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In the business world, the story of evolving technology is often one of intense competition, do-or-die, where a company that makes products that consumers want wins.

Rewind to the classic videotape format wars of the 1970s between Betamax and VHS (Sony v. JVC). Ultimately, the JVC’s grainier VHS format won out because it cost less and could record longer shows – up to four hours compared to the 60-minute limit for Betamax. More recently, the once dominant business-style Blackberrys have been pummeled by Apple’s iPhone, with its higher-res display, cool apps, super-easy internet browsing, and the ability to check Facebook and Twitter with just a thumb-stroke.

Now, shift to the world of electronic health records (EHRs), also big business: U.S. industry revenue was a staggering $6.5 billion in 2012. Even more impressive is its growth – up from less than $1 billion in 2009. The EHR explosion is sparked by new “meaningful use” requirements in the HITECH Act of 2009, where hospitals receive incentive payments for implementing EHRs and will face penalties for not having them by 2015.

EHRs these days are clearly today’s business “winner”. Much in the way that VHS clobbered Betamax, and iPhone eviscerated Blackberry, EHRs have dominated antiquated paper-based charting systems.

But wait! There is one glaring difference between the EHRs and the nifty iPhone you had no problem shelling out $500 to buy: iPhones are a design-marvel while some of today’s most successful 21st century EHRs have more in common with failed products that consumers never really liked such as the Pontiac Aztek, Apple’s Newton, and smokeless cigarettes.
Some ED EHRs these days are more “lemon” than supercar, slowing down fast-paced EDs, and even repeatedly causing dangerous medical errors through gawky, overly-complex design.

So how did the EHR industry grow more than six-fold in the past three years by marketing products that are just about as usable as 1980s TV remotes? The first reason is that the end user (in this case, the ED provider) is not the most important EHR customer. (Remember that end users decide which videocassette player or smartphone to buy). With EHRs, hospital chief executive and information officers make buying decisions. Factors such as price, interoperability across the hospital, and ensuring every dime of revenue is captured are important factors, while to ED providers, workflow and usability issues – such as being simple to use, reducing unnecessary clicks, and facilitating (not interrupting) ED workflow.

To be fair, some EHRs are better than others and really do facilitate emergency care. The problem is that some of the worst-designed systems are outcompeting best-designed ones, precisely because they seem like a better buy to the CEO and CIO, among other reasons. At this point, what can ED providers do to make our work-lives better and our departments safer in the 1.0 world of “lemon” EHRs?

The answer depends upon whether your hospital has already bought their EHR. If it hasn’t, then the strategy is to become the customer. While the ultimate decision may not be up to ED providers, getting a seat at the EHR decision table can have a big impact. The most important thing is to bring data. Talk to colleagues who’ve implemented various EHR systems and communicate their feedback.

A major “data” limitation is the paucity of ED literature that compares EHR products head-to-head. What is mostly out there is anecdote: stories of nightmare implementations that “ruined” an ED, laden with frustration, heartache, and inevitable staff migration.

There are consulting groups out there such as KLAS research who rate ED EHR systems, but their methodology aggregates provider survey feedback rather than comparing objective performance data such as changes in ED flow or quality after implementation. Studies in the peer-reviewed literature are sorely needed to help ED leaders advocate for the more usable systems.

Note: the more usable systems are the ones that were designed for the ED, where the ED “module” wasn’t an afterthought, retrofitted from the inpatient system where workflow and safety issues are different.

If the system has already been purchased and implemented, getting the hospital to switch systems is probably not going to happen. For example, if your mother accidentally buys an Atari 2600 instead of the Xbox 360, she can easily bring it back to the store. Not so with EHRs. High switching costs in the EHR business make the “just return it, mom, you bought the wrong one” argument impossible.

Given that whatever EHR your hospital chose is probably there to stay (at least for the short term), the first focus after implementation should be setting up a local committee of clinicians and IT professionals to monitor ongoing issues. The group should assess flow and safety concerns and implement workable solutions. The good news is that some of the EHR version 1.0 “lemon” problems are actually fixable with concerted effort.

But the real question is how can we motivate EHR vendors to innovate, and redesign their 2.0 systems for all ED providers to be less clunky and more user-friendly? Specifically, how do we get the EHR vendors to compete based on the needs of the end-user: the ED provider?

The answer is that we, as a specialty, need a coordinated approach. A first step is already done: an article from ACEP’s Quality Improvement and Patient Safety section that details quality and safety issues in ED EHR systems is provisionally accepted in Annals of Emergency Medicine.

But this is only a start. Next, we need to focus on studying EHR systems: what works and what doesn’t. Local successes should be spread widely through the peer-reviewed literature and other information portals – of course, while complying with your local EHRs disclosure clauses.

Once sufficient literature has been generated, we need to do what only providers can do: create evidence-based guidelines for EHR best practices in the ED. The next step is to move from guideline to quality metrics, and from quality metrics to value-based purchasing. Then, what will become important to the real EHR customer (the CEO/CIO) will be aligned with the end user (the ED provider).

