June 28, 2011
John Bosco, CIO at North Shore-Long Island Jewish Health System in New York, emphasizes that the EHR vendor or the hospital's IT department must let clinicians see that, once past their learning curve, there will be clear-cut efficiencies. Regarding that frequent complaint about alert fatigue, he recommends that when an EHR is first installed, the alerts be configured "lightly." That is, choose them carefully and put them in place gradually.
Bosco likes to use the wedding/marriage analogy when discussing EHR implementation. You and your fiancée spend months planning a wedding--just as the IT team and clinical staff spend months planning the EHR's installment. Then the big day arrives, you throw the switch, and the system goes live. But IT executives and doctors, just like man and wife, have to realize that this is only the beginning. The IT team and clinicians have to remain committed to a long-term relationship that involves hard work, compromises, and maturation. Process Mapping Of course, both groups have to do a great deal of prenuptial work for the marriage to work. Clinicians must do intense "process mapping" so that they understand how patient care and administrative services occur step-by-step in the paper world. You want them to think through their work patterns as they document patient care--in painstaking detail: Which vital signs are recorded and which staff member records them? How are medical histories taken? What kind of post-visit documentation occurs, and who inputs that information? Many more process points must be mapped, either using flowchart software or pencil and paper, depending on the complexity of the process. Only after the clinicians have a complete picture of their workflow process can you have an intelligent conversation about how that process will be disrupted--and improved--after the electronic system is in place. Clinicians who have a hard time seeing the many aspects of their current work process may benefit from an EHR primer like Electronic Health Records for Dummies, by Dr. Trenor Williams and Anita Samarth. The News Is Not All Bad All this talk of physician pain and compromise might suggest that EHRs are more trouble than they're worth. But myriad success stories demonstrate that EHRs and related electronic tools can have a profound transformative effect on patient care. So why are many clinicians still hesitant to make the workflow changes needed to reap the benefits of EHRs and other electronic medical tools? Frederick Knoll from Stanford University once outlined five steps involved in accepting medical technology: horror, denunciation, skepticism, evaluation, and finally acceptance as the standard of care. Many clinicians are still stuck somewhere between denunciation and evaluation. One of your jobs as an IT executive/psychologist is to figure out where each clinical team fits on this continuum. Another useful scale to help measure clinicians' resistance was outlined many years ago by Everett Rogers in Diffusion of Innovation, in which he described the innovators, early adopters, early and late majority adopters, and laggards, who often require a direct order from their superiors to act. It's almost a cliché to say laggards fear change; still, it helps to understand what's behind such fear. Some docs fear being embarrassed by their inability to speak the language of technology. I remember working with an older academic physician who couldn't locate desperately needed research articles on the Web and had his secretary handle most of his email. He was clearly uncomfortable admitting his ignorance. For other clinicians, the problem is abundant self-confidence. When physicians have spent a quarter of a century running a lucrative practice using paper and pencil, they have good reason to believe in the status quo. When a group of young technologists suddenly suggests they're dinosaurs--well, you get picture. Using well-reasoned arguments, positive case examples--and your best bedside manner--will go a long way toward winning over resistant clinicians. The Healthcare IT Leadership Forum is a day-long venue where senior IT leaders in healthcare come together to discuss how they're using technology to improve clinical care. It happens in New York City on July 12. Find out more.
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