Health IT in Georgia Lessons Learned from Providers, Clinicians, and CIOs
Executive Summary In April of 2012, the Georgia Department of Community Health (DCH) partnered with researchers from Georgia Tech s Institute for People and Technology to conduct research and gather community input on the goals, motivations, and concerns of Georgia healthcare professionals regarding health information technology (IT). The initiative informs a customer-centric approach to DCH and its partners programs in support of health IT, including electronic health records (EHRs), meaningful use, and health information exchange. Georgia Tech s research consisted of three complimentary efforts: An online survey of Georgia physicians Interviews with healthcare professionals across a range of roles and organizations A literature review of peer-reviewed papers and industry articles Survey The online survey used a combination of structured and open-ended questions to collect information about participants backgrounds, demographics, and outlook on health IT. Of the demographic data collected, the three most signifi cant differentiators regarding providers attitudes on health IT are number of years of experience (i.e., age), organization size, and level of technology adoption. The survey found that: Fewer years of experience, larger organizations, and higher levels of technology adoption correlate to more positive views on health IT. More years of experience, smaller organizations, and lower levels of technology adoption correlate to more negative views on health IT. Overall, physicians feel that health IT will improve patient outcomes and quality of care. Overall, physicians do not feel that health IT will improve cost savings; respondents in large organizations were a notable exception to this trend. Out of seven possible options, Impact on Workfl ow and Ease of Use were selected as the most important criteria for evaluating health IT by a strong margin; Cost was a distant third. 1
Interviews Over forty individuals across a range of roles were interviewed, including providers, clinicians, offi ce administrators, CIOs, IT directors, and directors of service area HIEs. In addition to their different roles, participants represented a diverse sampling of locations, organization sizes, and patient populations. Interviews were synthesized into Personas detailed portraits of fi ctional characters representing the real viewpoints expressed by participants. The activities and attitudes of Georgia healthcare providers documented in the Personas help readers put themselves in the shoes of research participants, which in turn facilitates better collaboration and decision-making. 2
The Kano Model of Customer Satisfaction An area in which interviews especially complemented the survey was the recognition that participants priorities followed the Kano model of customer satisfaction. The Kano model is a business theory that identifi es three types of product attributes, each of which has a unique value curve: Basic attributes are taken for granted when fulfi lled but result in dissatisfaction when not fulfi lled. Performance attributes have a direct correlation between the degree of achievement and customer satisfaction. Delight attributes are wow features; they provide satisfaction when achieved fully, but do not cause dissatisfaction when not fulfi lled. Delight attributes frequently become performance attributes over time as customers come to expect them. Participants consistently ranked performance attributes as their top priorities and were most vocal about those concerns. Basic Attributes Performance Attributes Delight Attributes Privacy Security Reliability Open Standards Meaningful Use Workfl ow Ease of Use Cost Integration with other care settings Ubiquitous access (online, mobile Unexpected timesavers smart fi lters, short codes 3
Additional fi ndings have been organized into six categories: Health Information Exchange, Workfl ow, Ease of Use, Cost, and EHR Selection. Health Information Exchange A central goal of the research was to understand participants outlooks on health information exchange. In order to avoid potential connotations associated with the terms HIE and health information exchange, Georgia Tech opted to use the slightly awkward but less loaded phrase electronic exchange of health information throughout the research process. Participants were rarely enthusiastic about health information exchange as a capability unto itself, even when asked directly. However, they were emphatically positive about the outcomes associated with HIE again and again, participants spoke about the need for better integration in transitions of care. Key Findings Integration of transitions of care is viewed as one of the most valuable payoffs of health IT investments, but most have yet to achieve it. The highest demand for HIE is between ambulatory and acute care settings within local communities. Physicians and clinicians frequently must switch between two or more EHR systems, often in the same patient visit. You want something that is going to work with our Development of a service area HIE is partly a business decision with the potential to preserve hospital. access to patients and providers, especially in highly competitive markets. HIE is a strategy to get physicians and patients virtually connected it s a battleground you can t see. It s a battle to tie physicians and patients to your brand. Hospitals and practices alike are ambivalent about who should bear the cost of HIE implementation and participation. Given the substantial outlay for initial implementation of an EHR, many practices are reluctant to make additional investments in HIE beyond what is required for Meaningful Use. Although many regional and service area HIEs are planned or underway, only a small number are operational and active. 4
