How to Build a Better-loved EHR

The early adopters are all in, avoiding paper charts and embracing electronic interfaces like they’re the second coming of the horseless carriage. The organization has passed Meaningful Use (MU)  Stage 1 requirements for both Medicare and Medicaid. The initial incentive payments have arrived from the state as well as the feds. The checks have been celebrated and banked if not cashed and spent.
Congratulations. Your EHR is not just established but embedded. Now comes the hard part: making its use commonplace throughout your institution as you advance toward Stage 2 incentives—and as your organization averts lingering chances for noncompliance penalties starting in 2015.

Such is the scenario at many hospitals and provider networks, and insiders agree that maintaining the momentum will call for nothing less than cultural transformation coursing through every healthcare institution. After all, the physician population may have topped the majority mark in 2011, when the Centers for Disease Control and Prevention’s National Center for Health Statistics reported that 55 percent of U.S. doctors were actively on board with EHR systems, but physicians are only one subgroup of stakeholders. And stragglers still abound, including more than a few who say yes to the idea of the EHR while failing to let their actions follow.

For this month’s Profile in Leadership, experienced Meaningful Use evangelists offer three key tips that can help take your EHR from meaningfully used to maximally activated.

1. Operate more like a change manager than an information executive.

First order of business in getting folks to make behavior adjustments: spell out the rationale behind the need to make a change. Stated another way, you need to secure buy-in on a mass scale. “You can’t say, ‘We’re making this conversion because the government says we have to,’” says David S. Muntz, MBA, principal deputy coordinator at the Office of the National Coordinator for Health IT (ONC). “You have to say, ‘We’re embracing Meaningful Use because it will enable us to achieve the goals of the three-part aim behind it—improving the health of the individual, improving the health of the population and improving our efficiency, so we can prosper with the new payment models. ’”

Getting that point across may mean you need to perform some armchair psychology. “Many people, including me, draw our identity from the role we play during the biggest portion of the day, which is the workday,” says Muntz, who spent 38 years in hospital IT leadership positions before going to work for the government. “When you ask doctors and nurses to change the way they’ve been doing things for years, you are challenging their very identity—even when they want to exchange one system for another. The day the outgoing system is most popular is the day before you turn it off, and people have to mourn the loss of the old world before their allegiance takes root in the new one.”

During the transition, Muntz says, the familiar duties of an information systems expert must give way to a new directive in the job description: Lead the charge on institution-wide change.

2. To snowball acceptance up and down the org chart, combine C-suite level forces.

At 259-bed Elmhurst Memorial Healthcare in the western Chicago suburbs, CMIO Robert M. Whitcomb, MD, works closely with the vice president and CIO to whom he reports, Charles Colander, MS, to exhort the institution from the top down. Whitcomb preaches to the physicians, Colander to pretty much everyone else, and, not infrequently, they jointly approach their C-suite colleagues and the hospital’s board members.

They deploy various communications tools—internal e-blasts, high-level committee meetings, newsletters tailored to various stakeholder groups—but do much of the persuading, explaining and cajoling on Meaningful Use in planned and spontaneous personal exchanges. “Sometimes it’s a little good cop-bad cop dynamic, but we work as many angles as it takes to make this thing work,” says Colander, who makes it clear that he’s the owner of the proverbial black hat. “The culture change push is a shared responsibility between the two of us.”
The two-part harmony is working, as evidenced by the organization’s receipt of state and federal MU incentive payments, but major challenges remain. Everyone in the organization knows the importance of clinical quality, says Colander. “But is everyone sold on the idea that the use of the EHR is going to allow them to improve clinical quality in a substantial way?” he asks. “Not everyone is on board with that. Or they think the price to pay for converting all their workflows to something electronic is too high” in commitment and inconvenience. The need for cultural change, he says, extends from “the nurse who’s been working here for 30 years to the executive level.” On the former, he and Whitcomb look to the nursing education staff to play a more proactive role than they have so far in imbuing the culture with an appreciation for the role of clinical informatics in improving patient care. On the latter, says Whitcomb, “We could do more with getting our board really engaged and behind us. That’s something we’re going to work on over the coming months.”

