Sunday, February 22, 2009

The spread of EMRs

We had our monthly departmental meeting recently; about 50 to 60 local family physicians regularly attend. These colleagues tend to be more involved in the department (teaching, committees etc) than those who don't attend. My hospital is community-based, but has a strong teaching mandate, especially in family medicine; several of us are involved in research activities.

Our Chief asked people who are or were about to start using an EMR to raise their hands. About 85% of those present did so. Granted, this does not represent all of the family physicians in this area, but it was impressive to see this. Perhaps we have a technology cluster in this area. Certainly, EMR is a frequently mentioned at our meetings. We recently had a brainstorming session for priorities for our department at our executive; members then voted on their top two priorities. The #1 priority was linking the hospital and the community EMR electronically: we all want to reduce scanning. This has not happened yet, but now there is vocal demand for it.

I belong to a Practice Based Small Group (PBSG); we meet monthly for ongoing medical education, since 1995. A year ago, I was the only one using an EMR. This year, out of 11 physicians, three are currently using EMR, three have purchased and are about to start, and two are in the process of buying an EMR. Only three of us do not have immediate plans to start. We use four different EMR systems, which is going to make sharing information and EMR processes a little challenging!

I think that, at least in some geographic areas, we are now past the early adopter stage, that is, an Early Majority of physicians are now purchasing these systems. Purchasing does not mean implementing; I think we will continue to see implementation failures, and the focus of support may need to change towards supporting those who have purchased, rather than encouraging purchases.

I write the occasional PBSG educational module; we have just finished work on the module on Depression. It incorporates some information relevant to physicians using EMRs. I think EMR-specific information will become increasingly added to other types of medical communication and educational materials, as more physicians adopt these systems.

I will be attending the Quality Improvement and Innovation Partnership (QIIP) introductory meeting this week. This is for members of Family Health Teams interested in systematically improving quality in their practices. Although having an EMR is not a requirement, I don't think that many QIIP Teams are still paper based; it is simply too difficult to audit practices without electronic means. Our FHN administrator, our RN, our FHT Clincal Pharmacist and Dietitian are on the Team. It is a good mix. The FHT Executive Director and Medical Director will also be coming. We have two EMRs in our FHT, so a team using the other EMR application will also be participating--and I think this is a very good thing. Unfortunately, some of us have become very proprietary about our EMR application (my EMR is better than yours), and we sometimes forget that we are all on the same Team. Having us participate as a Team in the same project will help us figure out what is similar about our EMRs, and how we can run programs in common across applications (at least to some degree). Or, perhaps we'll have some competition as to who can provide better quality--and that's not a bad thing to be competing about.


Monday, February 16, 2009

Structure, process, outcome

An academic group I belong to has been having a pretty lively discussion on the initial difficulties with starting an EMR. There is consensus in this group (in which everyone is using different EMR systems) that, for the first little while, there is a lot of loss of efficiency. You are quite a bit slower on the computer than on paper. The gains don't come until later, and many people still find that recording a consultation in the EMR (while the patient is in the room) is slower than on paper.

Why is that? Paper is simple. You write things down. It doesn't matter how you write things down. Paper doesn't crash.

The benefit of the EMR is that you can have point of care reminders and you can mine your data for useful information at the practice level. This doesn't happen until (and unless) you enter information consistently, and in the right areas--in other words, you have a well-tempered chart. It is harder to do that than to just jot something down on a piece of paper, and the EMR can make it difficult to enter things in the right area. I went to a conference where the keynote speaker, a GP from England, showed a short clip of how he struggles to write a prescription--after more than a decade of using EMR.

The initial difficulties are magnified by the start-up problems inherent in this technology. Let me explain what I mean by that.

The EMR involves both software and hardware. The hardware means lots of different machines that all have to work properly together. The number of hardware permutations and combinations (servers, routers, firewalls, connectivity, networks, printers, scanners, labelers and all their assorted drivers and software applications) is very large. Failures due to issues involving hardware are very common since there are so many possible points of failure, and can be very difficult to diagnose. There is no dedicated funding for hardware maintenance, nor local expertise in most small medical offices. The EMR companies know more about their own software than about our hardware; they cannot possibly be aware of all the different hardware pieces present in many different offices (unlike corporate branch offices, each medical office is an independant operation, with an individual IT setup). Sometimes the EMR company can't help with hardware problems; we have machines from different vendors, and it can be very difficult to know who to call for help. We also lack the knowledge to plan for hardware failure and redundancy.

"Structure" failing means your printers won't print, your computer doesn't work, you can't connect to your server, your speed is slow. If you don't have a sound Structure, you can't even get to your Processes, and you certainly can't change your Outcomes. Structure is where many EMR projects fail to launch, and the root causes of this are systemic (see above). Paper has a very simple basic Structure (filing cabinets, file folders, pieces of paper), and can't fail at this stage. EMR can, and does.

"Process" is the way in which we do things. If you can't access your records because of a Structure failure, this is moot. If you have solved the Structure problems, then you have to tackle Process; not always easy or intuitive--takes time and thinking. Those that have not bought into the EMR, but are just there along for the ride because their group got one, are much less likely to invest in this. They may benefit from herd immunity, because the group is now functioning better, and the front staff is more efficient--but will be slower with their own patients and in most aspects of their practice.

"Outcomes" is where the big payback happens. This means that the quality of care actually changes: more of your diabetics now have their BP at goal. This requires the ability to not only enter data properly (good Structure and Processes), but also the ability to audit your data and then decide what processes to change, and then re-audit. This is present in potential form in the EMR, but cannot and will not happen unless and until we solve the earlier steps--and if this doesn't happen, you will continue to see studies showing that the EMR is not making much of a difference.

We had a FHN meeting recently; we regularly have EMR booster education sessions at our FHN meetings now. I demonstrated changes since the recent upgrade, such as improvements in our drug module and consultation letters; I also handed out notes. I think it is important to have on-going EMR education. Interestingly, the mood was quite a bit different than in some of our previous meetings: we had less complaining (but not zero), and more interest in what the EMR can do for us and our patients. One of my FHN colleagues talked about how he uses his diabetic reminders to recall people who haven't shown for their regular 3 month visit: he can see the list of overdue visits. This represents a change in Process that is likely to produce a change in Outcomes. It took us three years to get to this point.

Structure - Process - Outcome is a very common way to assess the quality of health care. I think it is equally applicable to EMR implemention.