Recommendations Promote open standards and interoperability between EHRs. If banks can talk together, why can t physicians and hospitals? I can go to Chicago and get money out of my bank account, but [hospitals] can t access my healthcare information. Create facilities for demonstrating and testing health IT integration between acute and ambulatory settings. The hard thing about transitions of care is that you can put all that stuff in the EHR, but if it s not being received by the end user, it doesn t really matter. Coordinate communication and collaboration between directors of regional and service area HIEs. Workfl ow Adapting to health IT requires a compromise the organization must change its workfl ow to accommodate the technology, and the technology must be customized to support the unique needs of the organization. For implementation to be a success, they must meet somewhere in the middle; organizations that fail to close the gap fi nd themselves in limbo. The transition can be especially taxing for small practices, which face many of the same challenges as larger organizations but with much smaller revenues to absorb the cost. Not surprisingly, organizations that already have well-defi ned processes and workfl ows tend to have smoother transitions to health IT adoption. Key Findings Many organizations are using health IT adoption as an opportunity to realize effi ciencies through process-oriented practice management and workfl ow. 5
For organizations of all sizes, health IT requires new roles that frequently require re-training and re-thinking of responsibilities. Integration as an organization, we re still trying to get comfortable with the concept of what it means. It means that a lot more people initially may feel a loss of control. Integration of computers into face-to-face patient interactions and widespread use of tablet/ laptop computers by clinical staff appear to correlate with more successful adaptations to health IT. However, providers and clinicians who are new to EHRs frequently have not yet invested in tablets/laptops and may be uncomfortable using computers in front of patients due changes in interaction style or risk of embarrassment. I m more of a people person, so I don t like going into a room with a laptop or tablet because I don t want them to think I m not paying attention to them. Providers are frequently subject to deadlines and penalties for completing patient notes; one benefi t of online access to EHRs is that it allows them to log in after hours from the comfort of their home. Recommendations Proponents of health IT should recognize that paper-based systems have their upsides, including fl exibility, simplicity, and familiarity. Health IT implementations should seek to preserve as many of those positive qualities as possible. I try to be new-wave but old-fashioned at the same Develop case studies and reference implementations for different types of organizations time. that highlight common problems/solutions and lessons learned. Communicate the value of health IT and secure commitment by actively engaging providers and clinicians in change management. Promote the long-term benefi ts of optional components of EHR implementation that cost more initially but pay off over time. These include change management consulting, initial reduction of patient volume, hardware investment in tablets/laptops, and template customization. 6
Ease of Use Ease of use impacts workers directly and continuously as health IT becomes a part of their day-today responsibilities, and has a signifi cant impact on productivity and satisfaction. There is plenty of room for improvement overall, ease of use for EHRs lags behind what users have come to expect from consumer technology such as websites, productivity software, and smartphones. Compared to other roles, clinicians are the most impacted by ease of use, but they usually have the least infl uence in organizations decision-making. Poor ease of use can lead to low morale and even outright rejection of health IT; to reduce that possibility, organizations should look for ways to engage staff at all levels during the EHR selection and implementation process. Key Findings Ease of use is a complex challenge software is usually a part of the problem, but workfl ow, training, and natural resistance to change are also factors to consider. Users perceptions of ease of use are infl uenced by technology previously used by the organization (e.g., practice management software) and other technologies in their daily lives. EHRs with too many required fi elds can actually introduce errors by providing an incentive for providers and clinicians to enter bad data so that they can move on to the next task. However, users acknowledge that there is value in the structure that EHRs impose, especially for patients. [The EHR] doesn t make you faster, but it makes you potentially more honest and more representative of what you do. Information overload is a frequent complaint of providers and clinicians, who are particularly concerned that critical information will blend into the background of an EHR and escape their attention. Technical problems such as crashes and bugs are disruptive and embarrassing. Providers expect systems to perform reliably, without compromising patient care. My biggest fear is the system going down. When the system goes down, we re totally blind. 7