3. Let unexpected pressures remind you to stay involved with your people.

Alan Greenslade, MBA, CTO at Parkland Health & Hospital System in Dallas, has plenty of experience practicing grace under pressure. This serves him well as he carries out his expanding EHR-related responsibilities. Texas health regulators recently hit Parkland with a record-shattering $1 million fine for past compliance failures that, in 2011, led the Centers for Medicare & Medicaid Services to put the historic institution on notice and, earlier this year, on probation. The good news is that Parkland has since made much progress and is readying to move into a new, state-of-the-art campus in 2014.

Working in an atmosphere of ongoing institutional anxiety would test anyone’s nerves, but, in Greenslade’s case, it’s an opportunity to get better at his job as a Meaningful Use facilitator.

“We’re really pushing a lot of technology into our older hospital in preparation for the new facility’s opening,” says Greenslade, adding that this has meant testing and piloting new tools, including iPhones for nurse-call integration, while also reducing the sheer number of information devices the staff has to carry. “We’re doing a lot with mobile and wireless right now. How do I consolidate multiple functions down to as few devices as possible to make people’s jobs easier and less burdened? This is all tying in with Meaningful Use. A lot of people don’t consider infrastructure part of the picture, but without infrastructure, you’d have very limited capacity for Meaningful Use in your EHR.”

Also important, according to Greenslade, is working with his staff on integration of medical devices with the EHR. “The biomedical engineers have gained an understanding of network technology that they didn’t really need in years past,” he says. “So, now we have to give the IT people an understanding of biomedical devices and how they relate directly to patient care. That’s important, because the end user has to experience our support as seamless.”

Greenslade believes it’s equally essential to  remind staff of the organization’s mission. “When you start thinking in terms of ‘patient service first,’ and work back from there, then you’re really doing your job. Because, at the end of the day, even though the application teams and the biomed teams and the doctors and the nurses and the administrative staff and the environmental service staff are all my customers, really, when you get to the end of the line, the patient comes first. That’s a perspective you have to help your people understand.”

Meaningful Use-driven culture change, here we come.

Technical Challenges Take Time Too

Nearly every challenge is an opportunity, and few are purely technical or completely cultural. Here are the top items on the “challenges and opportunities” to-do list of Alan Greenslade, MBA, CTO at Parkland Health & Hospital System in Dallas:

• Security and compliance. “It takes a balancing act to figure out how to maintain compliance and security without overly impacting patient care and provider workflow.  We don’t want to make things so secure and compliant that physicians and nurses can’t function. If we do, we’re delaying patient care.”
• Reporting. “How do we manage a reporting environment and the metrics around that? We have a dedicated reporting database just for Meaningful Use. The reporting needs, especially with the inpatient EHR, are huge and can be hard to manage.”
• Telehealth and video services. “Reducing readmissions and total length of stay, along with avoiding unnecessary transport to the hospital—that’s really a big challenge and opportunity that Meaningful Use is driving. Teleservices from peoples’ homes and, in our case, from the jails that we service, can help us achieve that.”
• Mobile healthcare. “We’re getting tons of requests for iPads. Part of my job is protecting users from themselves, making sure they have not what they want, but what they need for the tasks they have to complete.”
• Staffing. “Right now, we’re looking for people who have direct experience supporting mobile devices. We’re looking to bring them in and get them supporting these devices and then teach them how to support the rest of the environment—rather than take a skill set that isn’t really there yet in someone and try to teach it to them.”

Greenslade is not the only one feeling the pain on that last item. In late September, the College of Healthcare Information Management Executives (CHIME) released the results of a survey showing that 67 percent of hospital IT departments are short-staffed, and 59 percent said their staff shortages would “definitely or possibly” impact their capability to earn EHR incentives from the government.