Why Do Certain Electronic Health Record Installations Fail?

The article Denver Health CIO, COO quit, blame pricey Epic EHR installation, says Denver Health Medical Center (where Dr. Kamens and I trained during our early EM careers) our alma mater had considerable financial and personnel problems during their Electronic Health Record installation. As one might expect, the vendor and the hospital had different versions of what actually happened. Lots of finger-pointing ensued.

Implementation problems of this type may be caused by locally specific factors, but are not unusual throughout the EHR industry, and appear in diverse locations. Finding out (and revealing!) what those fundamental issues were would be a great help to other institutions and vendors.  Unfortunately scenarios of installation blunders are only rarely shared outside the vendor’s office, and we are left doomed to repeat history from which all could have learned.

In the old days (circa 1970’s-80’s) it was common to attend a hospital educational programs called M & M conferences. The New England Journal weekly case discussion at Mass General was a paradigm for many through which medical prowess could be advanced.  M & M stood for Morbidity and mortality. Wikipedia notes:

“M&M conferences “are traditional, recurring conferences held by medical services at academic medical centers, most large private medical and surgical practices, and other medical centers. They are usually peer reviews of mistakes occurring during the care of patients. The objectives of a well-run M&M conference are to learn from complications and errors, to modify behavior and judgment based on previous experiences, and to prevent repetition of errors leading to complications.^[1] Conferences are non-punitive and focus on the goal of improved patient care. The proceedings are generally kept confidential by law.^[2]M&M conferences occur with regular frequency, often weekly, biweekly or monthly, and highlight recent cases and identify areas of improvement for clinicians involved in the case. They are also important for identifying systems issues (e.g., outdated policies, changes in patient identification procedures, arithmetic errors, etc.) which affect patient care.^{[1][3]  “}

In the purely clinical realm, perhaps due to present liability issues, M & M’s may not be as forthright as in the past. For certain, every intern and resident dreaded to be on the podium at one of these events.  “And what were you thinking at that point, Dr. Ausgiblinken?  Today, it is likely that the extent of dread probably includes most staff, physicians, attending, and others. After all someone has to take the blame when things go south.

Knowing an implementation is coming up is a common cause for major anxiety too. Can we do anything about the fact that many doctors, nurses, other providers, and administrators shake in their boots when a new installation is on the calendar? Wouldn’t it be nice if they could be at least as relaxed and as confident as when about to have a colonoscopy? That should not be such a distant dream.  Really.  Nobody puts the clinical, IT, and administrative teams into Sims or Trendelenburg. But to look at their faces the week before the new system arrives, you wouldn’t know it. 

Could we have M & M conferences for EHR implementations, sharing analyses of the good as well as the bad?  Publically available, they could vastly improve implementations, avoid common failures, and create an important knowledge base. Such M and M reviews would be welcome tools from which to learn about what really happened and what problems could have been avoided.

One might discern whether problems encountered were:

1. Systemic
2. Caused by individuals, particular departments, or departmental relationship
3. Resulted from lack of buy-in by the providers
4. A result of insufficient training
5. Caused by Hardware and/or software issues
6. Plagued by Usability issues
7. Due to an absence of effective leadership
8. Arose from a combination of two or more of the above
9. Etc.

Data gleaned from such open discussion would certainly help all institutions and vendors. Become more effective at EH R implantation, for the overall benefit of patients, and healthcare delivery.

Being Honest about Electronic Health Record Costs

In the article Hospitals face budget woes with switch to electronic records, Brigham and Women’s, one of the most famous and profitable hospitals in the USA, lost money in their transition to an Electronic Health Record.

The article is interesting and hospital administrators should pay attention.

            The Electronic Health Record is potentially a great tool when built and used properly. These advantages have a steep price tab when all aspects are factored in.

1. Cost of system (including hardware and software)
2. Cost of ongoing Support
3. Data storage (consider HIPPA compliance)
4. Training
5. Repeat Training
6. Learning curves
7. Difficult user interfaces, frequent updates. These require re-learning and workflow readjustments that are seriously expensive. 
8. Costs of customization
9. Hiring more personnel
10. Getting providers to cooperate
11. Keeping EHR costs within rising clinic and physician budgets.
12. Matching the right diagnosis codes, right diagnosis, and accurate documentation.
13. Over-coding and under-coding
14. Charts that are written in “computer-eeze”.
15. The additional costs of needed modules.  For example: Voice Activated Technology and/or other programs make enterprise systems more user friendly (sometimes).
16. Malpractice worries with mega-data
17. HIPPA concerns
18. Computers and programs can be used to help solve problems but they do not accomplish this “magically”.
19. Volumes of incoherent data collected
20. Burn-out of the staff and providers
21. ETC.

A great many such costs are hidden. We see a good number of task forces created to improve efficiency.  Often they accomplish that goal by jury-rigging work-arounds that only last as long as the task force. A year goes by, and the facility is back to ground zero.

Bottom line, the EHR is a tool; it is not a global solution.  Hence EHRs should be customized to meet the clinical needs of the providers and staff, first. The wishes of the accounting department can be addressed after all the patients are cared for.  

Have You Lost That Burning Desire?

Professional, occupational or job burnout is short-term exhaustion, lack of enthusiasm/motivation, feeling drained and most times there is negative emotions and cynical behavior that result in reduced professional efficacy within the workplace. 

The article Is Technology to Blame for Physician Burnout analyzes the Medscape Physician Lifestyle Report, which states the electronic health record is a factor in physician burnout.  The data identifies three key factors: insufficient income due to reimbursement cuts, extended hours to maintain the status quo, and the negative impact of technology (time, money, and more staff).  When is the last time you had someone smile when the acronym EHR is mentioned??

It is no secret that physicians, as well as all other health-care providers, have been endlessly bombarded with massive political, economic, and social change.  Simply for survival, most every physician and provider has had to rethink priorities just to keep afloat. 

The EHR was once touted as a solution to the chaos in health-care. Instead of being an answer, it has become an added burden for providers'.  Why?  One thing, lack of standardization has created an additional unknown in a providers' environment.  What problems is this thing going to give  me today?  Even physicians who practice every day in the same location, are face with technological impediments.  Those who work at different sites, often have to readjust to a different interface on the fly.  Such impediments include surprise updates, new facility and regulatory requirements, restructured workflows, unpredictable interfaces, and software that is anything but friendly. Add to all that the failed pledge of interoperability- my system will talk with your system- and it is easy to see why the EHR simply has not lived up to its promise--Not even close!  These studies show that a majority of physicians have felt that the presence of EHR technology decreased face-to-face time and the ability to see patients, while only a minority felt that the quality of their practice was improved.

Burnout is a major potential problem for the health-care system, for patient care as well as for the individual provider that may fall prey.  In this environment, the EHR is a natural scapegoat for the deeply entrenched ills of the system.  With the rapidly aging physician population, once can understand that doctors are expressing a desire to get out of the click race.  Hopefully, the next generation EHR will be better than the current one.  Maybe the psychological and emotional contribution to the specter of burnout will perhaps lessen, if not disappear.