Recommendations Promote best practices and resources so that organizations don t waste time and money reinventing the wheel. Ease of use and workfl ow go hand in hand; optimizing processes enables organizations to implement customizations that will serve them well into the future. Everyone s trying to design a model that everybody can customize to their own practice style. It leaves it so broad and so open, there s so much work to be done. Encourage organizations to limit numbers of fi elds and data requirements to simplify the experience of the end user and decrease the likelihood of erroneous data entry. EHRs should support a range of experience levels. New or infrequent users need an intuitive interface with clear controls, while experts benefi t from more advanced features such as shortcuts and hotkeys. Custom reports and templates should account for differences in needs and usage patterns between providers and clinicians. Cost For participants whose responsibilities include the business side of healthcare particularly CIOs and independent providers cost is a signifi cant concern and source of stress. The costs associated with health IT threaten many organizations fi nancial sustainability, especially those already impacted by larger market forces such as consolidation and an economy in recession. For at least the fi rst year of adoption, the costs of EHR implementation usually outweigh any potential savings by a signifi cant margin. Most providers agree that health IT will lead to improvements in patient care and outcomes, but many are skeptical that it will ever result in cost savings once additional expenses are taken into account. Key Findings Cost savings is not a guaranteed outcome of health IT, especially in the short term. Emphasis on cost savings has the potential to undermine the credibility of health IT advocates. The incentives and future penalties associated with Meaningful Use are a strong infl uencer of health IT adoption, especially for public hospitals serving rural communities and organizations with signifi cant Medicare and Medicaid patient populations. 8
As small business owners, independent providers are especially mindful of cost when it comes to EHR selection and implementation decisions. I m in private practice; I defi nitely need to worry about the profi tability of a system. Indirect factors such as impact on productivity and patient load can make the true cost of EHR implementation diffi cult to calculate. Many organizations, especially those whose budgets are already stretched thin, are reluctant to accept that they will need to invest in and update their technology on an ongoing basis moving forward. Technology changes so much, you don t want to throw a lot of money into it and 3-6 months later have to pay for something else. Providers are apprehensive that EHR adoption will ultimately cost more than it saves. Recommendations Provide roadmaps that set realistic expectations for indirect costs of EHR implementation and time for organizations to realize a return on their investment. Highlight opportunities for organizations to reduce overhead costs and demand for in-house expertise by leveraging HIE and Software as a Service (SaaS) for storage, backup, and security. How much do you want to pay to house someone else s information when you can get it from the HIE on demand? Provide EHR contract boilerplate and suggest best practices for negotiating licensing and support agreements. Continue to promote awareness of Meaningful Use with an emphasis on timelines for incentives/penalties and setting expectations for future phases. 9
EHR Selection Interviews revealed that the EHR selection process is a signifi cant pain point, especially for independent practices transitioning to electronic records for the fi rst time. It can be diffi cult for small organizations to know whom they can trust for advice vendors are obviously biased, and hospitals/hies have an incentive to standardize the ambulatory software used in their catchment areas. Hospitals and large practices face their own set of worries when it comes to EHR selection, including interoperability with existing systems, vendor lock-in, and initiatives that are too big to fail. Key Findings There is a reasonable fear of commitment in selecting an EHR vendor; the cost of implementation is so high that once a decision has been made, the organization is usually locked in for several years. Decision-makers want to be in charge of the EHR selection and purchasing process, but they often feel that the vendor is in control. It s not always clear to buyers which capabilities are available out of the box and which ones require custom development. Some organizations felt that vendors had overpromised on what their software could do. Compatibility with software used by others in an organization s local healthcare ecosystem is a factor in the EHR selection process. Some HIEs and hospitals offer providers discounts on selected EHRs to encourage adoption and platform standardization. Recommendations Provide EHR selection guidelines targeted to the needs and priorities of key decisionmakers, including hospital CIOs, CEOs and IT directors of large practices, and providers in independent practices. Create a statewide directory of organizations EHRs and encourage peer-to-peer interaction for sharing best practices and lessons learned. Promote webinars and demonstrations by unbiased, non-vendor sources, including veteran users and early adopters. Encourage the development of purchasing cooperatives for ambulatory EHRs to give smaller practices more power to negotiate. 10