It's been almost three years since President Barack Obama signed the American Recovery and Reinvestment Act (ARRA), a $728 million stimulus package that set aside a relatively modest $20 million for electronic medical records (EMRs). The initial spark has smoldered since those heady days, and presenters at the 2011 meeting of the American College of Healthcare Executives (ACHE) said most challenges can be traced back to management teams that all too often lack clear goals for flashy EMR systems. In an hour-long presentation called "EMRs: Finally Realizing the Promise," Erik N. Steele, DO, emphasized that EMR success requires leadership and high expectations. "We believe an EMR in an organization that does not have a bold vision for how to use it to drive rapid improvements in quality and cost containment is a very expensive nail without a hammer," said Steele, vice president and chief medical officer, Eastern Maine Healthcare Systems (EMHS). "We want you to see yourself as the hammer, so you can maximize the potential of this nail and drive these objectives in your organization." Co-presenter Catherine J. Bruno, FACHE, vice president and CIO for the seven-hospital EMHS, said that EMRs at their best can help eliminate the inevitable errors caused by human memory. "You must hardwire the desired functions if you want outstanding performance," said Bruno, a 24-year veteran of health care leadership. "As we look forward to the new world of payment reform within accountable care organizations, we know we must get costs under control." Eliminating Errors So-called hardwiring can take many forms, but it boils down to relying on entrenched electronic systems that will literally not allow clinicians to move forward without completing proper protocols. Nagging people will not make things better, because people are all too human. One way to reduce human error is to hardwire the EMR to give specific cues. "You can't move on until you acknowledge the cue," explained Steele, who is still a practicing family physician in addition to his leadership duties at EMHS. "Require a double-check process confirming that you have the right patient. That is hardwiring a reminder system. Insert barriers to the wrong choice. Make it harder to do the wrong thing. Insert various go/no-go points in the decision-making process that make it impossible to go forward until the mandatory action is taken." According to Bruno, EMR hardwiring tools go by names such as: hard stop systems; hardwired reminder systems at the decision point of care (decision supports and alerts); real-time failure identification and remedy (fail-safe systems); error potential reducers and eliminators; empowerment and efficiency enhancement; and performance improvement. For organizations that have already spent millions of dollars to eliminate errors, Steele and Bruno say it is not too late to get a good return on investment. Education and data feedback can bring staff members quickly up to speed and accelerate the timetable for paperless solutions, in addition to the high-level hardwiring. "We used to run reports and go find paper charts," said Bruno, who helped EMHS win a 2008 Davies Award from the Healthcare Information and Management Systems Society. "Now we sit at computers and review critical clinical information. It's not all about the doctor anymore." Meaningful Uses Since passage of the Health Information Technology for Economic and Clinical Health Act (HITECH Act), which was part of the ARRA, meaningful use has remained a prominent, if somewhat mysterious, phrase in the health care world. Even today, the definition is still evolving. Steele and Bruno eschewed a specific definition of meaningful use in favor of examples that demonstrated the utility of EMR. In choosing their examples, they asked: How can we use the EMR to hardwire processes? How can we use the EMR for monitoring? "A computer is not just a typewriter," Bruno mused. "And you must bury the idea that an EMR is just an EMR." In the case of venous thromboembolism, EMRs can exceed traditional expectations, possibly even preventing a death thanks to proper identification and prophylaxis of high-risk patients. "Our goal became zero missed screens or missed prophylaxis of high-risk patients," Steele enthused. "We hardwired reminders at the decision point of care with real-time failure identification and remedy. We spent 12 months educating providers and staff and developing processes. "We did risk training, and prophylaxis ordering was hardwired into the admission process," Steele continued. "You cannot complete the process until you have established the patient's risk level and set up the high-risk patient for prophylaxis. Every morning, all admissions are reviewed by one staff member at each hospital via EMR. All high-risk patients who didn't get prophylaxis are identified, the provider is found for each missing patient, and the screening/prophylaxis is completed. Out of 6,100 admissions in a quarter, we had 60 failures. In the second quarter, it will be half that—less than 1%." Additional Projects EMHS officials next applied the power of the EMR to reducing pricey, and often unnecessary, blood transfusions. Using reminders at the point of care and real-time failure identification and remedy, clinicians changed their thinking on the risk/benefit analysis of transfusing certain patients. "The price is $260/unit for packed red blood cells, and could get to $1,000 per unit with admin costs," Bruno reported. "We were paying for 8,000 transfusions a year, and that got the attention of our CFO. We set a new target to reduce transfusions to those absolutely essential." With the help of an EMR-generated model, there are now evidence-based guidelines for ordering a transfusion. As a result, transfusions for hip patients dropped from 37% to 2% in the first two years, with a similar impact in cardiac bypass across the whole hospital. "There was a reduction in blood product use of 57% in one year," Steele said. "We had an estimated savings of $1.8 million in one hospital, plus the reductions in complications are priceless." Yet another ambitious goal has been getting all women over 50 to have a mammogram every one to two years, or provide documentation that it was offered and refused. Steele admits EMHS is not quite there yet, but the EMR is getting them closer by generating an accurate list of patients and protocols. "The bottom line is there are lots of barriers to everything we are trying to do," Steele said. "It's a journey. When you have a problem to solve, ask yourself how can you hardwire it? If you really want to get to zero errors, you need a vision for how your EMR can help you get there."Greg Thompson is a contributing writer for HealthCXO.