EHR Optimization – Finding a Balance (Featuring Dr. Dwight Eichelberger)

“The work of the organization is providing health care, not populating an EHR. It is imperative that IT staff understand the clinical scenarios they are supporting – not to simply re-create, or “pave the cowpath,” but rather to understand the end game – what clinicians are actually trying to accomplish.”  
Dr. Dwight Eichelberger, MD, Medical Director of Informatics at Lancaster General Health
The strategy for optimizing Electronic Healthcare Record (EHR) software requires a delicate balance of evaluating open opportunities to fix or improve existing functionality and workflows in comparison to weighing the pros and cons of implementing new functionality that can accompany a system upgrade.  In order to determine what to optimize or how to optimize, it becomes extremely important to connect with and understand your end-users.

These days, we all have tighter budgets and shorter timelines, often making us go-live quickly with the infamous “80/20” mentality and using as much of your EHR vendor’s out-of-the-box or model system set-up as possible.  Typically, extensive customization is resisted unless absolutely necessary. During the months following a go-live, major issues should have been resolved and you are most likely in a period of control or stabilization, giving your organization ample opportunity to begin evaluating optimization options.  Knowing which optimization options you have will allow you to focus attention on those that will deliver the highest measurable impacts.

Determining What to Optimize
There is a wide breadth of end-users that IT directors and managers converse with and support on a daily basis; from registrars and schedulers to ambulatory providers to inpatient technicians and hospital billing staff.  Each group adjusts to an EHR differently and can require different optimization approaches.  If not already completed, each EHR application team should categorize stakeholder groups that own specific department workflows to help with prioritizing your project plan tasks and milestones.

The ultimate question is: “How do we know what to optimize?” With the help of each stakeholder group, you should be able to identify:

  • Any remaining issues from the initial set-up and system configuration
  • Inefficient workflows that have changed due to the EHR implementation, and that are now causing longer process times than previously experienced
  • Workflows that require additional training

The most successful EHR implementations are those that are not only patient-centric, but end-user centric as well.  The happiness of your end-users directly impacts the level and quality of patient care provided, so the involvement of stakeholders is crucial and cannot be stressed enough.  Not only will they value your proactive approach to addressing their concerns, but you will earn operational sign-off and buy-in that IT management needs when making system changes or enforcing additional training requirements.  It’s often a task as simple as shadowing that puts your staff in front of your end-users and allows them to recognize the issues and difficulties being encountered on a daily basis.  Identifying “quick win” opportunities can yield an important, immediate result – higher EHR satisfaction.

Optimization Prioritization
The conventional wisdom is to begin assessing new functionality to implement during optimization phases; the “20” (20%) that was left out during the initial install or the new functionality that comes with a vendor upgrade.  While you should eventually consider new functionality, that mindset may cause your organization to miss out on “quick win” opportunities and may even cause angst and resistance amongst your end-user population.

“Many times when optimizing your EHR, you are trying to meet an end user’s request to make their workflow more efficient.  This can vary depending on the vendor functionality and ability to modify standard workflows. Vendors always try to have customers stick to the ‘model,’ but sometimes a practical solution is more important than following the norm,” says Eric Croteau, Sr. Consultant with Pivot Point Consulting.

Put yourself in a physician’s shoes.  You received adequate training before the initial go-live, but the system is quite cumbersome and you are still learning the most efficient steps to get through your workflows.  All of a sudden, the system upgrades and your IT team has implemented several new features that change your workflows and require additional training.  That feeling of trying to catch a moving train sinks in and causes frustration.  Unfortunately, this is not an uncommon situation in our industry and we see it happen time and time again.

Dr. Dwight Eichelberger, Medical Director of Informatics at Lancaster General Hospital, has been using an ambulatory EHR since 2007 while practicing primary care.  He has been through his fair share of optimization phases, and he has seen the struggles organizations come across when evaluating how to optimize.

“The paper chart world was full of convoluted workflows that relied on the physical presence and handling of the chart, and yet one always knew where the puck was on the ice. EHRs change that, allowing many simultaneous updates from dispersed locations, but that very same ethereal record has now lost the security of sequential, hands-on processing,” says Eichelberger.

He adds, “Optimization is what organizations have to do as consequence of the concessions to achieve adoption, as much if not more than, it is about mitigating initial software shortcomings via upgrades. So ask the question “What are you trying to accomplish?”, and then ask “Why?” at least five times beyond.  It may get irritating to the recipient, but much less so if you evidence some understanding and appreciation of the stresses and pressures and traditions of the world clinicians inhabit.  Realizing there is rarely a perfect solution that is both on time and on budget, finding an acceptable middle ground between use and usability is best for both clinicians and IT, and positions the EHR as the best proxy possible for assessing how we are doing along the way.”

While vendors regularly offer new features that improve patient safety; give managers better reporting ability; and present a return on investment opportunity; stabilizing an EHR should come first and foremost for your end-users. They are the masters at knowing what is needed in order to be the most efficient at their workflows.   Additional education, tip sheets, and shoulder-to-shoulder training may be all that’s needed. It’s all about understanding the balance between those “quick wins” in order to stabilize versus the need to upgrade. You won’t truly know know what to optimize until you connect with your end-users.   Adam Briggs, former Epic Systems Corporation employee and now Sr. Consultant with Pivot Point Consulting, has conducted numerous upgrades at multiple client sites and offers the perspective of the EHR IT application team member,

“Sometimes just the slightest changes, like reordering forms in registration, or adding a new column to a report, can save multiple clicks for every single patient and end-user accesses – and the time savings can add up fast. Also, getting the registration system in synchronization with the billing and claims systems can help identify issues that could delay billing much earlier in the process. In addition, improving patient flow throughout the facility can also provide big wins for an organization. No two patient-care sites are the same, and the tools they use can benefit from some site-specific analysis to determine the best way to route patients where they need to go, whether it’s the registration desk, the cashier, the lab, or the waiting room.

Be sure you are continuously soliciting feedback from your end-users, either by your issue ticket system, regular meetings, or site visits. Listen to their thoughts, needs, and ideas, and work together to figure out what would work best – they know the process and you know the functionality, and only by working together can you develop optimized workflows,” says Briggs.

The rapid adoption of EHRs and the frequently changing regulatory requirements will continuously present obstacles and challenges for your organization, meaning optimization will never be done.  It is a permanently iterative process, where changes here today set the stage for changes elsewhere tomorrow.  Regardless of the reasons for optimization, strive hard to push in directions that help your clinicians and revenue cycle staff provide effective, accessible, and sustainable health care for the patients your organization serves.

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