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How CIOs can help alleviate EHR issues

EHRs can be more problem than solution for healthcare organizations, but CIOs can help by talking to practitioners and holding vendors accountable.

It's no secret that electronic health records can be more of a hardship than a blessing for practitioners, but CIOs and health IT teams can take on some of the onus by identifying problems and then making adjustments.

One of the most important steps CIOs and healthcare leaders can take to address EHR issues and mitigate risk is to keep their eyes on the end users. Clinicians and nurses, those who interact with EHRs on a daily basis, should be kept in the loop when an EHR implementation occurs or when changes are made to the system after its installation.

When that doesn't happen, clinicians and nurses may take on the unnecessary burden of using an inadequate tool to do their job, which could lead to errors and physician burnout, according to Michael Hodgkins, M.D., chief medical information officer at the American Medical Association.

"You don't implement a system without the end user in mind," Hodgkins said. "You have to constantly be interacting with them, observing how they're using the system and looking for where the problems are."

Keep the end users in mind

Hodgkins said local implementation decisions can have an enormous impact on the way an EHR functions within a healthcare organization. 

He referred to a study conducted by the AMA and MedStar Health, a nonprofit healthcare organization in Columbia, Maryland, that studied four healthcare organizations -- two that underwent Cerner EHR installations and two that underwent Epic EHR installations. As part of the study, users from the four organizations were asked to perform specific tasks such as prescription and imaging ordering. The results showed significant variation in the amount of time, number of mouse clicks and error rates for task completion -- even between sites using the same EHR technology, according to Hodgkins.

A photo of Michael Hodgkins, M.D., CMIO of the American Medical AssociationMichael Hodgkins, M.D.,
CMIO, American Medical

"That can only be attributed to local implementation decisions," he said.

Some EHR issues stem from problems that are beyond a healthcare organization's control such as systems that fail to sync with the EHR system. But some EHR issues are the result of a healthcare organization's own doing. They can be created by complex customization or configuration decisions, which can alter the usability and performance of the product.

Despite implementation decisions made by a healthcare organization, EHRs -- and their vendors -- shouldn't be let off the hook when it comes to EHR issues, Hodgkins said.

Vendors started out with products intended to offer a significant amount of customization, enabling healthcare organizations to incorporate their own ideas about what they wanted out of the system. Now, Hodgkins said, major vendors are emphasizing "standard installations," where vendors ensure a certain level of performance, and are moving away from free-reign customization, something Hodgkins supports.

For CIOs, Hodgkins advised resisting the urge to change and customize the EHR.

"I think it starts with resisting customizing the tool, using a standard implementation and then going from there through observations and interactions with your user community to make very deliberate decisions about whatever changes you're going to make," he said.

Another pitfall is failing to communicate the number of disparate systems a healthcare organization may have, according to Michael Jude, an analyst with market research and analysis firm Frost & Sullivan.

A photo of Michael Jude, an analyst with the market research and analysis firm Frost & SullivanMichael Jude, analyst,
Frost & Sullivan

When sitting down with an EHR vendor, Jude recommended that healthcare CIOs be completely up front about what the organization's environment looks like and what essential integrations are needed, he said.

He stressed that it's important for CIOs to perform due diligence and ask the right questions of vendors, including how the product was developed, whether it has open application programming interfaces, and what's the company's track record.

"I want to know where you've deployed this, what kind of a success story you've had there. I want to talk to the people you've provided these solutions to," Jude said. "I think CIOs can ask those questions, and if they get bad answers back, they may want to reconsider that vendor or they may want to write different contracts. It's addressable."

Assessing and testing current EHR systems

If changes like a software update are made to the EHR, CIOs should conduct rigorous testing to identify usability issues that may come up, a process Hodgkins said is often left wanting.

The AMA, MedStar and The Pew Charitable Trusts issued a report listing four distinct features of what constitutes a rigorous, safety-focused clinical test that CIOs might find useful.

Test cases should focus on how the care team may interact with EHRs and should represent realistic clinical care processes to identify problems that could come up during patient treatment. Concrete goals should also be established with clear, predetermined measures of what success and failure looks like. The test areas must also include known risk areas or areas that could produce inefficiencies. Focusing on those areas can help an organization implement corrections to address clinician concerns, according to the study.

Lastly, the test cases need to be designed for specific stakeholders, such as vendors or providers, and clearly note the intended participants, including nurses and physicians.

CIOs aren't the only ones on the hook to conduct this kind of testing. Hodgkins said vendors should be testing throughout the development process, while CIOs are responsible for testing before and after implementation changes at local sites.

Need for transparency

CIOs can only do so much to solve EHR issues without more openness and a stronger partnership with vendors, Hodgkins said. He called for more transparency from EHR vendors when it comes to bugs or issues with their systems.

Contract clauses between healthcare organizations and EHR vendors today often do not allow healthcare organizations the freedom to raise issues about potential usability problems, he said. And healthcare organizations have to seek the vendor's permission to share information or use a screenshot of the vendor's product for a potential patient safety issue.

"For instance, at one institution, they may find a problem in their EHR and they're trying to sort out what the cause of the problem is," Hodgkins said. "And there may be another system across the street or in another state that has a similar problem, went through the same analysis, found a fix -- and yet nobody shares that information."

A task force within the Health Information Technology Advisory Committee met April 11 to talk about information blocking and how much protection to grant safety researchers who want to share screenshots of issues within EHR systems, a topic that continues to be up for debate. 

"If the vendors were more accommodating, or if the policymakers were more demanding of the vendors, we would've had much better insight into the issues and many more opportunities to take corrective action," Hodgkins said. 

Frost & Sullivan's Jude echoed the sentiment, comparing EHR issues to the Titanic. They're so big that they may need miles to turn around, he said.

"We've invested in a lot of technology and it's got problems," Jude said. "But it's a really big investment, so you have to be fairly focused and pragmatic and deliberate in addressing those problems and doing something about them."

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