Q&A: Adoption, not implementation, drives EMR success
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Woodside is former executive vice president and chief medical officer at UT Medical Group. His career spans more than 30 years and includes faculty appointments at the University of New Mexico School of Medicine, University of Texas Medical School at Houston, and the University of Tennessee College of Medicine.
Haugen, who holds a doctorate in health information technology from the University of Colorado Health Sciences Center, is corporate vice president of research for The Breakaway Group, a health IT consulting firm. She holds a faculty position as co-director of health information technology at the University of Colorado.
Q: Was there a watershed moment that spurred you to write this book, or is it based on a chronic condition that you’ve seen repeatedly?
Haugen: Probably more of a chronic condition. As Jeff and I were working with our clients on the implementation and adoption of EMRs, we were seeing some recurring themes. We started doing some formal interviewing of CMIOs and CMOs. We thought, ‘someone needs to publish a book about this,’ not just a paper but really a methodology around barriers.
The research that we did was over about an 18-month period of time, although we’re continuing with that research, we are collecting data through our survey now and will continue to collect data. Our client experiences [span] many years; our actual research where we were collecting data was just under two years or so.
Woodside: I experienced firsthand a failed implementation, the major cause being lack of adoption. The EMR was implemented well, but it soon became apparent that many users, physicians in particular, were actively seeking workarounds to using the EMR as it was intended to be used.
As Heather and I conducted our interviews and further research, it became apparent that organizational focus was on implementation rather than adoption, e.g., using the EMR according to organization’s policies and procedures and best practices. Metrics were not being routinely collected to determine one way or another whether it was actually being adopted.
Q: In your work, have you seen any organizations that got EMR deployment right the first time?
Haugen: I don’t think very many people get it right the first time. Maybe that’s because no matter what we’re doing, we look with a critical eye to what we could do better. There are degrees of doing it really well. Adoption is pretty dynamic, so organizations have to continue to make adoption one of their highest priorities. If you don’t think about how to sustain adoption, if you think you’ve achieved it, it often degrades over time.
Woodside: Many of our earlier clients engaged us in the midst of a problematic implementation. What we’re encountering more often in this era of ARRA and MU are clients with 500 to 2,000 employees looking at a very short MU timeline and wondering ‘how can we possibly do this on our own?’ They simply don’t have the internal resources to successfully implement and adopt an EMR. They are engaging us to assist them over a much shorter time frame than probably either organization prefers.
Q: Do you believe the proposed meaningful use requirements will encourage adoption as opposed to implementation?
Haugen: Yes, I think they are on the right track by requiring adoption, but it depends a little bit on how they require people to report and what we’re going to ask them for. As I saw some of the criteria looking at patient outcomes, the one thing I think that MU doesn’t address, and it purposely doesn’t address this … is the financial outcomes. I don’t mean make more money, but somehow, even if it’s not in the beginning, we have to gain some efficiencies or believe that financially, we’re doing better charge capture or becoming more efficient in areas that impact our financials.
Woodside: I don’t know that there’s the emphasis on adoption as we think of it, but to satisfy the MU criteria the EMR will have to be adopted, perhaps to a lesser degree initially and a greater degree in the long run. But sustainable adoption won’t occur just by satisfying MU criteria. Those important criteria can provide useful benchmarks and metrics of adoption, but won’t necessarily lead to the full adoption and embrace of the EMR and its routine use in patient care.
Q: What is the most important step a CMIO can take to keep EMR adoption on track?
Haugen: In my opinion, it is the performance metrics. We invest so much time in getting applications installed and trying to get the end-users to use them, that we get stuck in that cycle, and we never stop and say ‘what is it we were going get out of the application?’ If you can provide a dashboard of metrics to the leadership team you can dramatically improve how engaged they are in achieving adoption. Even if you start with a couple of critical metrics, you will gain momentum in the area of performance metrics, that’s good for the organization. It also helps you recognize problem areas, where adoption is low because of inadequate training or because workflows need to be redesigned.
Woodside: I think physician adoption is critical to the success of an organization’s EMR. Physicians bring patients to the hospital, order and/or personally deliver patient care and thus drive the patient safety and quality of care and drive the organization’s costs. They’re enormously influential in the organization through their informal power derived from trust and credibility with staff and colleagues and their medical expertise. They may adopt and embrace the EMR and thereby motivate other physicians and staff or they can subtly communicate negativity that can be infectious. I think the key to physician adoption is to formally involve them in the governance structure of the EMR project.
Q: Of the steps outlined in your book, is there one that is routinely overlooked or underestimated?
Haugen: Too often, the end user is overlooked. In our research, a common theme was a belief that physicians will resist technology. I believe physician resistance is the symptom of a bigger organizational problem. Getting clinicians up to speed quickly in the new application and getting them back to treating patients should be the goal. If you don’t invest in educating all the end-users and helping them feel comfortable treating patients with the new application, you have done them a disservice and they will resist change.
Woodside: Most organizations involve physicians to a degree in the EMR selection and implementation process. But their involvement often does not include a formal governance structure with wide representation and responsibility and leadership empowerment to develop and monitor the policies and procedures relating to physician use of the EMR. I believe this is critical for physician participation to embrace and adopt the EMR.