Despite a 2005 prediction that electronic health records (EHRs) would save $81 billion, RAND Corporation just validated clinicians’ complaints in a report describing EHRs as “a unique and vexing challenge to physician professional satisfaction.” The American Medical Association also published EHR “usability priorities” – strong evidence that current EHRs don’t support doctors in practicing medicine.
In a world of Apple-typified simplicity, why is it so hard to get the right EHR? Because, unlike Apple, EHR designers haven’t started with the question of how value can be created for users of the technology. Technology isn’t the problem. The challenge is in articulating clinicians’ information needs and meeting them by making the right tradeoffs between corporate and business unit strategies.
EHRs can, and should, provide relevant information when and where clinicians need it, recognizing that care is not a commodity and that different care processes have different information needs. User interfaces must anticipate clinicians’ needs rather than require individual user design. EHRs need to eliminate low-information pop-ups and alarms and instead provide alerts and reminders that are both timely and relevant. They must be designed with assiduous attention to data entry requirements, replacing blind mandates with thoughtful assignment of the task and the timing.
In this post I look at how rethinking the design of EHRs can better balance the different strategic needs within care delivery organizations.
Corporate and Business Unit Strategy
A hospital combines multiple businesses, usually described as service lines, within one organization. As a result, they have two types of strategies: Business strategies contemplate how individual service lines—orthopedics and obstetrics, for example—create value for different segments of patients by providing services and solutions to meet patients’ needs. Corporate strategy seeks to increase the value of the individual businesses by operating those businesses under one corporate umbrella. The problem of clinician-despised EHRs results from hospital leaders ignoring the differences between these two types of strategies.
Hospitals must decide what services to provide and how to organize the businesses to achieve greater financial results than would be possible operating them independently. A hospital offering orthopedics, heart care, and women’s health would formulate its corporate strategy to make those service lines more profitable than if they were stand-alone units. While corporate strategy encompasses the heady stuff of portfolios, synergies, and integration, it’s famously difficult to do successfully.
The work of physicians, nurses, and other clinicians is to meet the needs of patients. The multiple business unit strategies within a hospital are necessarily different from one another depending on the health problems of the patients. A man with prostate cancer, a child with asthma, a pregnant woman, and a frail elderly person all have different needs. Business unit strategies contemplate how to care for patients in ways that result in improved health outcomes for patients and profits for the hospital.
Hospitals compound the difficulty because they organize around medical specialties, procedures, and facilities, not how each business creates value for its patients. The regular cycle of conglomeration and divestiture—in health care and every other field—demonstrates that achieving greater results through combinations is difficult — though that hasn’t altered business leaders’ confidence.
The Strategy-Induced EHR Problem
In the era of paper records, hospitals struggled to collect information from across their business units. Nurses attached charge stickers on their sleeves and those stickers got lost on the way to the nursing station. Billing required staffs of experts toiling in dungeon-like record rooms, pulling sheets of paper from files, and manually compiling statements.
The service lines were also plagued by information management problems. Information about medical conditions, current medications, and drug allergies was often gathered repeatedly, or sometimes not at all. Test results couldn’t be located so delays and repeated tests were typical.
EHRs were proclaimed the solution to these and other challenges. Drug interactions could be anticipated and avoided, doses could be checked and all-manner of reminders delivered. Information about patients could be collected once and made available to all clinicians. Electronic orders could improve charge capture and automate billing. EHRs’ potential seemed boundless.
The Strategy Conflict
But the EHR push lost sight of something critical: Businesses exist to meet the needs of their customers. That is how businesses create value. As every clinician knows, hospitals don’t meet patients’ needs; clinicians do. Caregivers execute business unit strategy and create value when they interact with a patient and the patient’s health improves.
Shared activities can help the service lines of a combined business create more value. Combining human resources, facilities management, and similar services should improve results and lower costs. EHRs are a form of shared service and therefore should support the interactions of caregivers and patients to improve patients’ health. But most EHRs were designed around corporate priorities—billing and high-level record keeping—and their support of the corporate strategy comes at the expense of the service lines. These EHRs treat care as a commodity and raise costs by shifting the burdens of data input onto clinicians. As a result, these EHRs don’t add enough value to care delivery, even though care delivery is why hospitals exist.
In fact, care is not a standardized commodity. Treating a sports injury is a different task, with different information needs, than treating infertility. Yet, the information EHRs offer clinicians doesn’t differentiate enough between a fracture and infertility. When EHRs spew a cascade of menus and information that is irrelevant to the immediate situation, clinicians get frustrated. While caregivers need some of the information in a typical EHR, the systems would create more value if most of the information was targeted to the medical circumstances of the patient being seen.
At the same time, EHRs changed and expanded the burden of information gathering, shifting many tasks to clinicians and imposing rigid data requirements. While a patient’s family history of colorectal cancer should be known, it doesn’t make sense to have emergency department clinicians input that information before treating the patient’s broken arm.
Toward an EHR Solution
Looking ahead, providers can help the cause. Beyond asking clinicians to choose the least-bad of poor choices, care delivery organizations should invest in clinician-assisted designers to better articulate information needs. At Boston-based primary care provider Iora Health, for example, clinical teams meet regularly with chief technology officer James McElhiney and his software engineers to define technology needs and prioritize software development projects. New versions of Iora’s EHR are launched as often as twice a month.
In addition to frequent clinician feedback, interoperability is also essential. For two decades policy makers and engineers have tried to give disparate IT systems the capacity to work seamlessly together. At a national level, the lack of system interoperability undermines health information exchanges and raises the costs of administering health care. But for clinicians, the biggest interoperability challenges are within the walls of the hospital. The inability of a hospital’s own systems to function together creates daily headaches and workarounds that undermine effective and efficient care.
At the Delaware-based Christiana Care Health System, CIO Randy Gaboriault seeks to provide clinicians what he describes as an “integrated information ecosystem.” Software designers work with clinical teams to define both the content and the presentation of information, and the technical teams ensure that the organization’s multiple IT systems interoperate to deliver it.
Supporting clinicians’ information needs is also easier when hospitals better organize care delivery. It’s not a coincidence that hospitals with the most effective EHRs and most satisfied clinicians are organized around how patients experience health, not medical specialties and procedures.
Clinicians practicing in related medical specialties at the Cleveland Clinic are organized into Institutes. That structure not only enables more integrated care for patients, it makes it easier to organize IT support because clinicians within each Institute have similar technology needs. It isn’t a coincidence that Geisinger Health System, Intermountain Healthcare, and other providers that are structured to deliver full-cycle care to patients also lead in value-creating EHRs.
Providers will keep buying EHRs. Hospitals are installing new EHRs, and industry monitor Klas estimates that more than a quarter of clinicians want to replace existing ambulatory EHRs. Before buying the next unsuitable EHR, hospital leaders need to address the strategic issue at the heart of the EHR problem: Get an EHR that makes clinician’s professional lives easier, while making patients’ health outcomes better and their health care experiences smoother.