of mistakenly prescribed drugs, among other ailments of the healthcare system.

From 2004 until last year, David Brailer, a physician and the first national coordinator for health information technology, led a Bush administration initiative to persuade the nation’s 885,000 physicians and the management of approximately 5,000 hospitals to invest millions of dollars in electronic health information systems and connect them to form a national network. Brailer readily acknowledges the challenges of convincing clinicians to change long-standing business processes, of delivering an ROI, and of ensuring interoperability among doctors’ offices and hospitals on a grand scale.

Meanwhile, John Glaser, CIO of Partners Healthcare System, and Hilary Worthen, a physician and senior director of clinical informatics at Cambridge Health Alliance, have labored for years in the trenches to deploy EHR systems. Partners is a network of 7,000 physicians and 10 hospitals, including Mass General, a teaching affiliate of Harvard Medical School. Cambridge Health Alliance includes 25 outpatient centers and three hospitals in the Boston area. The organization records some 600,000 outpatient visits and 20,000 hospital discharges a year. Most of its patients are low income or face language and cultural barriers to accessing health care.

CIO brought Brailer, Glaser and Worthen together in a conference call and via e-mail during October to trade their insights about managing the transition to EHRs successfully.

CIO: Why do we need EHRs?

David Brailer: There are a large number of issues that have reliance upon accessible use of EHRs. First, there are efforts to get more affordability of healthcare services that are based on having information that can allow better decisions to be made. Second, dealing with the quality of care crisis, which is the direct outgrowth of physicians not having the information they need to provide proper healthcare.

Our efforts to try to improve monitoring at the national level of bioterrorism are hampered because [such monitoring] relies upon a very antiquated paper-based system. And finally, the growing need for consumers who recognize that their information should follow them to help improve care. So all of these vectors have come together, resulting in a major change in the trajectory of healthcare IT.

John Glaser: We will have computer physician order entry by the end of this year in all of our academic and community hospitals. [These are systems physicians use to store and manage patient information and to order tests and prescriptions.] We have some early efforts on giving patients access to their data and some early, early efforts in genomic or personalized medicine that use EHRs to support research in genomic-based diseases. It remains a challenge to implement these things. The process redesign is hard. It can be hard to persuade physicians that this is really important to do. Nonetheless, we are shifting—because I think people understand the need to sign up—to an emphasis of effectiveness of use. Often, the physicians will still ignore the guidance that we give them. So, they have “adopted” it, but they are not using it well, and, as a result, the data is incomplete. It’s inconsistent and we are seeing very uneven performance gains.

Adoption is a major issue. The Mass General/George Washington University report shows that doctors are not moving to EHRs as quickly as previously thought.

Brailer: If there is anything that we try to do it is to have a physician realize that this is not an easy process. The issues that really matter here are changing how doctors do what they do, in collaboration with other parts of the healthcare system, from pharmacies and labs in hospitals to nurses, front desk clerks and others. That whole workflow, obviously, must change to achieve the kind of high performance healthcare system that we want, and it goes far beyond loading software.

Hilary Worthen: I am not surprised at the gap between the number of places with a partial implementation and those few with a full one. The most sophisticated parts of EHR functionality are those that support critical multidisciplinary workflows, often involving multiple departments.

You can implement the more basic EHR functions and still have people happily working in their silos, but to do the hard stuff, people need to change their entire way of thinking to a much more collaborative, system-based approach. From what I see, this poses a much deeper challenge than just getting docs to use a computer. We have implemented Epic’s EpiCare system in the [outpatient] realm and we are just now launching it on the inpatient side. Convincing people to do the optimization [of business processes] and to help them understand [how EHRs work] are the big challenges we are facing now. The whole idea of process improvement is something that clinicians do every day. They are trying to improve the process of getting patients to take care of their diabetes, for example. But when you start to articulate it in business terms, it doesn’t instinctively grasp clinicians’ interests. We are working pretty hard to try to get doctors and administrators to understand each other’s languages and to collaborate in the way to make those workflows affected by EHRs much more reliable and accurate.

Glaser: The 10 percent figure means that advanced features will lag in adoption as long as there is little incentive, such as reimbursements, for doctors to use those features and incorporate them into their daily practice.

But, the first thing we have to remember is that sometimes we label users as resisters and sort of cast them as being 4-year-olds who need a nap. Frankly, we are asking them to do tasks that they didn’t do before. The way we get them through this is to engage them quite extensively in decisions of how we implement. You do as well as you possibly can on the software to make it as feature rich as possible. You try to make it as reliable as you can.

We’ve also begun to work with some insurance companies so that if you are a physician who is using this and you are using it well, there’s additional money you will get from the insurance company that can sort of make the economics better.

As we see with Kaiser’s EHR implementation, there are significant technical problems to overcome too.

Brailer: Major corporate change projects of any sort tend to be complex and full of surprises, and Kaiser’s is no different. Someone has to pioneer the EHR in large corporate settings, and it might as well be Kaiser.

Worthen: I am not unbiased, since our organization is an Epic customer too. There are certainly a lot of examples out there of robust Epic implementations. When you add up the number of sites and the hours affected [by system downtimes]—given the scale of the implementation I am not sure anyone can do much better. That said, the scale of Kaiser’s project is indeed enormous, and that level of complexity is likely to uncover unforeseen issues. I’m not sure it means that organizations tackling a less ambitious implementation need to alter course.

CIO: John brought up another important point: money.

Worthen: The leadership of our organization has understood that it is very hard to measure the ROI in strictly dollar terms. If you look at the better quality of care that we can practice, if you look at the better clinical outcomes and so forth, you can’t necessarily translate those immediately into dollars. So they have not been very demanding compared to what they would probably want to see if we were to get a new machine of some sort.

Glaser: The advice that we would give is to plan out the nature of the mission, realizing there are limits to what you can do. Depending on your market, deploying an EHR is becoming something you have to do competitively. It is like online banking. [If you’re a bank], you have to do it if you want to be around.

I think for a larger organization you can get an ROI. It takes a lot of work to get it, but you can get it. I do think there is a need for capital contributions for smaller organizations, which don’t have much in operations to begin with. It’s harder to get these ROIs. There are no clerks to [lay off] and not all that much process to make more efficient.

Brailer: We should bear in mind that, particularly in physicians’ offices, the discussion about ROI is often moot. I say that because providers with EHRs bill markedly more. Doctors call this “better charge capture.” Payers [such as Medicare and insurance companies] have a less friendly way of viewing this increased payout.

But whatever it is called, when EHRs go in, billings increase. I think doctors’ groups have appropriately said that with these technologies, doctors have the ability to provide more documentation and to support and justify their work. But in the end, Medicare and other payers look at the money, and this is causing them to take a negative view of the financial promise of health information technology. In their view, these tools may or may not save money in the long term from safer care, but they are certain that they cost them a lot more in the short term.

Medicare and other payers pay for the volume of procedures doctors provide, not for quality or efficiency. Therein lies the challenge for IT. We can push IT a long distance, but the transformation will only occur when there are market fundamentals aligned toward quality.