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Accenture

If it addresses their concerns and helps them provide better care, physicians will adopt a changein clinical processes.

As hospitals contemplate implementation of EHRs, they need to be realistic about what physicians are willing to adopt. Importantly, designers must monitor and understand how willing their medical staff will be to adapt their clinical processes to a new electronic environment. The goal is to create a clinical information system and an electronic environment that physicians will want to use, both in the beginning and increasingly over time. The ability to interact productively with an integrated clinical information system providing access to a global and comprehensive EHR and providing computerized physician order entry is rapidly becoming a vital part of every physician’s medical practice. But physicians are diverse in their aptitudes and appreciation of these technology tools. To lead their physicians gracefully (i.e., not kicking and screaming) to a necessary electronic environment, hospitals must disabuse themselves of two prevailing myths, each pointing to an opposite but equally unhelpful implementation strategy:

Myth 1: If You Build It, They Will Come

Adopting an electronic environment for the long term means providing benefits that are worth the effort of learning the system and the perceived time it takes to use it. In order to gain physician acceptance, any new technology must have a positive and convincing answer to the question, “How’s this going to help me and my patients?” There must be personal and professional gain, because physicians, although they’re slowly beginning to accept some organizational values, are typically still autonomous and individual in their values and culture. To date, IT vendors have had limited success gaining physician acceptance of computerized clinical systems.

Myth 2: Physicians Are Averse to Technology

In fact, physicians see themselves as scientists, believe in evidence- based medicine and routinely take the time to learn technology they perceive as useful. Physicians in general embrace technology as soon as they are confident it can help them provide better care to patients.

Attractors: What’s in It for Me?

As caregivers and as gatekeepers to various and occasionally costly medical interventions, physicians have had their motivations closely examined. Money? Power? Largesse from pharmaceutical companies? The consistent answer in surveys and questionnaires, and as evidenced by physician behavior is — cynics beware! — the desire to give quality care to patients. The real reason a physician gets out of bed at 3 a.m. to care for a patient having a serious episode in the ER is a professional commitment to quality health care. In implementing EHR and its processes and technology, there is no stronger motivator for physician support than a clear demonstration that the system will help them take better care of their patients.

Increased safety for patients — and the resulting mitigation of risks such as malpractice — also motivate physicians. If the hospital can show them — all other things being equal — that EHR and its accompanying electronic environment can give an alert when the physician prescribes a drug to which the patient is allergic, or issue a reminder when a diagnostic test is overdue or tap into its evidence-based treatment protocols at 3 a.m. when the physician perhaps isn’t thinking all that clearly, they would see those benefits of EHR as powerful motivation for change.

Any system that integrates electronic health records (EHRs) into an electronic, interactive environment will include an order management tool. Ample data demonstrate that where such tools are in place, the time between the physician prescribing a drug and the patient experiencing the therapeutic effects of the drug is dramatically reduced compared with a paper-based process that involves prescription pads, several handoffs, inboxes, fax machines and other manual processes.

Owning the system and its processes is another important attractor for the physicians who will use the clinical information system. Physicians — or any other users of such a ubiquitous system — tend to be more forgiving of the system’s imperfections and the bit of extra time it may take to use it if they were involved in its design and implementation from the beginning. As owners and sponsors, they tend to expend effort remedying the inevitable “bumps in the road” rather than blaming those who shoved a pre-ordained set of policies and practices down their throats.

The issue of physician ownership must be addressed early and often. Physicians must share the hospital’s vision of why a computerized information system is worth their time and trouble and must take a pivotal role in deciding how the system will be implemented.Whatever costs are involved in developing the appropriate organizational structure, resource infrastructure, education and increasing cycle time for physician involvement will be returned tenfold in the hospital’s ability to achieve a successful system implementation.

Barriers to Implementation: How Much of My Time Will It Cost Me?

Solution vendors like to claim that an integrated information solution around EHR is time-neutral or perhaps a slight time saver. Realistically, from the physician’s perspective, interacting with EHR takes a little more time than handling pieces of paper, although it reduces the clerical functions of other clinical staff. Physicians have three kinds of interaction with a clinical information system:

• Access to results;
• Electronic documentation; and
• Order entry.

There’s no question that access to results such as lab tests, radiology images and other diagnostic procedures is most quickly and easily accomplished in an electronic environment. Physicians perceive this aspect of the electronic environment as a strong benefit.

Documentation control, such as inputting treatment notes and updating medical histories, can be time-neutral or burdensome, largely dependent on the physician’s typing abilities. This aspect of interacting with EHR can be agonizing for a physician who is a hunt-and-peck non-typist.

Viewed narrowly — i.e., how long does the interaction take me versus how long does it take between the time I order an intervention and when the intervention happens — order entry takes 10 to 20 percent longer in an electronic environment, especially for a novice or inexperienced computer user.

Experience has shown that the real challenge in gaining physician acceptance of a clinical information system is in reducing the perceived time to conduct a transaction. Typical issues include:

• Placement of terminals; and
• Complexity of logging in.

There’s often a discrepancy between the number of terminals clinicians think they need and the number administrators are willing to buy. Practitioners who see a resident, a physical therapist and a social worker queued up at computer terminal are not going to wait in that line to place an order. Many hospital architects still like providing bedside terminals, even though doctors and nurses both are saying that’s not an access point they want to utilize. Hospitals need to bring more sophistication — such as dynamic queuing modeling familiar to supermarkets and fastfood restaurants — to planning terminal usage. The food may be fast, but if the line is slow, the customer opportunity may be lost. The same is true with physicians’ access to terminals. The cost benefit looking at the number of terminals and/or hand held tablets or PDAs must be completed with the end goal of maximizing physician use and minimizing physician time.

