A Prescription for Achieving Long-Term EMR Adoption

Heather Haugen PhDNovember 4, 2011

Corporate VP Research, The Breakaway GroupInstructor & HIT Co-director, University of Colorado

San Luis Valley Health Information Technology Symposium, November 4, 2011

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The material in this tutorial is copyrighted as indicated in each slide footer and any references made by the author.Companies and individuals may only use this material in accordance with copyrights expressly stated. Contact the speaker directly for further informationNeither the Author nor the Presenter is an attorney and nothing in this presentation is intended to be nor should be construed as legal advice or opinion. If you need legal advice or legal opinion, please contact an attorney.The information presented herein represents the Author’s personal opinion and current understanding of the issues involved. The Author, the Presenter and the San Luis Valley AHEC do not assume any responsibility or liability for damages arising out of any reliance on or use of this information.NO WARRANTIES, EXPRESS OR IMPLIED. USE AT YOUR OWN RISK.

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What is the single most significant barrier to end-user adoption in your organization?

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Lack of resourcesProhibitive expense

Applications are not intuitiveIT owns the projectInadequate trainingCompeting priorities

“There is no more delicate matter to take in hand, nor more dangerous to conduct, nor more doubtful in its success, than to set up as a leader

in the introduction of changes. For he who innovates will have for enemies all those who are well off under the existing order of things, and only lukewarm supporters in those who might be better off under

the new.”

~Niccolo Machiavelli 1532

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Physician Adoption Research • Background

– Recognized physician adoption as significant challenge to adoption of EMRs

– Less than 17% of physician practice groups have adopted today (DesRoches). Approximately 1.5% of hospitals have comprehensive EHR (HIMSS Analytics, 2009)

– Current literature doesn’t differentiate between installed system and a system being used for clinical benefit.

• Research– Interviewed physician leaders representing 3575 physicians

and 496 ambulatory sites– Our objective was to identify the barriers to adoption and

develop strategies to overcome them

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Physician Adoption Research Conclusions

1. Implementation is not adoption. The implementation of an EMR is only a milestone on the journey toward full adoption.

2. Physician adoption is highly dependent on having engaged leaders.

3. Traditional training methods are ineffective for achieving proficient users.

4. Most organizations are not tracking meaningful metrics.5. Sustainment of EMR adoption requires significant resources and

must be maintained for the life of the application.

The Promise of an Electronic Medical Record

“Has the potential to transform healthcare by providing clinicians access to comprehensive medical information

that is secure, standardized and shared.”

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Our Current Reality…

• Fewer than 2% of hospitals believe they can meet the meaningful use criteria today (Jha, 2010)

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EMR Implementation: Hospitals

• Survey of 3049 hospitals (63% of acute hospitals)• 2% had comprehensive EMR, 11% had basic EMR• 17% implemented CPOE• 75% lab and radiology reporting• More likely to have EMR if: large institution, major teaching

institution, part of large hospital system, urban area• No correlation with ownership status- public versus private • Barriers: 74% capital, 36% lack HIT resources• Facilitators: 82% additional reimbursement from EMR

Jha et al., Use of Electronic Health Records in U.S. Hospitals, NEJM, 2009.

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EMR Implementation: Physician Practices

• Smaller practices lag larger practices• Significant increase in adoption in last

3 years• 60% of hospital and health system

owned practices use EMR, 40% of independents use EMR.

• Specialties leading the pack: dialysis, pathology, nuclear medicine. Laggards: psychiatry and holistic medicine.

Practice Size Adoption

All U.S. practices 40.4%

Solo practices 30.8%

2 physician practice 41.6%

3-5 physician practice 51%

6-10 physician practice 63%

11-25 physician practice 71.6%

26+ physician practice 75.5%

SK&A, Bi-Annual Survey, Physician Office Usage of Electronic Healthcare Records Software, Oct 2010

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What Is Causing The Gap Between the Promise and Reality…

“The difference between the promise and our real-world experiences is borne in the assumption

that implementing an EMR and adopting an EMR are the same objective.”

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Consider the marriage not just the wedding!

Consider the marriage, not just the wedding!

