Using EHRs To Reduce Practice Variation


Manuel Lowenhaupt, M.D., Lawrence M. Hanrahan, M.D., Scott J. Cullen, M.D.

November 13, 2005

The impending necessity for physicians to interact with the EHR of their patients affords providerorganizations the opportunity to translate medical knowledge into consistent action.

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As health systems design the processes and information systems through which their physicians view, add to and modify EHR, they are able to structure the interaction in a way that encourages physician compliance with accepted practices – where appropriate – without diminishing the role of the practitioner’s professional judgment.

Most physicians accept the premise that reducing practice variation is a good idea – that it results in better patient outcomes, more efficient use of resources and improved reimbursement statistics. However, strategies to encourage physician compliance with best practices must:

  • Collaboratively seek their advice and consent regarding what those practices will be;
  • Provide credible, reliable data as evidence that the new practices or treatments provide better patient outcomes than the prior ones;
  • Support the new practices with information systems that make it easy for them to interact with EHR and to order the “right” medical interventions for their patients; and
  • Provide feedback so that practitioners can see how their treatment choices compare with those of their colleagues.

You Can’t Tell the Players Without a Scorecard

In a paper-based environment, it is very difficult to determine whether or not significant practice variations exist. Any kind of retrospective review of paper records is immensely tedious and requires enormous resources, only available to providers practicing in academic medical centers. Agencies and organizations that conduct sample-driven chart reviews are usually looking for answers to specific, narrowly focused questions. Chart reviews aimed at determining whether physicians are generally aligning their practices with prescribed protocols or Center for Medicare & Medicaid Services Core Measures that potentially drive reimbursements, are onerous to conduct in a non-electronic environment. Since managing any sort of process requires measurement of appropriate parameters, reducing practice variation depends first on electronic records.

Integrating EHR with a CPOE (computerized physician order entry) system gives all associated physicians access to the comprehensive, current patient information they need, and provides the hospital with essential monitoring and measuring tools to determine which practitioners are choosing – consciously or unconsciously – to vary from established practices. Only a process-driven IT infrastructure can easily track the degree to which physicians are complying with practices and protocols they previously adopted as best practices. An electronic environment makes analyzing practice compliance easier. It can be done routinely in a background mode, presenting the medical director with a daily report of doctors who have complied and who have not complied with use of pre-established order sets, and the extent to which they have deviated from the pathway. Importantly, data gathered during this process can also shed light on why there has been deviation, if it was appropriate and, if not, what steps can be taken to ensure the probability of future deviation is decreased.

This Is Not a Technology Journey

Hospitals and healthcare systems must realize from the beginning, and throughout the implementation process, that EHR is a tool for change, not the driver. The real benefits of EHR come from redesigning clinical processes, aligning the tool to support best practices and providing appropriate incentives to encourage those practices. Implementing EHR within the hospital is a process redesign – not a technology – journey.

Share a Common Vision

A certain amount of practice variation reflects the diverse nature of a hospital’s patient population and is appropriate, even desirable. Use of EHR to monitor and measure practitioner compliance should not be construed as limiting a physician’s treatment options in situations that warrant varying from usual practices. Physicians who participate in the design and implementation of EHR understand that reducing inappropriate practice variations is a desirable outcome. All physicians who practice in the hospital also must come to that understanding. So before implementing the technology that supports EHR and the collection and reporting of compliance data, hospitals must:

  • Communicate a clear vision to all practitioners that reducing inappropriate practice variations is a desirable outcome that benefits them personally.
  • Establish a systematic decision-making model, which requires both an infrastructure and a process, so that decisions regarding best practices can be made and compliance with the practices monitored.

If, for instance, in following a coordinated process of physician involvement and consultation, the hospital decides that Product X is the preferred antibiotic for prophylaxis, does the hospital have the infrastructure that can make that decision stick? Or is the situation more like “1,000 points of veto,” where each doctor feels free to make an independent clinical decision, with no higher authority to consider, no accountability outside their conscience?

Vision sharing is an organizational challenge, not a technological one.

Make It Easy to Do the Right Thing

As a hospital designs the interfaces, menus and data-entry screens by which physicians and other clinicians — and sometimes patients — interact with the EHR, it also structures the processes by which best practices can be prescribed and compliance with them measured. Consequently the design process provides a vehicle for steering the physician toward best practices by making the compliant path easier to negotiate than the noncompliant path. A powerful way to encourage compliance, when appropriate, is to construct order sets in such a way that choosing treatment that complies with established care guidelines can be accomplished with a minimum number of mouse clicks, whereas varying from the established treatment requires a more laborious pathway through various menus, confirmation boxes, authorization screens and so on. The idea is to create an ease-of-usepath that makes it easier to comply with the aligned care model than to order noncompliant treatment. Most records are well-suited to presenting protocols that organize data and present them in structured ways, so that the user selecting a compliant path can enter a large amount of information with a single keystroke. The system must also permit the user to change the protocol and edit the choices on the screen, but less conveniently than ordering the “standard package.” This “convenience lever” is a powerful tool that EHR can bring to the challenge of reducing inappropriate practice variation. Tools such as automatic reminders and protocols simply make it easier for physicians to do the right thing.

Use the Scientific Method

Physicians are scientists and, like all good scientists, good physicians respond well to good data. They enjoy drawing diagnostic conclusions from good data. In delivering care to patients, physicians are empowered by temperament and training to make important decisions based on the medical data in front of them. Physicians will almost always respond well to complete, accurate and comprehensive data, whether about the supply chain and the use of different medical supplies and devices, preferred drugs or different treatment options. If the hospital links good data with what they feel is an appropriate, clinically relevant outcome and a practice that supportably delivers that outcome, physicians will embrace the new practice. They welcome accurate, comprehensive and regular displays of data about how they practice relative to their colleagues. Often doctors are actually searching for a sign to make sure they are applying the right therapeutic intervention or utilizing the right medical device. The ability of physicians to quickly access accurate, comprehensive data through EHR enables the hospital to share best-practice information and data about each physician’s treatment choices compared with that of colleagues. Doctors will change their behaviors if they’re convinced the new practice is significantly better than the old way of doing things.

However, doctors are wary of case studies, group studies with too few cases to be clinically relevant or inferior data based on ad hoc chart audits or surrogates like claims data to get at how doctors are practicing.When confronted with bad or unreliable data, doctors usually reject it and go back to their original practices.

Be Careful What You Ask for

Experience has shown that physicians like knowing how their treatment choices compare with those of their peers. Their performance improves. However, experience also shows that posting these data the wrong way can have unintended and undesired consequences. Doctors are not immune to peer pressure, and so there are helpful and unhelpful ways to share compliance information. Portraying compliance as an unqualified virtue may bring the lower-performing physicians into better alignment with prescribed practices, but it may also have the undesired result of discouraging the higherperforming doctors from varying from prescribed practices when situations warrant.


Often, we know, or think we know, the right treatment options for a patient, but our actions aren’t always consistent with our knowledge. Failure to comply is almost never due to bad intent, but to the complexity of the real world of care delivery. For example, we analyzed the treatment practices of a large group of orthopedic surgeons to determine whether or not they routinely administered anticoagulants to their patients after surgery, a protocol they had all previously agreed upon. Compliance with the accepted protocol was little better than 50 percent, usually because of process delays. This was a failure of execution, not knowledge. EHR can help create a different environment where knowledge is translated into consistent, appropriate action. The power of a clinician’s insight added to the foundation of a computer’s ability to offer consistent and up-to-date knowledge creates the environment for world-class care.

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