Sparrow Health System in Lansing, Mich., went live with its electronic health record (EHR) system at its main hospital on Dec. 1, 2012. For a year and a half, the system was untapped, innovation-wise. Very few features were turned on, and it sat relatively idle with regard to quality improvement. Hospitalists and others used the EHR, but not ambitiously. Everyone, essentially, used the post-launch period to catch their breath. Some even decided it would be the perfect time to retire, rather than confront the new reality of the EHR.
“It took a good 6 months, probably longer for some, for people to feel comfortable, to start smiling again and really feel like, ‘This isn’t so bad and actually might be working for us,’ ” said Carol Nwelue, MD, medical director of Sparrow’s adult hospitalist service.
Although Sparrow is now probably ahead of the curve when it comes to maximizing its EHR use, its story carries themes that are familiar to hospitalists and to the medical field: The beginning is scary and bumpy; there typically is a long getting-used-to period; and then some hospitalists get ansty and try to get more out of the system, but only gradually – and not without pain.
The bottom line is that most hospitals have a long way to go, said , a hospitalist and assistant professor of medicine at the University of Mississippi Medical Center in Jackson.
“We are nowhere close to using the technology to maximum benefit,” said Dr. Palabindala, also a member of the Society of Hospital Medicine’s information technology committee.
How well hospitalists are maximizing their use of EHRs varies from center to center and doctor to doctor. But, for those that are more advanced, Dr. Palabindala and other advocates of better EHR use mention these characteristics that drive the change:
- They have hospitalist leaders with a strong interest in IT who like to tinker and refine – and then share the tricks that work with others at their center.
- They belong to EHR-related committees or work at centers with hospitalists with a big presence in those committees.
- They keep their eyes on what other centers are doing with EHRs and use those projects as models for projects at their own centers.
- They are willing to make changes in their own processes, when feasible, so that they can better dovetail with the EHR.
- They keep their lines of communication open with their EHR vendors.
- They attend user meetings to get questions answered and share information and experiences.
At Sparrow, two committees – one nurse-led and one physician-led – guide EHR enhancement. The committees are a place where, yes, doctors can vent about the EHR (the phrase they use is “pain points”), but also a place where they can get constructive feedback. The committees also keep an eye out for EHR projects elsewhere that they might be able to do themselves.
EHR: a CAUTI example
In 2014, Sparrow doctors and nurses wanted to lower their number of catheter-associated urinary tract infections (CAUTI). With the EHR that had gone live 2 years before, they had the data that they needed. They just had to figure out how to turn the data into a workable plan. Ah, if only things were so simple with EHRs. As any health center that has gone through the great transition from paper to digital can attest, having the data only puts you at the foot of the mountain.
But using a program that Texas Health System had developed as a model, Sparrow got its CAUTI program up and running. The new system included not just a placement order, but the discontinuation order, too. Advisories on best practice were built into the work flow, including alerts on when catheters had been in for 48 hours, and metrics were created to track how well the whole thing worked.
“Once the data [were] obtained and validated, it was quickly shown that more needed to be done within this clinical program to impact our CAUTI numbers,” she said. “With collaboration from end users, the system was tweaked more and BPAs (best practice advisories) were added and removed in certain areas and shifted the focus from physician-facing to nursing-facing in most areas.”
It appears to be working: CAUTI incidence at 836-bed Sparrow Hospital has dropped from a total of 52 in 2014 to 11 over the first 3 quarters of 2016.
Sparrow has also built programs to better use its EHR for sepsis, medical reconciliation, and methicillin-resistant Staphylococcus aureus screening, and one is being developed for heart failure.
Vendor engagement = QI opportunity
Sparrow and many other health systems are motivated to use more of Epic’s features and to innovate through an Epic rewards program that gives rebates for advanced use that can total hundreds of thousands of dollars. That innovation helps Epic problem solve and it can then point to that innovation in its marketing.
