overcoming barriers to physician adoption of EHRs

TECHNOLOGY REPRINT February 2014 Stuart M. Hochron Paul Goldberg healthcare financial management association hfma.org overcoming barriers to physician adoption of EHRs AT A GLANCE > A hospital s success in implementing an electronic health record will depend largely on physicians willingness to adopt the new technology. > Therefore, before embarking on such an initiative, finance leaders should conduct a targeted survey to assess the likelihood that the initiative will meet with physician resistance. > The survey results can provide a basis for developing an outreach program that will bring physicians on board by helping them understand the initiative s purpose and giving them a stake in its success. The purchase and implementation of an electronic health record (EHR) together represent a significant investment of time and money for a hospital. Such an initiative can deliver tremendous potential benefits, yet achieving these benefits will depend in large part on physician acceptance of the EHR. Therefore, before investing in an EHR, hospital leaders should consider how ready and willing their physicians are to adopt the new technology. Hospitals often find that delays in EHR implementations or in any other key strategic initiatives, for that matter resulting from physician nonadoption are difficult to predict and prevent. Physicians are likely to applaud a smooth EHR rollout as long as their concerns have been addressed in the process. Indeed, over time, physicians are likely to gravitate to hospitals with the most physician-friendly EHR systems. In our experience, hospitals with high physician adoption rates reach meaningful use criteria earlier and report higher levels of physician satisfaction. Hospitals that have managed physician adoption of EHRs less effectively are more likely to experience delays in achieving meaningful use, to report lower physician satisfaction, and to incur EHR re-engineering costs. In the worst case, delays caused by a failure to align medical staff can lead to physician defections, poor patient outcomes, and financial losses. hfma.org FEBRUARY 2014 1

With such potential for adverse consequences, healthcare senior finance leaders should take steps to help mitigate the risks. Here, we offer an approach that a finance leader can apply effectively not only to an EHR implementation, but also to any other similar initiative that could encounter physician resistance. The Role of Finance Finance leaders role in addressing risks and controlling costs related to physician adoption of EHRs should include: > Participating in oversight of EHR purchase and implementation and providing advice to the EHR team > Asking IT to report on the status of medical staff adoption issues > Offering direct advice to evaluate and focus resources on solutions to physician adoption > Assisting with the development and management of metrics related to adoption program costs and adoption rates Finance leaders also should play a role at the very start of an EHR initiative in anticipating and helping to minimize the costs associated with potential delayed physician adoption of EHRs. To evaluate and minimize the risks associated with physician adoption, finance leaders should assemble a multidisciplinary team comprising finance, IT, informatics, EHR project management, and members of the organization s medical staff to conduct a survey of physicians focused on identifying potential barriers to EHR adoption. Survey Objectives The survey s results can provide a basis for the organization s strategy for physician alignment. For example, using the survey results to categorize physicians according to criteria such as their likelihood to adopt, the barriers they envision, their degree of understanding of the initiative, their training and support requirements, and their preferred method of communication will make it possible to tailor communications to address specific physician issues and thereby increase medical staff cooperation. Through a simple information request, the survey also can serve as a means to obtain accurate office email addresses, personal email addresses, and complete personal cell phone listings for physicians, where physicians are willing to provide this information. Inadequate information in these areas undermines communication between the hospital and its physicians and can contribute to lower physician adoption of key initiatives. At the highest level, to provide the information needed to facilitate adoption of the EHR, the survey should have three primary goals: > To provide insight into the relative receptivity of individual members of the medical staff to the EHR > To identify barriers to adoption > To identify teaching methods best suited to break down these barriers As the saying goes, You can t manage what you can t measure. To obtain clear measures of physicians attitudes and perceptions regarding a proposed EHR, the physician survey should seek to ascertain: > Which issues are important to physicians (e.g., the system s ability to support a physician s independence, its scalability for physicians who practice at multiple locations, and its applicability to physicians whose primary practice site is not the hospital) > The extent to which physicians understand and approve of the initiative > Which segments of physicians are likely to be promoters and early adopters of the initiative, which are likely to be neutral, and which are likely to be resistant to the initiative or be outright detractors > How best to communicate with and manage each segment of physicians It is critical that future actions be guided by the survey results, not by preconceived notions. Managers almost invariably find that their expectations for medical staff groups and for individual physicians change markedly as a result of this process. Project leaders also should not be tempted to assume that anyone on the team already knows what the physicians are thinking. The only way to be certain is to ask the right questions. We have seen one hospital completely redirect its plans on finding that its staff physicians were eager to press on with the EHR but were pushing back only because they did not understand the hospital s plans. 2 FEBRUARY 2014 healthcare financial management