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Implementation Versus Adoption

Implementation Adoption

Emphasis Go-live (Event) Outcomes (Process)

Ownership Technical / IT Clinical / Executive

Success Criteria Technological Integrity Role-based Performance

Management Focus Project Milestones & Cost Quality Of Care

Workflow Expectations Repair Redesign

Clinical Involvement Negligible – Short Term Critical – Long Term

End User Attitude Apathetic Or Prejudiced Adaptable

Metrics Project Milestones Outcomes

Training Design Demonstrate Feature Role-based Simulation, & Function Task Completion

Sustainment Post Go-live Left To Chance Primary Management Focus

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Archetypes:Limits to Growth

Fixes that Fail

Peter Senge: Systems Thinking

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Understanding The System

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Physician Adoption Research Conclusions

1. Implementation is not adoption. The implementation of an EMR is only a milestone on the journey toward full adoption.

2. Physician adoption is highly dependent on having engaged leaders.

3. Traditional training methods are ineffective for achieving proficient users.

4. Most organizations are not tracking meaningful metrics.5. Sustainment of EMR adoption requires significant resources and

must be maintained for the life of the application.

Having Engaged Leaders is Unconditional

• Tone at the top• Governance• Importance of clinician

leaders• Staying engaged for

the life of the application

A “reinforcing” system

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Physician Adoption Research Conclusions

1. Implementation is not adoption. The implementation of an EMR is only a milestone on the journey toward full adoption.

2. Physician adoption is highly dependent on having engaged leaders.

3. Traditional training methods are ineffective for achieving proficient users.

4. Most organizations are not tracking meaningful metrics.5. Sustainment of EMR adoption requires significant resources and

must be maintained for the life of the application.

Revolutionize “Training”

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Focus on Proficiency Not Training

Training:• One time event• Classroom/Scheduled • Scheduled • Goal: mastery• Generic content

Proficiency:• Accumulation of experience• In work environment• Anytime/anywhere• Goal: fluency • Role-based content, 80/20 rule

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Precise and Fast, Simulators by Role and Task

Flight Simulation & The Breakaway Method™

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Proficient by Role- Fast

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Physician Adoption Research Conclusions

1. Implementation is not adoption. The implementation of an EMR is only a milestone on the journey toward full adoption.

2. Physician adoption is highly dependent on having engaged leaders.

3. Traditional training methods are ineffective for achieving proficient users.

4. Most organizations are not tracking meaningful metrics.5. Sustainment of EMR adoption requires significant resources and

must be maintained for the life of the application.

Metrics

• End user adoption- Knowledge and certification

• Utilization metrics• Performance metrics- clinical and financial outcomes

- Quality and safety- Meaningful use- Productivity- Cost of ownership/maintenance

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Utilization Metrics

Survey of CHIME CIOs• n = 45• Hospital characteristics

• 89% >100 beds, 40% >400 beds• 60% fully or almost fully implemented EHR

• Adoption defined as 75% of physicians using the functionality according to prescribed best practices

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Utilization Metrics

Functionality Installed Physician Adoption

Clinical Documentation 91% 40-55%

Testing & Imaging Results 91% 90-100%

Clinical Decision Support 84% 41-65%

Computerized Provider Order Entry 73% 16-64%

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Performance Metrics

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Physician Adoption Research Conclusions

1. Implementation is not adoption. The implementation of an EMR is only a milestone on the journey toward full adoption.

2. Physician adoption is highly dependent on having engaged leaders.

3. Traditional training methods are ineffective for achieving proficient users.

4. Most organizations are not tracking meaningful metrics.5. Sustainment of EMR adoption requires significant resources and

must be maintained for the life of the application.

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Lifecycle of Adoption

Optimization

Fluency

ThresholdProficiency

Readiness Implementation Utilization Upgrades/Additions

ADOPTION

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Sustainment

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This Just In…Clinical Outcomes

• Review of current literature• 1995-2004 Chawdry et al• 2004-2007 Goldzweig et al• 2007-2010 Blumenthal et al

- 154 studies- 96 (62%) positive improvement in one or more aspect of care- 142 (92%) positive or mixed positive (overall positive, at least

one negative conclusion.

Blumenthal et al. The Benefits of Health Information Technology: A Reviwe of the Recent Literature Shows Predominately Positive Results. Health Affairs, March 2011.

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Factors Influencing Negative HIT Results

• Lack of clinical leadership• Staff skepticism• Leadership turnover• Unrealistic schedule• Vendor products not ready on time• Workflow issues

Blumenthal et al. The Benefits of Health Information Technology: A Reviwe of the Recent Literature Shows Predominately Positive Results. Health Affairs, March 2011.

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EHR- A Competitive Advantage

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THANK YOU!

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Please send any questions or comments to:hhaugen@thebreakawaygroup.com

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