The complexity of logging in to a clinical information system can present another barrier to physician usage. A client hospital with an investment of many tens of millions of dollars in a clinical information system discovered that only 20 percent of its medical staff were logging in to use the system. An investigation revealed that their system was so secure that no one could use it. Logging in involved two levels of security, each requiring tedious data entry, a password that expired every 60 days and other measures. The designers reasoned that compliance with HIPAA necessitated such onerous security measures. However, they also neglected the fact that a clerical or administrative user logs in only a few times per day and interacts with the system for hours at a time, while a physician must log in to the system dozens of times per day for only short periods. In the end, a much-simplified system used each physician’s proximity ID card — the same one used to gain access to the physician parking lot — to identify each physician, and a simple biometric fingerprint scanner that used each physician’s index finger as a password, to take physicians directly to the application they use 80 percent of the time. Log-in time decreased from nearly two minutes to a few seconds. With these improvements, 80 percent of the hospital’s physicians now actively use the system.

Continuous Improvement: Recognizing This Is a Journey, Not a Sprint

Physician adoption of the capability to interact with EHR through a clinical information system is not a one-time project; it is a never-ending process (or at least a 10-year hyper-marathon). Continuous improvement of the system is required to retain physicians previously recruited. For one thing, expectations change over time — often dramatically. In one example, a client with a clinical information system in place for seven years initially had 60 to 70 percent of its physicians agreeing that the system brought value to them personally. In two years’ time, that percentage of physicians viewing the system favorably fell to 40 percent, largely due to changing expectations. In the beginning, the ability to retrieve results of current lab tests represented satisfactory performance. Now physicians want to see retrospective results, such as a patient’s glycohemoglobin levels for the last 20 instances. If the system is clumsy in its ability to access that depth of retrospective data, physicians feel disappointed. As expectations change, cuttingedge capabilities become baseline functions almost immediately. Functions that weren’t even on the physicians’ radar screen in the beginning become essential capabilities.

Hospitals need to realize that the original planning of their EHR system deployment — everything from application design to placement of workstations throughout the hospital — must be constantly re-evaluated in the light of changing expectations and evolving needs. The key to retaining physician usage is disciplined, structured, two-way communication between system users and system implementers. Hospitals with EHR implementations that have been most successful at not just recruiting but retaining clinical users have built disciplined and formal communication models around the experience of using the tools. One hospital’s IT department sponsors free pizza lunches to keep an ongoing dialogue with the house staff using their system. They ask for and receive feedback on how the system is working and how it is keeping up with escalating expectations, what new features and functionality are desired and other relevant issues.

System implementers must avoid surprising system users with enhancements that alter the ways they interact with the information they need. Physicians with busy schedules and/or waiting patients who need to get at their patient records quickly, and who log on to discover that the system has changed and they can’t readily find the information they’re looking for, get angry and frustrated.When changes occur, physicians must have simple, one-step access to a “super user” or other real person to help them.

Pay Your Respects: Design Alternative Pathways Before Users Do It for You

In any system implementation, users fall into four broad categories: the technophiles or early adopters who like computers; the majority who aren’t especially interested in using computers except when it can benefit them personally; the occasional users who will use the system only infrequently; and the active resisters, the vocal minority who oppose changing the paper-based “natural order of things.” Most system implementations focus on providing a satisfactory experience for the majority of users, and although that’s the right group on which to invest the most time and effort, the other groups deserve a fair share of consideration.

The technophiles will appreciate being able to bypass some of the menu-driven pathways to frequently accessed functions and information. Treating them as “power users” and letting them go below and beyond the user-friendly interfaces lets them save time and better tailor their interactions to their individual needs.

Many doctors nearing retirement are reluctant to invest in learning new processes and practices. They’re hoping to just ride out the computer revolution. In the case of private hospitals, where practitioners have shown great loyalty over many years, establishing a “take it or leave us” attitude toward computerized access and data entry would be disrespectful, and many hospitals have built a transition pathway with a clear end date. Though investing in this parallel pathway puts some burden on the hospital’s operations staff, the good news is that many senior and influential physicians, given the extra time to get acquainted with the tools, eventually develop a comfort level using them and become proponents of the electronic environment.

The hospital that neglects to respect its technophobic physicians sometimes sadly discovers that the resisting physicians, who tend to be senior, influential practitioners, have more clout than the hospital thought — these physicians conspire with their colleagues to bring the whole electronic initiative to a dead halt. Showing respect for these active resisters is an effective strategy, even though there are costs involved in providing a parallel pathway. The parallel pathway should not be so attractive as to cause defections from the groups adopting the new tools, but hospitals that fail to provide a workaround for resisting practitioners often learn that the physicians have built them themselves, usually at higher cost and greater inconvenience to support personnel than if the hospital had provided the option. Typical workarounds include asking nurses or ward secretaries to work with the resistant doctors to print out lab tests and patient records, and to type in orders, treatment notes and other data from the physician’s handwritten notes.

Summary

Obtaining physician adoption of a realistic and workable electronic environment requires careful examination — and a persuasive response — to the following issues:

• What are the attractors that would compel physician acceptance of an electronic environment?
• What barriers keep them from adopting such a system?
• Once implemented, what methods of continuous improvement will be necessary to keep physicians using the system?

Physicians will adopt a change in clinical processes and technology if they believe it will help them provide better care for their patients, that their interests and concerns are adequately addressed and that their professionalism is respected.