Almost all hospitals, and their hospitalists, are using the EHR for such basics as reducing unnecessary testing, medical reconciliation, and to document more accurately, said
Dr. Palabindala pointed to record-sharing features as a way clinicians can share records within minutes without having to bother with faxing or emailing. Integrating smart-paging into the EHR is another way for doctors to communicate – it may not be as good as a phone call, but it’s less disruptive during a workday, he notes.
Epic is just now rolling out a secure text-messaging system hospitalists and others can use to communicate with one another – the header of the text thread clearly shows the patient it is referencing, Mr. Helsher said. Other EHR uses, such as telemedicine, are being used around the country but are far less widespread. But users are generally becoming more ambitious, he said.
“For the last 5-10 years, we’ve been in such an implementation rush,” Mr. Helsher explained. “ Now, at much more of a macro scale, the mentality has changed to ‘OK, we have these systems, let’s go from the implementation era to the value era.’ ”
Corinne Boudreau, senior marketing manager of physician experience at Meditech, said their sepsis tool has been very popular, while messaging features and shortcut commands for simpler charting are gradually coming into wider use. Meditech also expects their Web-based EHR – designed to give patients access on their mobile devices – will give doctors the mobility they want.
Still, there’s a wide range in how much hospitalists and other doctors are using even the fundamental tools that are available to them.
“I think that between implementation and maximization there is a period of adoption, and I think that that’s where a lot of folks are these days,” she said.
As “physician engagement” has become a buzzword in the industry, Meditech has worked with physician leaders on how to get doctors to absorb the message that the EHR really can help them do their jobs better.
“If you get [doctors] at the right time, you show them how it can make things easier or take time off their workload,” Ms. Boudreau said. “For some physicians that time to get them might be first thing in the morning before they see patients. Another physician might want to do it in the evening. If you hit that evening physician in the morning, you’ve missed that window of opportunity.”
Given the demands on doctors’ time and either an inability or unwillingness to put the time in that’s needed to learn about all functions the EHR can offer, there’s a growing acknowledgment that doctors often can’t simply do this on their own.
“There’s more recognition that this is a project that needs to be resourced,” Ms. Boudreau said. “They’re already strapped for time; to put something additional on top of it needs to be accommodated for. It needs to be resourced in terms of time, it needs to be resourced in terms of compensation. There need to be governance and support of that.”
Early adopters vs. late bloomers
Many hospitalists and HM groups have advanced, but some places have lagged behind, said John Nelson, MD, MHM, a veteran hospitalist, practice management consultant, and longtime columnist with The Hospitalist.
“We find it’s reasonably common to go to a place where they’re still keeping their census in an Excel spreadsheet,” he said. “Last year, we found people who do billing on paper and index cards.”
He said that often, a failure to adopt new EHR functionality isn’t because hospitals and HM groups are avoiding it. He said he sees IT shortcomings as a major blocker.
“They want to use it,” he said. “Inertia might be part of the reason people are failing to fully capture the benefit the EHR could offer, [but] the bigger reason is local IT configurations and support.”
As an example, Dr. Nelson explained that at some of the centers he has worked with the name of the attending physician is not always reflected in the EHR. That’s a big no-no, he said. The problem, he’s sometimes found, isn’t really the EHR, but quirks in the hospital system: The EHR is locked down for that information and can be changed only by a person in the admitting department.
“It would require the hospitalist to call down [to admissions] and get someone else to make that change – and that’s tedious a big headache. They give up and don’t do it anymore,” he said. “Ideally, you’d want to make it so the hospitalists can make the change themselves.”
At his center, Overlake Hospital Medical Center in Bellevue, Wash., a go-to hospitalist is David Chu, MD, who has gone through Epic training and shares tips with colleagues. He is one of a relatively few physicians there who has taken the time to use the drop-down menu feature for putting information into a chart.
That might sound like a fairly basic use for a multimillion-dollar EHR system. But it still can take hours and hours to get it right.
“The way to do it is a little bit of a programmer’s way of looking at things,” Dr. Chu said, noting it involves programming-style language with double colons, commas, and quotations marks.
“For me, I think it took a good 10, 12, 15 hours on my part to get things going,” he said. “It was a good time investment up front to help me on that end, but it’s just hard getting people to want to commit that time, especially if they’re not that savvy with computers.”
