By Jonathan Teich, M.D.
Physicians can do much to facilitate the selection and adoption of electronic health records (EHRs) and e-prescribing systems, including clinical decision support (CDS) technologies that bring important information to the physician’s attention just when it is most needed.
CDS has been shown to produce very significant improvements in quality, safety, efficiency and cost when properly implemented; however, sometimes it is not utilized to its full effectiveness, due to barriers related to design and communication. The physician champion participates in design, selection, testing, and communication to others, and plays a vital role in harmonizing clinical needs with technology possibilities.
This article outlines the steps physicians can follow in taking on the roles of information technology champions, mentors, facilitators, communicators and cheerleaders. Here are some of these steps:
Define your victories in advance. At the end of your implementation, what improvements will the system bring that you can measure and celebrate? Outline high-level clinical benefits for the organization, including improved care safety, outcomes, reimbursement, cost effectiveness of care, and compliance with clinical guidelines, as well as enhanced patient education and fulfillment of clinicians’ information needs. Document and target potential clinical benefits as the fulfillment of the organization’s mission, vision and values.
Also, focus on more specific clinical benefits and goals such as decreased complications, minimized adverse drug events, optimized transfers of care, improved billing and reductions in unnecessary tests and length of stay. Throughout your implementation and beyond, communicate successes that have occurred as a result of the new technology.
Showcase business benefits in the context of a transformed organization. Similarly, show how implementation will influence business operations for the better. Zero in on reductions, increases, improvements and enhancements. For example, address how EHRs and CDS can reduce wasted resources, costs of care, liability insurance premiums, and the costs of medical errors. At the same time, unveil possible business benefits such as increased revenues and market share, staff retention and utilization, health services research, medical education, quality of care and outcomes.
Identify criteria for technology selection, based on adoptability and value. Success in technology implementation is the product of ease of implementation, likelihood of adoption and potential impact. To be successful, EHRs and CDS systems must fit the job at hand, making your current work easier and not adding a lot of new work. Make sure that the EHR/ e-prescribing vendor can enhance your workflow with clinically oriented display and entry, support of typical practice patterns, relatively short learning curves, and easy access to the information you need next. Develop “day-in-the life” scenarios of your practice day, and test your prospective vendor’s ability to support them.
Also, concentrate on the ease and trust of the vendor/organization relationship by reviewing evidence on vendor staff experience and knowledge, implementation, training and support programs. Reach out to executives in other organizations served by the vendor, and bring their comments and experience back to your team.
Deliver actual evidence, not just anecdotes, on CDS performance, including improved safety, efficiency and performance on quality metrics. Balance case studies that tell of the highs and lows of a particular implementation with empirical research from many sites.
While clinicians may enjoy hearing stories of healthcare technology successes and failures, they also seek hard evidence, including how EHRs and CDS can increase guidelines adherence, decrease medication errors and adverse events, increase surveillance and monitoring, improve preventive care and resource utilization, and save money. In making the case for EHRs and CDS, turn to peer-reviewed journals such as JAMA and Archives of Internal Medicine along with news reports and features within trade magazines such as Health Data Management, Health Management Technology and Healthcare Informatics.
Be the early adopter and “super-user”. As a physician champion, you will be asked about the new system by anxious colleagues who have not developed a trust relationship with the vendor, but do have such a relationship with you – you’re one of them. If you learn the system early on and understand how it works best with your clinical workflow, you will be in position to motivate your colleagues when they go through the inevitable startup learning curve.
In addition, as an early adopter you are in position to bring requests back to your implementation team and vendor, if some of the system’s screens and data need to be changed to fit your practice properly.
Overcome and counter the myths of EHRs and CDS. Fellow clinicians sometimes arrive at a new project burdened by myths and stereotypes grounded in personal experiences, rumors, gossip and horror stories in the trade media. Technology champions must be prepared to counter myths and reservations with corresponding facts, truths and realities. Among the most common myths related to EHRs and CDS are these:
• “Implementation is easy. All you have to do is remain organized.” Implementation is as much about culture, communication skills and psychology as it is about organization.
• “Once you’ve selected the system, the hardest work is over.” Implementation management is usually considered to be 2/3 of the work in bringing in a new system successfully.
• “The best time to add safety features and extensive CDS interventions is at the beginning.” Try to make the system a friend to the clinician, before rolling out alerts and extra features.
• “ CDS is mostly about getting alerts on your computer.” There are many other forms of CDS, including smart forms, data displays, facesheets and order sets, and some of those can be more effective and acceptable in certain circumstances.
• “What’s so bad about the old way of doing things?” Change is always hard. By demonstrating the victories ahead, you can help colleagues to glide through the initial adjustments – until this becomes the standard..
• “This technology is just going to make my life more complicated. No one will get their work done and I’ll end up losing patients.” In fact, EHR implementations may cost some efficiency for the first few weeks – but the system usually makes up for that that, and more, after it is well ingrained into the practice.
Turn fellow clinicians into consultants. Recruit clinicians who are willing to take on standard implementation challenges such as speed, usability and workflow, culture change, and gaining buy-in and support from clinical colleagues and management.
Participants can include an organization’s chief nursing officer, chief medical officer, chief quality officer or directors of intensive care units (ICUs) or oncology services. Each can help to review original concepts, contribute to the design process, and translate high-level goals into clinical objectives with corresponding actions, baseline performance measures and desired outcomes.
Turn fellow clinicians into technology champions. Find people from throughout the organization who will embrace and share the message of technology innovation. Successful organizations say that the right set of champions is “the smallest set of persons to whom everyone else will listen.” Among possible advocates are the chief information officer, pharmacy directory, patient safety officer, medical director of information systems, director of nursing, and respected physicians from various services and departments.
Provide these professionals with coaching and training on how they can use channels such as e-mail, websites, departmental meetings, breakfasts, one-on-one conversations and educational sessions to address the following questions:
• What is it like to use an e-prescribing system or an EHR?
• What is CDS? How does it affect my work?
• How is it different from what we do now?
• How will it benefit quality of care? What are the business rewards?
• Who else in the country uses this technology and how has it made a difference?
• How will this technology change the way I work and how will it benefit me as a professional?
• What could possibility go wrong? What are the potential problems and liabilities?
• What are the next steps? When will it happen and how much will it cost?
Respond early and often to complaints. New technology projects are often the target of criticism and complaints. If a complaint is justified or reasonable, accept it and treat it like a problem in need of a resolution. Acknowledge that you have a serious challenge ahead and make it clear that you intend to address it within a specific timeframe; then be a reliable conduit to others on the implementation team who can work on the concern.
If you are not sure the complaint is justified or you need additional time to think it over, you can simply acknowledge that you appreciate the feedback and will get back to the person as soon as possible. In some cases, you may want to invite the person who made the complaint to be part of the selection and implementation process.
Achieving success with EHRs and CDS requires that clinicians document the realities and benefits of a transformed organization, select the right solutions, communicate early and often to all important stakeholders and inspire technology adoption, ownership and use. CDS can facilitate improved safety, efficiency and performance on quality metrics if clinicians take on the roles of technology communicators, champions and cheerleaders.
Jonathan Teich, M.D., is chief medical informatics officer for Elsevier and an attending physician and professor in emergency medicine at Harvard’s Brigham and Women’s Hospital.