Curbside Consult with Dr. Jayne 9/12/11

Mr. H’s recent Time Capsule on hospitals wanting software to do the dirty work of changing physician behavior is as true today as it was five years ago. All too often, we see the fallout of this strategy – poor adoption, user dissatisfaction, and worse.

The editorial mostly discusses CPOE, which was the hot ticket item at the time. Back then, there wasn’t a lot of attention to the ambulatory space, although Meaningful Use has certainly brought that to the forefront for many organizations.

Changing physician behavior on the ambulatory side, whether in an integrated delivery system or in a private practice, brings different challenges than on the inpatient side. Hospital have well-defined governance rules and entities to deal with problems when they arise. (note that I said ‘when’ – this is not an ‘if’ situation. There will be problem providers.)

Typically, you have a medical executive committee of some kind, made up of department chairs, service line directors, administrators, etc. Each specialty department typically has a chair who can address behavior issues with providers. Providers (both compliant and difficult) are used to these enforcement structures as they pertain to delinquent medical records, unsigned verbal orders, and the like.

Providers are used to JCAHO-dictated processes and procedures, care plans, and lots of administrative involvement and oversight. They are typically subject to medical staff bylaws of some kind and can lose their hospital privileges for misbehavior.

The ambulatory space in many organizations, however, is like the Wild West. Physicians are used to a high degree of autonomy. Even in hospital-owned provider organizations, leadership is often unwilling to be the ‘stick’ needed to change behavior. The average primary care physician generates roughly $1.5 million in downstream revenue and organizations are afraid of disruptions to referral and test ordering patterns. Unless there are legal or regulatory issues at stake (and sometimes even in those cases), physician non-compliance is often overlooked.

Implementing an ambulatory EHR is seen by some as a relatively easy way to address these behaviors. Rather than deal with true process and workflow issues, the thought is to just mandate the behaviors through system configuration. The software becomes the third-party “bad guy” to force change.

This rarely ever goes well. Users placed in these situations (both provider and other) immediately demonize the software, the implementation team, the selection team, and the vendor. This negative response isn’t very helpful or productive for anyone.

I’ve been involved in implementations where physicians were told that something is required by JCAHO or Meaningful Use when it frankly had nothing to do with either. It was just used as an excuse to try to make physicians behave one way or another. That puts implementation staffers in the middle of this fight. I’ve seen savvy physicians who know their facts completely derail training and implementation efforts as they argue with training staff who may or may not know they’re part of a manipulation effort, but either way, are not decision-makers.

Independently owned or smaller practices are also subject to manipulation efforts, but usually from within (unless there’s a Stark-related subsidy involved – that adds an additional level of potential control.) Typically, a subset of partners or a lead partner will try to leverage the EHR to change colleague behavior or practice patterns rather than addressing them head on.

We all know the old adage that putting automation on a dysfunctional process will only serve to make it more dysfunctional at a faster rate. Practices who try to implement EHR without cleaning up internal issues first place themselves at significant risk. Much like a driver’s license exam, there ought to be a test before practices are allowed to implement. I know some vendors who do readiness assessments and will reschedule practices who don’t have their acts together, but most seem to allow them to forge ahead regardless of the risk.

Some key advice for ambulatory organizations ready to implement EHR:

• Decide on what level of customization will be allowed. Will it be at the practice, specialty, or provider level? If you’re really willing to support provider-level customization regardless of outcomes, cost, or impact, then you don’t have much to worry about as far as changing physician behavior.
• For practice- or specialty-level decision-making, start the change management process prior to implementation. Standardize order sets and get agreement in the paper world. Make sure new protocols and initiatives actually work in your culture before adding an EHR to the mix.
• Revisit state and federal laws and regulations. Ensure compliance before implementation so that providers clearly understand the origin of the mandate.
• Revisit standing orders and care protocols. Make sure they are up to date. Build them accurately into the EHR and work with your vendor to ensure effectiveness.
• Analyze staff roles and responsibilities. Optimize performance and clarify expectations. If staff isn’t up to par, start remediation now. Help staff understand that EHR will change their jobs regardless of their role, and if they can’t live with that, they need to adjust or start looking elsewhere.

These items seem deceptively simple, but in fact are the hardest things a practice needs to do to be successful and are often the ones that are ignored. Implementing an EHR is not going to accomplish this for you. There are no magical lines of code to deliver a keyboard-induced shock to their sneaky little fingers. Non-compliant physicians will simple use the EHR as an excuse for their behavior rather than change.

Organizations with large numbers of “outliers” may need a formal change management initiative in addition to EHR implementation efforts. The benefit is well worth the cost.

E-mail Dr. Jayne.