During recent conference "eHealth India 2008" at Delhi, India, one of the evolving theme was how to make clinicians use EMR.
I think this issue is universal. Since, we all are at various stages of initiating/implementing EMR, can we discuss and try to find out best methods of addressing implementation challeges including how to influence physician behaviour to use EMR.
This can take shape of good international guidelines.
I think that before starting with the discussion and at first we need to choose proper systematic approach to identify the problem. Obviously different approaches give us different lights. Here I used 'General System Theory' to highlight main obstacles in my opinion.
1- We have to wait for more competent technology which comes through advancements along the time because the technology is yet incompetent. Informatics still lacks many benefits of traditional paper based approach: Less availability (location, time, environment), less stability, more complexity, more cost, more training, less easy to use.
2- It needs a parallel usage growth for IT in other fields. While comparing to paper based systems, informatics has less prevalence in higher, lower and parallel systems among the society, it is not likely to be able to push clinicians to use IT solutions.
3- Changes in collective unconscious imaginaries are required. The tradition of medicine is mixed up with the concept of paper work. Even in advanced clinics of advanced countries both the patient and the physician refer to the same imagination of the prescribing process: A physician who writes something on the paper and vice versa.
4- The training of healthcare personals must move to E environment. A medical student who always worked with EMR, (s)he won’t work with paper based files.
May I call you Abbas and request you to use my first name to have a closer feeling.
1. Thank you very much for your response. I agree with you that the discussion should start with identifying the problems for utilizing Electronic Medical Record (EMR), before identifying the solutions for the same. When I said “implementation challenges” I meant,
1. identifying the issues,
2. Root-cause of those issues,
3. Addressing root-causes to enhance adaptation of EMR.
So as advised by you, I would like to invite the interested people to identify and enumerate what are the obstacles, in their opinion, for implementation of EMR. Initially if we can collect all such obstacles, identify major obstacles which are occurring/likely to occur in different scenarios and list them in priority, based on certain agreed criteria, at least we have a starting point.
2. I agree with your observation that at the moment, the technology is not at its best in these areas. However, I am of the opinion that while working towards best technology, we need to initiate EMR adaptation to start benefiting from EMR utilization. It may not be out of place to mention here that technology and practices, even though are interdependent, are in fact separate issues.
3. The intention should not be to push clinicians to utilize EMR, but the effort should be to make them addicted to EMR and its benefits. However, we can only make them addicted, when they start using it and also by providing more benefits out of EMR. One of the main benefits which we can provide to clinicians is better patient care. Most of the clinicians would go an extra mile if they are convinced that a particular method would enhance the quality of patient care, however, the crux is the differences amongst clinicians about how far they go towards that extra mile, more so when it is difficult to adopt new methods/technology.
4. The major obstacles in my opinion are the “dynamics of change management”, of course in addition to, as you rightly mentioned, the technological perfection.
5. The training of clinicians and medical students definitely play an important part in successful implementation.
6. Lastly I was personally looking at a small and specific focused area of the challenges i.e. influencing clinician behavior for adapting EMR. In this direction I was looking at various methodologies that were being used/proposed by various hospitals/HMOs and other health organizations to influence the clinician behaviour while implementing Clinical Practice Guidelines (CPGL)/Evidence Based Medicines (EBM). The clinician behavior to adopt CPGL/EBM was/is more or less similar to adaptation of EMRs. I am also of point that, at some stage, the EMR will adopt the medical algorithms (of CPGL/EBM) in to EMR for better clinical decisions.
Yes doc you are right. Actually this issue to implement EMR in all the practices in USA is very critical. I am searching for different vendors for Electronic Medical Records,Practice Management and Medical Billing all in one software and what i found is pretty much impressing its CureMD All in One Electronic Medical Records,Practice Management and Medical Billing Service Solution.
As I see you are looking more practically to the issue while my approach is more theoritical. I believe that looking for theoritical basis prevents late failiures.
Seeking for methodes who are applyable in peripheral non-academic centers is an important issue. Most of success stories comes from well organized, rich and limited centers, which I think are less than 1% of the target population.
Human kind seeks for the pleasure and avoids suffering. Medical staffs are the same. So it is important to recognize the pains and pleasures who are comming by electronic environment. Thereafter we will have the master plan, which I believe it would be:
1-Change environment to suffer more with paper work.
2-Change environment to increase pleasure of electornic work.
i- More payment.
ii- More academic output.
iii- More organizational and academic awards.
3-Use technology to decrease the pain of the electronic work
i-Mental overhead in electronic work is the major problem, I believe. So the electronic environment and devices should first aim at lowering this mental overhead.
ii-Many other factors
Attention to upper, lower and side by side systems and automating thoes and promoting integeration of systems (not at technologic level but in business logic) is very important.
1. Cost - EMR systems are not cheap. Rarely do they simply involve software licensing costs. Iknowmed, for instance, requires all pc's to meet minimal specs of a pentium 4 (dual core preferred) and 1 gb memory. For most locations, this requires a large capital expense replacing all non-compliant systems. It also calls for administration. A small rural health clinic is very much at a disadvantage when it must move to any electronic systems. I have seen many cases where individuals will write code to meet a clinic's requirements and sell it to other clinics, charging all the same price.
