Been There/Done That: Bravo, bravo… Beautifully stated.

These two entries by p-anon and Been There are SO true, yet so often disbelieved or just not understood how true it really is.

There are many, many attributes needed to help assure an excellent system, and any weak or missing link can decrement the probabilities by magnitudes.

I will say this again – it is one of the hardest jobs that exists. Everyone wants change but no one wants to BE the one who has to change.

I love and salute ALL healthcare workers, especially physicians, nurses and pharmacists. They work in an incredibly difficult climate of budget cutbacks and governmental and regulatory controls.

And I also love and salute all IT developers who strive valiantly to deliver solutions that healthcare workers will use to deliver better care and save more lives.

Envisioning a “future state” is hard. Most people are not equipped to truly envision it. They might be able to envision some improvements that directly impact a workflow that they use every day. But few can truly envision a radical, enhanced workflow that eliminates existing steps and even anticipates the need for information before its’ requested.

This is a huge conundrum. Healthcare providers want things to be better but they’re not sure what an improved workflow would look like, especially when it crosses interdisciplinary and departmental lines. IT developers ask questions and model new applications and workflow with healthcare providers, but they are often given misguided or highly biased responses. And getting everyone to “buy in” to the design decisions takes months and months of debate in committee meetings. And sadly, another observation from working decades in healthcare IT – many hospitals will assign their “weakest” links to the IT projects – people that they don’t know what to do with or want to keep out of their hair. People that aren’t good communicators and concensus builders. Folks without vision.

So, how does a hospital end up with a great system implementation? By creating the best design they can – and then constantly watching it, adjusting it, making steady and swift incremental changes. Many of this board have made the same observation that I now state – “Once the system is turned on – that’s when the work really begins”. Once you’re using the system, don’t be afraid to constantly revisit your decisions. Keep investing in making it better. Many systems out there are highly configurable – which means you can alter how they will behave by adjusting configuration settings (vs. waiting on IT software modifications).

Keep working at it AFTER the implementation. Don’t hold on to bad decisions out of pride. Watch and listen to your end users. Respond swiftly to improvements that can be made that will help them get the most out of it. Don’t make them wait years while you send things through endless committees. I could tell you horror stories of hospitals dealing with daily pain in using a system when a 2-minute configuration change could have removed it – but they insisted on months of sending the “change control” through a zillion committee meetings.

Be safe. But be practical. Be diligent. And never stop revisiting your design and workflow processes. You will not have the best system on day one of implementation. But with constant improvements, practically and swiftly implemented, you will win over your end users because they will be able to SEE the system adapting to their needs.

Is it expensive to do this? Yep. But, you should have factored that in at the onset.

I wish everyone out there good luck and best wishes. What you’re doing, whether it be on the IT side, or the clinical side, is HARD. Do not believe otherwise. It is incredibly hard. But, it’s do-able. And there ARE returns on investment if you keep at it. Don’t believe those that are afraid of automation and don’t see the benefit in EHR’s. Clinical patient information MUST be readily available in electronic form to those that need it to take care of patient lives. To believe otherwise is, in my opinion, dangerous.

Regarding Mr. Badgers discussion of “Success with EHR’s in an Ambulatory Environment”—-do you really think you are representative of a typical independent practice? With 280 physicians, and a sense of pride in the important teaching your staff does in association with the University, with students, residents and fellows, clearly it’s not the same “environment” as the typical, fee-for-service, non-salaried ambulatory practitioners out there that make up 60 or 70% of physicians in practice. Even with your stated average of 4,600 patients per day, that’s only 16 patients per physician per day on average. How many practitioners can even make a decent living seeing that many patients per day? But with that kind of load and income non-dependent on seeing more, many more things can be done with their time, I’m sure. Not the case for most physicians in “ambulatory” practices.

Barriers to EMR adoption by ambulatory practices in the broad market have long been more than just the purchase price. The alarming failure rate (“lack of successful deployment, didn’t work as hoped, too much resistance to using it, far more difficult to use than thought, took up way too much time and slowed the patient load, providers quit using it, etc) of EMR in ambulatory practices up to this point has caused considerable “collegial ambivalence”. This is a term now used to describe how providers themselves, when engaged by their colleagues about their EMR usage, are considerably divided on endorsing it. This is especially true among high-performance providers and specialists.

Most “certified” EMR’s available today, incur a significant productivity drag on providers with a high volume of patients, or whose exam-room time is shortened considerably by surgical or procedural schedules. The amount of time and frustration it takes busy providers to navigate the “point & click” menus that a traditional EMR employs to document an exam more that offsets the gains made by the tremendous advantage of getting all records, charts and reports into digital form and universally accessible.

Right now, providers and practices bear all the risk of a “failed” EMR implementation. They pay the price not only in the purchase, deployment and learning cycles, but in the on-going productivity hits to their practice as well. Even the ARRA stimulus funds won’t offset that.

Best advice for providers in ambulatory practices: FIND OUT WHICH EMR VENDOR CANDIDATES will provide several practices in YOUR PRACTICE SPECIALTY and SIZE/VOLUME OF PATIENTS CHARACTERISTICS. Find out how long it took to deploy and how productivity is impacted. Until there are some better industry studies to actually provide this data, all is anecdotal. And stories like Mr. Badger’s could lead practices with far less resources and patient-load burden….to make really wrong decisions.

On the other hand, system design, specifically flexible/extensible/usable system design, is NOT easy, and should NOT be practiced by amateurs (both clinical and non-clinical folk). User Experience experts, experienced business analysts (who are preferably clinicians), and a competent development team (what I consider competent, you may consider setting the bar high). The older wiser business analysts I’ve had the pleasure to work with have had a knack for :
a) getting to the core problem, instead of taking requirements at face value, i.e. “what are you trying to do again?”
b) simplifying
c) gently, subtly arguing with the customer, without getting their hackles up
d) other things I’m leaving out

Compare this to the clinician who is still enthusiastic about using technology to solve problems…the one who has written Access databases that have a 40 page manual detailing some 10 weekly processes, 50 extraneous tables, and which could be eliminated with Excel and some pivot tables. You don’t want that person designing a system, you want them to get some experience first. Any system they design is inevitably overcomplicated, precisely mirrors current broken workflows, and completely inflexible to change. Their system has 10 forms when an Excel spreadsheet would do. Their heart is in the right place, but they need some experience.

Unfortunately, as far as I know there aren’t good books to cultivate the skill of business analysis, just experience.

I’d be curious to hear if anyone has a good BA book or textbook they’d recommend.

Been There: You’re right… that is so absurd. And if it were true that clinicians can so readily learn IT, I think we’d see the wonderful results of their brilliance by now.