Dr. Stephen Beck, CMIO at Mercy Health (formerly Catholic Health Partners) discusses how his organization is approaching EHR usability to deliver improvements in efficiency, care quality and provider satisfaction.
Nearly every day I read a new article about physician dissatisfaction with EHRs. There seems to be many reasons for this attitude. Part of it is the need for better data collection tools to ensure ongoing optimization to keep pace with changing regulations. For example, an October 2009 AHRQ Publication pointed to an oft-cited limitation in the use of health information technology (health IT): the “usability” or, more broadly, information design, of EHRs. Information design represents the art and science of preparing and conveying information so that it can be used with efficiency and effectiveness.
It’s not that most EHRs aren’t usable. I think they are. But over the last year or so there’s a growing list of complaints from doctors saying they aren’t properly structured. It goes beyond baseline usability and points more toward requirements the government has instituted on providers regarding documentation and required actions, such as when it comes to Meaningful Use. If a physician is part of an ACO, there’s an additional list of items. This results in so many simultaneous government-based programs that, when Medicare’s requirements are thrown in, the situation becomes almost unbearable.
Challenges at the Government Level
The government has come up with a lot of great ideas but with so many hoops to jump through for implementation, many providers and organizations will face significant challenges unless they develop a more thoughtful approach that builds out new tools and structure. EHR vendors aren’t typically at the table when these mandate discussions take place, so the functionality and features necessary to comply with many of the requirements aren’t available out of the box. If one adds in the melting pot of Meaningful Use – which we all are focused on because of heavy incentives and disincentives in 2015 – it equals a lot of missed opportunities to begin workflow enhancements that will improve usability and functionality required to keep pace with a rapidly changing industry.
We currently have a reimbursement-based care system but what’s happening at the government level is changing the care model. For example, often the services provided by care managers for patients in medical homes aren’t fully reimbursed, or if at all. Further, 2015 will bring a continued adjustment required to keep pace with an evolving care model and an overall shift from fee-for-service to value-based care.
At Mercy Health, we are focused on leveraging staff, tools and workflow to improve patient care and clinician support. It’s the right thing to do, but it isn’t always aligned with reimbursement. That makes it very challenging. We are experiencing this first-hand with the Medicare program around Chronic Care Management (CCM). CMS’ proposed Medicare Physician Fee Schedule for 2015 includes a new code for CCM. Unfortunately, it also includes projected pay cuts required by the sustainable growth rate (SGR) formula used to determine physician payment.
As the Advisory Board Company outlined in an August 2014 Daily Newsletter, physicians who receive the fee must develop a comprehensive plan for each participating patient’s care. Physicians also must:
– Assess patients’ medical, psychological and social needs
– Ensure patients take their medications
– Monitor care given by other doctors; and
– Arrange for smooth transitions when patients move between different care facilities.
In addition, CMS will require physicians to start using EHRs to better exchange information with all care providers involved with a patient.
We are developing our own workflow and tools to support the requirements of this new regulation, which goes into effect on January 1, 2015. It’s a work in progress, but our hope is that this will lead to greater usability, better access and enhanced physician satisfaction with our EHR.
Ease of Access
Whether the goal is treatment recommendations, getting information on a lab result or providing patient education, integration brings into the workflow at the point of care the answers clinicians need.
Ease of access to that information is particularly important when one considers the impact that clinical decision support can have on patient care. For instance, studies have shown an association between use of a clinical decision support tool we use, UpToDate, and improved clinical outcomes. Most recently, in 2011, a study conducted by researchers at Harvard and published in the Journal of Hospital Medicine found an association between use of UpToDate and reduced length of stay, lower risk-adjusted mortality rates and improved quality performance.
Furthermore, in a June 2011 Clinician Study conducted by UpToDate, 91 percent of physicians indicated that having a clinical decision support tool embedded in their EHR was important to patient care and 89 percent said it enhanced satisfaction with their EHR. forty percent indicated it encouraged them to use their EHR.
EHR Implementation is Just the Beginning
For most healthcare organizations, EHR implementation is just the beginning. It is the responsibility of both organizations and vendors to continue to improve the usability of the provider/computer interface.
Part of what we are hearing as new regulations come out is that it’s more difficult for certain EHRs to keep up. We are large enough that we’ve been able to build and develop new workflows around our system, but one- or two-doctor practices may not have the resources to customize or leverage new tools on their own. They must rely on what the vendor provides out of the box.
Thus, EHR vendors will always need and want to update their systems to make them more usable, to add new features and enhanced functionality. On the health system side, we need to continue gathering feedback from our providers and fine-tuning our system independently but collaboratively with our vendor.
While Mercy Health is not perfect, we have made a conscious effort to:
1. Keep up with the latest versions our EHR company makes available,
2. Listen to the ongoing feedback of our markets and providers,
3. Be open to innovations in the workflow and new tools (such as population health) and
4. Maintain standardization of clinical content and tools to make the organization safe for patients and yet nimble enough to continue to modify workflows and tools as regulations change.
We found we weren’t 100 percent compliant with Fall Risk, a fairly simple measure for documenting whether or not a patient over age 65 is at risk. It’s a newer regulation for ACOs and one of the initial 33 required. We did not have the tool in our EHR so we added it to our nursing documentation workflow, that prompts staff to screen the patient if a risk assessment hasn’t been taken in a year. If the assessment is positive, we now have a separate alert that triggers an opportunity for clinicians to act on the positive screen by offering a home assessment, further evaluation or even physical therapy for balance.
There are many great tools which enhance providers’ EHR experience, although some vendors will always do a better job than others of facilitating workflow to help staff do the right thing at the right time. For instance, if a patient is overdue for a mammogram, I’d rather see my nurse or medical assistant use a decision support tool to begin communication with the patient and have an order queued up and ready to go for me.
These are just two specific examples of how we integrate and leverage clinical decision tools and staff to improve EHR usability. After all, meeting a government measure and delivering excellent care should ultimately make the healthcare experience better for patients and providers.
The usability of EHR systems, while recognized as critical for successful adoption and Meaningful Use, has not historically received the same level of attention as software features, functions and technical requirements (e.g., interoperability specifications).
Through collaborative efforts between physicians, researchers and vendors, these recommendations and frameworks can be further refined. When we promote the necessary industry focus on EHR design and its significance, we can more consistently deliver desired improvements in care quality, efficiency and provider satisfaction.
Stephen Beck, MD, FACP, FHIMSS, currently serves as Chief Medical Information Officer at Mercy Health (formerly Catholic Health Partners). He has more than 15 years of experience in planning, implementation, training and follow-up of EHR installations in civilian and military populations and was one of the first physician users of a fully integrated EHR in Southern Ohio.
Dr. Beck was among the first physicians to attain CPHIMS certification, has been a content reviewer for the HIMSS National Conference, and chaired the HIMSS National Professional Practice Task Force. He is a Fellow of both HIMSS and the American College of Physicians and serves on the HIMSS Clinical Decision Support Workgroup.