2. Fear of Failure - EMR's are computer systems. Therefore, downtime happens even with the best setups. Many facilities print schedules and data the day before to prepare for down time. This ensures if the computers are down, they can still service patients.
3. Return on Investment - Installing the EMR can lead to a massive initial investment. Computer equipment depreciates typically at a 3 year cycle, therefore, every 3 years requires an additional investment at best. With this in mind, it can be concluded that the EMR is a poor investment if it accrues no additional revenue.
Thank you for your response. Yes you are right about those 3 points.
However Health Care Organisations (HCO) should eveluate the benefit in terms of process improvement and quality of decision making (both clinical and managerial) on a longterm basis. Then the cost of EMR will make sense.
There are lot of opertunities to recover cost from the payers but that depends on the healthcare systems of the country. In India, where a greate componant is "out of the pocket payement", i have worked out many methods of recovering cost. A simple example being to charge a small amount from the patient suffering from chr. disease, to provide old lab results in a graphical form along with curent results.
Fear of failure is an issue of change management, and i would like to focus my discussion mainly on that challenge, that to changing the clinician's behaviour.
will be very happy to mould or Customize the EMR formulas in a very user friendly (as we say NOKIA 1100 Princple ) our motto s the EMR should reach all the Consultants as it is very easy to use.sugesst me how can we go ahed with this ..
Nokia Princple : : the mobile Nokia 1100 is very user friendly , so it can be used any were and anybody ,
I mean this emr in a span of 2 years should reach all the rural areas , as the healthcare awareness is very poor .
I'm Foyaz Ahmed from Bangladesh. I was working in Apollo Hospitals Dhaka, Bangladesh. My Future Vision is Try to Help to reach EMR system to all HealthCare Organization even in Small Clinic Level of Bangladesh. I’m Developing a EMR System Named HIMS (HealthCare Information & Management System). And This System is Implemented in 2 Mid Level Hospital in Bangladesh. I have a Plan to Develop a System for Those Physician Who are working in there own chamber. And I’m trying to Maintain All rules and regulation of WHO. Sometime I May required help from your end.
So I want your Full Support.
If leadres in this area from different locations start doing what you are doing in Bangla Desh, i am sure very soon EMR will have its presence all over the world. Congratulation and all the best. I am and i am sure everyone on this forum will be very glad to help every one who is working towards such initiative so feel free to contact me.
The most critical factor we found in EMR adoption by our providers was living in a "half-and-half" world. The decisions was made (prior to my hire) to start using the EMR on a specific date and go forward from there. No historic data was input and patients were added as they presented. I took us over a year to win our providers to EMR usage because part of their information was on paper and part was in the computer system so 1) their efforts were often duplicated and 2) their tasks took twice as long. Several of them essentially refused to use the technology. When we asked them for input on what data needs to be in the system - how may lab results in flow sheets; how many consultation and radiology reports; how many months/years of test results for patient types such as diabetic, cardiac, respiratory, etc. - we came to a consensus of the necessary historic data. A new employee was hired who started inputing the agreed upon data as well as allergies, medications, past medical history, and social history for patients we were seeing that week and then moving to patients in alphabetical order until all patients were in the computer system with enough historic data to make clinical decisions. When the providers could function in an entirely electronic world, their usage of the system jumped. If we tried to take away the computers now, we would face a riot in our clinic.
Our approach to an EMR in our hospital has to be staged due to cost and trying to prevent information overload in our employees. However, the success of our clinic EMR has resulted in our providers being much more willing to work in the electronic records that are available in the hospital.
The second biggest issue to adoption for us was hardware related. We started with traditional tablets but did not put docking stations in every room due to cost. We are now transitioning to convertible tablets because they have the flexibility of a laptop and the touchscreen capability of a tablet so we have the best of both worlds.
Yes! once data is available on their fingertips, they are addicted to it and will not like the manual systems any more. There may be however, thos section of very senior doctors, who feel that they are no more in command.
Bed side entry is another financial challege as you have rightly said. I have seen a system called C5 from motion computing .. something but again the cost ia an issue.
As far as historic data is concerned, i don't think we should compromise on discarding ant data, more so when the cost of storage devices contantly coming dowm. However, what period of historic data should be online, aand near on line and achival form is a question to be asked for.
In every Change Management, such as implementing EMR, there is the need to ensure that you use the formular for successful Change Effort (SCE)=DxVxFs. This means that there is the need to create the situation for the clinicians to realized that they are already dissatisfied with the current manual system of Medical Records management. When they are really dissatisfied with the manual records management, then help them to understand your new vision which is the EMR. When the vision is clear to them do not think that you can start at all level at a go. Take your small First step.
When they realised the benefits of the system, they will definately comply.
In addition, there is the need to properly study the culture of the Organization before you start the implementation. If the culture does not support the EMR system, you need to change the culture so as to help them accept the new system.
Also, involve all stakeholders in improving the system. When they don't own the process, it is likely they drag their feet. Don't just impose on them. Seek their views and make sure you let them know the benefits of the EMR