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EHR adoption: Issues and challenges facing physicians and providers

A Q&A with Donna Akerson, director, Deloitte Consulting LLP; Shantaram (Shaun) Rangappa, MD, director, Deloitte Consulting LLP; Tim Smith, principal, Deloitte Consulting LLP; and Harry Greenspun, MD, director of the Deloitte Center for Health Solutions, Deloitte Services LP, on the issues and challenges facing physicians and providers in the adoption of electronic health records (EHR).

Harry Greenspun, MD: There is tension among physicians and their adoption of EHRs. Can you describe the current state of EHRs and the impact it’s having on physicians and health systems?

Donna Akerson: Health systems have a real need for data to do the kind of analysis it takes to provide effective care at a lower cost to help make the system competitive. As part of that effort, health systems want to build close relationships with physicians. Providers recognize the very real issues physicians have with EHRs, but need to balance that with the need for discrete data to feed the analytic systems. Both physicians and provider organizations benefit from insightful analytics to manage and improve performance and outcomes.

Shaun Rangappa, MD: Physicians respect and acknowledge the need for data and for building EHR systems. But, they also have to take care of the patient sitting right in front of them. They have to deal with them as individuals, with their families, with their own physician colleagues, and with many other health care system stakeholders. That can cause conflict. There is a real concern that complicating the physician workflow with technology that is burdensome will create an additional barrier to a positive patient experience and good clinical outcomes.

Tim Smith: While I think that anything with a learning curve that temporarily reduces provider efficiency can lead to adoption challenges, I think that in many ways the rush to maximize meaningful use reimbursement has exacerbated the problem. Taking the providers through a process of understanding the change, giving time to adjust to the changes, and providing good ongoing support for them is as critical as human factors and other usability changes being suggested for EHRs. EHR vendors could definitely help the cause by better and further leveraging physicians in their design – most have some providers on staff, but few, if any, have established a broader advisory team of physicians who are active users of EHRs.

Harry Greenspun, MD: We’ve seen a broad spectrum of adoption of EHRs by physicians and their practices. Some have had difficulty making the transition, while others are making good progress. What separates the two?

Shaun Rangappa, MD: None of the EHRs are perfect. For successful engagement and adoption by physicians and other clinicians, there are core principles in play that physicians need to help address: How do EHRs affect individual and integrated clinician workflows and rounding efficiency? What is the quality and the evidence base of the content available within the EHR? What is the operational impact on patient care when these systems go live? Organizations that proactively address these local impacts seem to do much better at mitigating risk to wide adoption and eventual proficient use of the EHR systems.

Donna Akerson: The change management piece is really important in all of this. Physicians should be directly involved in the design of the system. As they transform their practices, being directly involved will mean they are going to improve the system to make it work more effectively for them and their patients.

Tim Smith: Some health systems have put all of their effort and investment into the initial implementation and have not sufficiently planned for the “optimization” that is truly needed after the go-live. Ongoing training, small or more significant enhancements, etc., are critical to further enabling productivity. Some vendors recommend downsizing the support team after go-live, and this rarely works as the demand for more only increases after the physicians and other providers have a chance to use the system. Optimization has come to mean, at least to me, “all of the things I couldn’t get done before go-live that I now have to do,” so sometimes the post-live effort is really to fix hybrid or broken workflow versus really optimizing.

Harry Greenspun, MD: How has the Meaningful Use program altered the health care view of EHRs?

Shaun Rangappa, MD: In the minds of many physicians, the program has helped set an expectation of use of EHRs. Since inception, the various incentives and penalties of each stage have had a catalytic effect toward more health IT adoption and EHR use. The challenge for many physicians is the combination of reporting requirements, needed investment outlays, and the changing payment landscape as organizations move to value-based care. It is not clear yet that there has been a sustained cultural shift towards an affinity for the new health IT platforms by physicians.

Donna Akerson: From a health system perspective, we’ve made use of EHRs as the norm. We no longer worry about how to get physicians to adopt the technology, but how do we make it usable for the physician, allowing them to perform all the basic functions and collect necessary data. It is then that they will be able to start using exponential technologies, exploiting the power of cognitive computing and machine learning. The move to value-based care is another area of impact, so we can more accurately measure outcomes and cost and make sound decisions to improve performance.

Tim Smith: Unfortunately, I think a lot about meaningful use has turned into a “check the box” exercise versus really improving patient/provider interactions and improving care. I think the best thing meaningful use accomplished was that it infused technology into health care that was moving too slowly prior to meaningful use, but now the industry really has to focus on obtaining real benefit from the technology.

Harry Greenspun, MD: How do health systems promote alignment?

Donna Akerson: There are basic issues that need to be improved: As systems come together and integrate ambulatory, inpatient, long-term care, and the continuum of care, they need to address value, improving outcomes while decreasing cost. The other key piece is improving the patient experience and their use of a portal to manage their health care. This has been a part of meaningful use where health systems can really help doctors both improve performance and strengthen their relationship with their patients.

Tim Smith: Providing support and enhancements to help the providers go more quickly through their administrative burdens is a great way to promote alignment. Looking for “wins” that help providers with documentation, dropping charges, doing follow-up all help promote alignment. Giving good transparency into their patients and the care they are receiving can also help.

Shaun Rangappa, MD: Creating a shared vision and goal alignment regarding the quality of care to be delivered by its providers and experienced by its consumers is a differentiating opportunity for health systems. The same goes for systems with significant educational and research priorities. When executed well, it folds a well-designed EHR into a welcoming work and care environment for its providers, patients, business partners, and multiple other stakeholders.

Harry Greenspun, MD: Given everything we’re seeing, do we believe that EHRs will remain as the primary platform or will we need to move onto another platform, something closer to a straight customer relationship management (CRM) tool?

Shaun Rangappa, MD: Until recently, the evolution of information platforms that clinicians (and patients) have had at their disposal has significantly lagged the experience in other industries. As a physician leader once told me, the name “EHR” inherently signals this. The fact that we still use “electronic” is somewhat anachronistic. Banking unveiled the then new-fangled “electronic” or “computer” banking in the 1980s. A higher level of consumer expectation ensued, and today it’s just “banking.” In the years ahead, we’ll have EHRs that are increasingly influenced by and likely part of a larger empowered consumer-owned health record.

Tim Smith: We all have the analogies that we like, but I tend to equate the EHRs of today to the engine and transmission of any vehicle. The EHR is a core component to get the vehicle moving, but without everything else that is needed to make the vehicle functional, we can’t really move forward. So all of the enabling technologies that can now leverage the EHR capabilities and data to drive population health, personalized medicine, patient engagement, and the like are what will really make the exponential changes to care delivery and administration.

Donna Akerson is a director with Deloitte Consulting LLP specializing in large system implementations, operational improvement, and performance transformation engagements for integrated delivery systems, academic medical centers, and community hospitals. Shantaram (Shaun) Rangappa, MD is a director with Deloitte Consulting LLP specializing in engaging physicians and other clinicians in process change enabled by EHRs and other technologies. Tim Smith is a principal with Deloitte Consulting LLP and the national leader for the Health Care Information Technology (HIT) practice.


Author bio

As director of the Deloitte Center for Health Solutions, Dr. Greenspun serves health care, life sciences, and government clients on key innovation and clinical transformation issues. He has been named one of the “50 Most Influential Physician Executives in Healthcare” by Modern Healthcare, co-authored the book “Reengineering Healthcare,” and has served on advisory boards for the World Economic Forum, WellPoint, HIMSS, Georgetown University. Prior to joining Deloitte, he served as the Chief Medical Officer for Dell.