But developing evidence takes time, money, and a coordinated effort, as does making quality measures. Wouldn’t it be nice if competition for EHRs worked the same way as iPhones? Unfortunately it doesn’t. Until then, it’s up to us to push the EHR vendors – who we may be stuck with – to refine their products to enhance flow and facilitate the safest delivery of emergency care possible.

Jesse M. Pines, MD
Director of the Center for Health Care Quality; Associate Professor, George Washington University

 

Meaningful Use – Propping up the EHR market without improving quality
EMRs were met with variable acceptance just a few years ago.  The value proposition was often focused on recouping costs from reduced reliance on transcription and enhanced revenue from improved charge capture.  That approach resulted in limited success with hospital CEO skeptics and CFOs looking for guaranteed return on investment for purchasing such a system. The tide turned when a guaranteed pile of cash was bestowed on any hospital meeting the “meaningful use” requirements. Ideally, this shouldn’t have changed the way CEOs and CFOs approached the question of whether or not to purchase an EMR and which vendors to consider.  Unfortunately, it did.  The penetration of EMR installs into the hospital market dramatically increased at this point.  Did quality of the products improve? Did their ability to independently provide a return on investment improve? Not a chance. What flipped overnight, triggering a windfall for EMR vendors, was the influx of new cash into the market and an immediate return on investment.

The total EMR market has been estimated at $6.5 billion, compared to $973.2 million in 2009 when only 12% of hospitals had purchased an EMR. Has meaningful use meaningfully contributed to the quality of care delivery and the availability of information or just removed the financial obstacle for hospitals to adopt EMRs?

-Kevin Klauer, DO, EJD 

 

 

 

Comments   

# Slavery in America in 21st CenturyCharles J. Neilson MD 2013-03-29 21:00
It is a fact that Black males are finding that being a physician in America is as close to being a slave as being on welfare. Except that they are being made to serve others at great expense and self sacrifice as opposed to just getting whatever "Massa happens to give them for being non-productive welfare recipients. There are many examples in medicine where government regulatory bureaucracies (Medicare, Medicaid, CLIA, EPA, etc), insurance companies, hospital administrators, Joint Commission, Hospital attorneys, medical boards, specialty societies, etc etc, all gang up on the individual doctor to impose a relentless barrage of requirements that never stops coming......and even threatens one with incriminating sanctions from just about every bit of minutiae each doctor is required to master.

The recent EHR requirement has impacted upon medical practitioners, doctors and nurses alike, or as said in your article, "the end user". It is tantamount to being relegated back to slavery when hospital administrators can have the controlling power to literally ruin the work place environment, harmony, and efficiency or physicians, particularly as now practiced in every emergency room in America. These administrators have not sought the input before purchasing an EHR of those "end users" who are actually in the trenches and having to use the system.

There are systems put together by obvious computer nerds that do not think like doctors nor do they use common terms that doctors use and therefore end up with a system that makes little sense to doctors and nurses. For example, in their quest to give the administrator an extra freebie by allowing the highest paid member on the team, the doctor, to also be a data form processor (so that ICD9 codes are filled out with diagnoses) these computer designers have listed a huge column of diagnoses in which to search for the doctor's diagnosis. It always seems that the common terms are missing or at the bottom of a long column of rare and unusual diagnoses that one never sees before finally finding the correct term (which is not always there). Looking for "Skin Avulsion Tear" and working through a column with "Skin Lesion with Yaws", "Skin Lesion with Syphilis", etc until you are dizzy makes this not only tedious but draws the process out until you have been pulled into a process now focusing on irrelevant minor needs only the computer requires so importantly.

I spent 15 minutes trying to find the diagnosis of 2nd Degree Burns to both lower Legs with complicating secondary bacterial infection only to find that in the data base it did not exist. For some reason, the data base had nothing to indicate lower legs could be burned. It still took me 15 minutes to find that out. In the name of Length of Stay, Patient Satisfaction, Left without Being Seen, Malpractice potential, time spent with patient, and other factors so important to administrators, why on earth would they pick systems that sabotage a good doctor's happiness in the work place?

This leads to an important question. Why have we not seen in the news at least a few of these thousands of American hospital administrators INDICTED by the feds for receiving kickbacks from these computer companies? If one assumes that there are sufficient doctors playing scams against the government and selecting pharmaceuticals for patients based on a free meal and an engaging interactive conference that pays a $100, then I do not know why the government thinks administrators are not inclined to bilk the system themselves. But they are selecting half a million dollar EHR programs with room for a $10,000 kickback and yet I do not see a "Stark Amendment", or the like, for them to feel singled out (sort of like a slave might have felt because the master expects him to think like that). Better yet, with human nature being what it is, I would bet 10% of administrators have received some form of "incentive" to buy a particular product that the doctors and nurses have NO say in purchasing..... ..yet must suffer at the workplace while the administrator avoids them. Maybe the administrator perhaps spends some time on a prepaid vacation or whatever.

Nevertheless, this EHR business has become the final straw and represents the ultimate slap in the face to physicians and it is no wonder that Black males are spending less money and shorter education times to become quickly more wealthy by avoiding medicine (where those things really were not the disincentive).. .......rather than being a slave to everyone else who has suddenly developed the power to issue the latest "requirements" upon doctors.
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