His hospitalist colleague, Ryan Chew, MD, is more advanced – he has a taxonomy-like shorthand he uses to give him the right set of basic fields for a given type of case. For someone admitted with pneumonia, he’d want to know certain things all the time. Were they short of breath? Did they have chest pain? What were their vital signs? What about inflammatory markers?
Dr. Chew can get all of those fields to pop up by typing “.rchppneumonia.” The “.” means that a special code is to follow. The “rc” is for Ryan Chew, the “hp” is for history and physical, and “pneumonia,” is the type of case. For cases that require other information to be entered, he can add that as needed.
Hospitalists might try to write shortcut phrases, but unless they have a well-defined system, it won’t be helpful over the long run, he said.
“If you don’t have a good organization system … you’ll never remember it,” Dr. Chew said.
But even he hasn’t created the drop-down menus. He said he just hasn’t been willing to take the time, especially since he feels his own way of doing things seems to be working just fine.
Effort is essential
Expanding the functionalities of the EHR takes effort, no doubt. As a result, some physicians and hospitalist groups have not been open-minded to the idea – and opportunities – of the EHR as a database.
“I think for some people, even still, working with the EHR, it’s become more something they’ve learned to get used to rather than something that they sought to take advantage of, in terms of helping things,” Dr. Chew said. “They’re still working against the EHR a little bit.”
Dr. Palabindala agreed, and said that regardless of resistance or complaint, EHRs work.
“No matter how much we argue, it is proven in multiple studies that EHRs showed increased patient safety and better documentation and better transfer of the data,” he said.
He suggests hospitalists make more of an effort.
“I strongly encourage hospitalists to be part of the every EHR-related committee, including CPOE [computerized physician order entry], analytics, and utilization-review committees,” he said. “Learning about the upgrades and learning about all the possible options, exploring clinical informatics on a regular basis is important. I also encourage [hospitalists] to participate in online, EHR-related surveys to learn more about the EHR utility and what is missing in their home institution.”
He acknowledges that it’s “hard to develop a passion.” Then he put it in terms he thought might resonate: “Think of it like a new version of smart phone. Show the enthusiasm as if you are ready for next version of iPhone or Pixel.” TH
Is hospitalists’ EHR efficiency taken advantage of?
Even though their level of EHR use can be hit or miss, hospitalists tend to be ahead of the game, many agree. But that can come with some drawbacks. They’re often the go-to people everyone else in the hospital relies on to handle the system that some think is too unwieldy to bother with.
“One thing that really distinguishes hospitalists from many other providers, particularly on the inpatient side, is just the frequency with which they use the EHR,” said Eric Helsher of Epic. Many hospitalists are chosen by administrators to test pilot projects for that reason, he adds. “They want to get it out there with a group who they know will have a lot of exposure to the system and may be more willing to make those changes for long-term gain.”
Sometimes that expertise leads to situations that go beyond the hospitalist simply being leaders of change – they’re doing work they were never really intended to do.
John Nelson, MD, MHM, a hospitalist consultant based in Seattle, said hospitalists tell him that a subspecialist might handle a case but will not want to be the attending physician specifically so they don’t have to deal with the EHR. He said the specialist in such cases will say something along the lines of, “You can call me, I’ll help you, and I’ll come by and say hello to the patient and make the care decisions, but I need you to be the attending so you can document in the chart and you can do the med rec because ‘I can’t figure out how to do those buttons right.’ ”
Some will ask hospitalists “for a hand” with a case when really all they want is for the hospitalist to enter information into the system. It’s a tricky situation for the hospitalist, Dr. Nelson said.
“Some will be transparent and say I don’t really have a medical question – I just can’t figure out how to do the med rec and the discharge, so would you do it?” he said, adding the systems issues are largely because of new rounding patterns sparked by HM’s expanding role in-hospital. “I think it meaningfully contributes to what I perceive to be a decline in hospitalist morale in the last 2 or 3 years.”
Tom Collins is a freelance writer in South Florida.