Survey Design Obtaining the information required to create and execute an effective adoption plan requires no more than 20 carefully crafted questions focused on seven areas of actionable intelligence: > Physician receptivity to adopting the EHR > Physician training preferences > Willingness of physicians to volunteer to serve as peer coaches > Physician interest in creating computerized provider order entry (CPOE) templates > Physician perceptions of the hospital system (i.e., the quality and nature of their relationship with the system) > Physicians specific concerns about the EHR implementation > Status of hospital system-physician communications (For a more in-depth discussion of these points, considerations for achieving a high survey response rate from physicians, and a summary of specific targeted survey results, go to hfma.org/ physicianehradoptionsurvey.) The survey results can be used to categorize physicians according to their likelihood to adopt the EHR, and these categories can be used to predict and avoid individual and group barriers to adoption. The following criteria can provide a basis for categorizing physicians: > Familiarity with technology, including physician office EHRs > Willingness to adopt the new technology > Personal expectations for, and previous experience with, hospital EHRs > Understanding of the hospital s EHR plans > Perceptions of the hospital > Expectations regarding training and support > Willingness to participate in the initiative > Preferred methods of communication (e.g., email, text, phone, peer, blog, print mailings, posters) Interpretation of Results The quantitative and qualitative survey results provided by physician respondents can serve as a roadmap for actions to enhance physician adoption of the EHR. Specifically, managers should be provided with individualized information on: > Physician appreciation of the EHR s importance > Physician understanding of the organization s EHR deployment goals > The levels of engagement among contracted, employed, and private practice physicians This information, combined with data regarding the degree to which physicians are engaged with the hospital system s email and other communication tools, can be used to guide educational outreach by identifying which physicians to target with communications outreach, and with what messages and mediums. Meanwhile, data on the average use of technology among physicians, both personally and professionally, can be used to project the medical staff s overall expected learning curve for EHRrelated initiatives. And data regarding physician s perceptions of whether the EHR will have a positive impact on their medical practices can help predict the level of physician pushback for EHR-related initiatives. Understanding whether a smooth deployment of the EHR is likely to improve any given physician s perception of the hospital can enable the hospital to take an individualized approach with each physician. The likely level of physician adoption also will be reflected in the numbers of physicians who indicate a willingness to play an active role in creating CPOE templates and serve as EHR physician coaches who would provide peers with training and ongoing support. Such survey results also will provide managers with the information they need to craft an effective EHR message for medical staff, target their efforts toward reaching key physicians who present a moderate risk for nonadoption, tailor their support system to reach physicians at high risk for nonadoption, adapt and personalize training methods, and identify previously unknown sources of physician support. Further, data gaps that result in communication barriers between the hospital and the medical staff also can be identified and corrected. hfma.org FEBRUARY 2014 3

