Quality And Safety Not Efficiency: Why We’ve Been Selling The Wrong Message on EMRs

… hospitals accidentally harm a lot of people, and much of this could be prevented using clinical decision support to assist in providing safety checking and the application of the latest medical knowledge at the point of care.  In that context, a more appropriate message to be sold in EMR business cases would be “EMRs – more work, to deliver improved safety to patients”*.

 

In recent weeks I’ve been working with a number of health organisations who have implemented Electronic Medical Records (EMRs), and have been somewhat disappointed and surprised with the outcomes.

Typically, clinicians and nurses are reluctant to use these systems, enter the bare minimum of data, and generally view them as an obstacle to be navigated.  And who can blame them?  The seeds of these issues are often sown in EMR business case and design phases where unrealistic expectations are set, disbenefits are ignored and user experience is overlooked.

Here are, in my experience, a couple of the key ways in which we go wrong…

 

We sell the wrong message

Time and again I see organisations tell their clinicians “an EMR will make your job more efficient”.  Except it won’t.  Unless you’re upgrading from a crappy EMR to a slightly better one.  But most organisations move to an EMR from paper, and user experience doesn’t get much easier than paper.

When you write medical notes on paper you never get stopped and told that you are writing something that is logically inconsistent, or that you need to clarify what you mean.  When you prescribe using paper you don’t get interrupted and told that the patient has previously had an adverse reaction to this medication, or that the dosage you have prescribed is outside a typical range.

From a clinical or nursing perspective, you can’t get much more “efficient” than paper.  That’s not really why we implement these systems.  Any program implementing an EMR that sells efficiency as a primary benefit to clinicians and nurses is setting itself up for future trouble.

The real benefits of EMRs fall into two major categories, and these benefits accrue more to patients and to health administrators than they do to clinicians or nurses.

  1. Quality and safety – In my experience, the primary benefit of EMRs should be quality and safety.  Frankly, hospitals accidentally harm a lot of people, and much of this could be prevented using clinical decision support to assist in providing safety checking and the application of the latest medical knowledge at the point of care.  In that context, a more appropriate message to be sold in EMR business cases would be “EMRs – more work, to deliver improved safety to patients”*.
  2. Capturing activity – Like it or not, health organisations need to captured detailed activity information in order to support their funding processes.  This does have inherent value for health organisations, but often not so much for clinicians and nurses.  Ideally administrative information would be captured as a byproduct of an EMR’s clinical value.  However, many first generation EMR systems (particularly in the US) have managed to be administration and activity focused, requiring excruciating compliance whilst simultaneously managing to commit user experience “war crimes”.  We need to do much better in making activity capture a byproduct of using systems for value-adding clinical tasks.

 

We don’t provide any reward for usage

One thing that consistently puzzles me is how health organisations expect clinicians and nurses to enter data into EMR systems without providing any “reward”.  Now I don’t mean financial reward (although that is another discussion…).  I mean the reward of insights into data that weren’t previously available.

If I’m a clinician and I’m going to go to the effort of entering high-quality data into an EMR, I don’t want to see it disappear into a black hole, where the value is mined by health administrators.  No, if you want me to keep entering data then I need to see that data reflected back to me in helpful ways.  I want to see dashboards where quality and safety data is presented in real time, allowing me to be made aware of risks, and to act on outstanding tasks that could mitigate these risks.  I want to be able to understand the performance of my department and how it compares with others, so we can take a pride in being the best.

 

I hope that future EMR implementation programs can take heed of these warnings and sell accurate messages about the true value of EMRs, recognising the genuine disbenefits to clinicians and nurses.  Future EMR implementation programs must give greater consideration to how users can be “rewarded” with insights in exchange for data entry.  And current EMR systems must do a significant amount of work on improving user experience…

 

* And yes, I’m aware that EMRs introduce new classes of safety errors, but that’s a topic of discussion for another day…

 

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