Action Steps The key action step likely to be necessary based on the survey results is to develop an aggressive physician communications program. By knowing which individuals and groups of physicians have issues with the initiative and what those issues are a hospital should be able to respond in a way that gets physicians attention, with a plan that builds physician confidence and acceptance. Such action following the survey is critically important: Making the effort to understand physicians needs without following-up with clear action is worse in the eyes of physicians than doing nothing. EHR Implementation Case Study: Jersey City Medical Center Jersey City Medical Center in Jersey City, N.J., used a survey like that described in this article before introducing its electronic health record (EHR). The hospital's preliminary rollout plan, developed just prior to the survey, emphasized physician education regarding the EHR s value for improving the quality of care. The initial plan, based on the premise that physicians adoption would depend on their understanding of the EHR's value, focused rollout efforts on underscoring the importance and relevance of EHR to physicians and patients. Survey findings disclosed that, overall, the medical staff: > Well understood the EHR s value > Were eager to see the hospital implement the technology quickly > Were concerned primarily about rollout details such as the level of support and timing issues Nonetheless, the survey did identify pockets of resistance, and it was possible to group physicians into several distinct categories according to the likelihood that they would adopt the hospital EHR. The hospital changed course after the survey and crafted a rollout plan that more thoroughly addressed the identified needs and concerns of its medical staff. The plan included sending repeated, detailed rollout procedural information and updates to physicians particularly targeting those identified as likely to be non-adopters via email, text, blog, print, and other media, offering individual and group training and support as well as peer coaching, and targeting messages to physicians that responded to their individual concerns. Results of this effort led the project manager representing the EHR vender to comment, "This was the smoothest rollout I have ever seen." The plan should communicate the benefits of EHR and its features to physicians and focus education, training, and support-building efforts where these efforts will do the most good. Traditional methods of communication such as posters, newsletters, and emails should be supplemented with targeted messaging to particular physicians (as identified by survey results) in the form of text messages, faxes, phone calls from a peer, and/or regular mailings from the CEO. To be effective, these messages should be carefully sequenced and bite-size using multiple modes of communication that unveil the hospital s story over time. Targeted message placement and highfrequency repetition is necessary to create 360 communications. Using a continuous drumbeat of information is the most effective approach because physicians are notoriously hard to reach. From the C-suite on down, the message needs to be the same: We have heard your comments, opinions, needs, and concerns. We understand what it will take to make our cooperative efforts a success, and we intend to carry out a plan that meets your needs. Post-Plan Assessment Once the communications and adoption-building plan has been in effect for 90 days, the project team should conduct a post-plan assessment using an abbreviated email survey to gauge the plan s success to date, to identify pockets of weakness, and to potentially reach outliers. This brief survey might consist of the following questions: > How would you rate EHR training and support? > How would you rate how well we kept you informed? > How has the way the EHR is handled affected your opinion of the hospital? > What type of communication most effectively delivers EHR information to you? Coordinating an Effective Communications Effort Experience in both health care and other industries suggests that high-resolution physician email surveys (surveys that result in individualized and highly specific answers to key questions) constitute the best way to gather reliable intelligence about physician 4 FEBRUARY 2014 healthcare financial management

concerns, whether those concerns relate to an EHR implementation and or to some other hospital initiatives. Such surveys can be performed effectively using secure mobile messaging technology, a new technology that offers managers new channels for engaging physicians and that promises to become a primary tool for reaching and engaging physicians with messages on a timely basis. Performed properly, surveys conducted using secure mobile messaging are quick and accurate, and provide ample actionable intelligence. Such objective survey results can greatly increase a hospital s likelihood of successfully introducing, and gaining acceptance of a new initiative. implementation and the communication plan developed to promote it address physicians needs and concerns, how effectively specific messages are targeted to specific individuals and groups of physicians based upon identified needs, and the degree to which the hospital follows through with addressing physicians needs. Meeting these requirements takes coordination and team effort, but the payoff will be greater physician adoption and engagement with hospital initiatives. Stuart M. Hochron, MD, JD, is chief medical officer, Navio Health, LLC, Newark, N.J. (stuart.hochron@naviohealth.com). Paul Goldberg, MS, is senior vice president and CFO, Jersey City Medical Center, Jersey City, N.J., and a member of HFMA s New Jersey Chapter (pgoldberg@libertyhcs.org). Nonetheless, physician acceptance of an initiative also will depend on how clearly the EHR Reprinted from the February 2014 issue of hfm magazine. Copyright 2014 by Healthcare Financial Management Association, Three Westbrook Corporate Center, Suite 600, Westchester, IL 60154-5732. For more information, call 800-252-HFMA or visit www.hfma.org. hfma.org FEBRUARY 2014 5