(Chest. 2006;129:1057-1060.)
© 2006
American College of Chest Physicians
Applied Medical Informatics for the Chest Physician*
Information You Can Use!—Part 3
William F. Bria, II, MD
* From the Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan Health System, Ann Arbor, MI.
Correspondence to: William F. Bria, II, MD, Medical Director, Clinical Information Systems, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan Health System, 1500 E Medical Center Dr, 3916 Taubman Center, Ann Arbor, MI 48109-0360; e-mail: wbria{at}umich.edu
Abstract
In this third and last part in our series on applied medical informatics (AMI), we will examine the following: (1) a concise wrap-up of the practice steps necessary to achieve the benefits from AMI in your practice; (2) an introduction to the patient health-care record and why it is important to physicians; and (3) a look at some of the latest developments in AMI that are of interest to the chest physician.
Key Words: applied medical informatics • computerized physician order entry • electronic medical records
"Ah, but a man’s reach should exceed his grasp—or what’s a heaven for?"
Robert Browning English poet (1812–1889)
The following are seven steps to aid the chest physician in evaluating, selecting, and obtaining the benefits from existing electronic medical record (EMR) systems, whether it be in a large multicenter health system or a small office practice.
Getting the Benefits From Applied Medical Informatics in Your Practice: Seven Steps to Success
- Set valued realistic goals for your EMR system implementation. The goal is not to be paperless; the goal is to improve the process of patient care. There is no getting around the reality that the implementation of an EMR, whether it be in a multihospital system or a small office practice, is a significant change. To be worth the inconvenience of the change, all major stake participants should have value to the group as a whole. For example, to implement an EMR to improve the overall efficiency, effectiveness, and safety of patient care means that everyone will need to pitch in. Ideally, in realizing that the purpose of the team is to deliver the highest possible quality patient care, all members of the group will be willing to absorb the change. This would be true whether individuals of the health-care team are advantaged after implementation or not, at least in the short term. Many EMR projects have failed due to the rebellion of a group that did not appreciate the central goal of the system implementation, yet realized very well the inconvenience they were being asked to absorb. A paperless environment, although administratively attractive, is hardly a strong enough incentive for health-care workers to endure the change of EMR introduction.
- Ensure that those who will have to adapt the most for a successful implementation to occur understand what is being proposed and have input into the decision-making process. Individuals who will use the EMR should have input into the details of the function of EMRs and have opportunities to more effectively incorporate the changes into their workflow rather than not knowing about the details of change until the time of system implementation. In the history of EMR implementation, the most likely group to experience this unhappy surprise is physicians. There are several reasons for this. (1) Physicians are busy people. In spending time in understanding the configuration of an EMR, gathering the collective wisdom of the physicians before installation is usually not a top priority. Often it is the attendees at the configuration meetings (eg, nurses and allied health staff) who are providing their best judgment on what the doctors would want, and therefore the systems may be installed without physician input. Believe it or not, internationally installed EMR systems have been developed and their implementation has failed due to this one element. (2) Physicians often regard computer systems as clerical in purpose, rather than a technology of actual care delivery. Although this attitude has largely disappeared over time, it is still an important barrier to encouraging direct physician involvement with EMR configuration. (3) Physicians should not be expected to actually design an EMR but rather should provide the key input from their experience of their workflow dynamics. This input is given to computer analysts who then can translate this information into the so-called business rules of an EMR system. This schema puts the highest value on the experienced clinician in providing input into the configuration of an EMR, and not on a technophilic physician who may (or most likely may not) be the most clinically experienced and influential. The importance of involving the clinically influential physician leader in EMR design and implementation for the overall success of EMR adoption within a medical practice has been demonstrated in the literature.1
- Do not wait for the implementation of the system to reengineer workflows and practices. Test them all in a paper world first and assess whether the changes are truly helpful. The complexity of workflow processes in health care has been said to be comparable only to that of the aerospace industry. In this setting, one of the most high-risk decisions may be to "Wait until the computer system is installed and then we’ll change how (fill in the blank) carries out his/her work." This is not to say that preparing for EMR implementation by introducing workflow change is ever easy, it is just a sure bet that if you cannot be successful in implementing a change without a computer, doing it with a computer will not make your chances of success any better. A classic example of this step is the effort to eliminate verbal orders with the installation of a computerized physician order-entry (CPOE) system. In the paper world, verbal orders are problematic especially in a medical-training program, where frequent handoffs of patient care by residents result in verbal orders being signed late or not at all, which is certainly a liability as well as a quality-of-care issue. However, without an effective pre-CPOE implementation campaign, verbal orders can actually increase due to resident physician avoidance behavior, that is, to residents calling in hospital admission orders from the phone just down the hall from the nursing station (from personal experience).
- Make as few changes to the base system as possible before implementation. This step has a profound impact on both the ultimate cost of an EMR system as well as on the time it takes to achieve implementation. This might seem a contradiction to step 2 above, but it is not. This is not a recommendation to steamroll over staff objections and turn on an EMR straight from the manufacturer. Rather, it is a hard-won lesson from experience that most clinicians really need to use an EMR system for a period of time before their recommendations constructively improve the functioning of the system, rather than just being an expression of inexperience with the full features/function of a base system. Any veteran computer analyst of several EMR implementations will report how often they have ended up changing how an EMR system worked at the request of naïve users, only to change it right back to the original specifications after a few weeks or months of use. There is no getting around the fact that these systems are very complex and that it simply takes time for users to understand the logic of the basic functions of the system before they start to recommend changes.
- Identify stages or milestones of implementation. Do not try to quickly force the EMR system in at the cost of the users’ acceptance or the effectiveness of the workflow in your office setting. The phased implementation of an EMR system along the lines of the gradient presented in part 2 of this series of articles on applied medical informatics (AMI) information that the chest physician can use allows the entire health-care team that you are attempting to aid with the automation to actually have the time to absorb the elements of results reporting, order sets, order entry, clinical decision support (CDS), and all of the other more sophisticated elements of the EMR system. Previously, we described the components of the EMR and its increasing complexity, from results reporting, to CPOE (in an ambulatory care setting using electronic prescribing), to decision support. In the implementation of this gradient of technology, there is a progressive intrusiveness of the elements of the gradient into the clinical workflow. This intrusiveness results in the increasing challenge of clinicians to effectively learn and absorb the technology into daily practice. Hence, the challenge of effectively introducing change into the complex environment that we call clinical practice dictates an incremental approach, allowing clinicians to absorb the change a little bit at a time, preventing, or at least minimizing, the chances that a negative impact on patient care will actually increase.2
- Train, orient, and take your time. Always have a backup/backout plan at every stage, and delay the next steps of implementation if daily operations are too severely impacted. It takes time to become proficient on an EMR system, and the more sophisticated the functions of the system (eg, order entry, CDS, and workflow support) the longer it takes to become effective and efficient in its use. As the use of an EMR system becomes more interconnected with the daily clinical workflow, problems may arise requiring a delay in rolling out further functionality, or even backing out parts of an EMR system for remedial training of users or reconfiguration of the system. While keeping improvement in patient care as the central goal of an EMR system implementation, these temporary delays should be minimal while avoiding the compromise of daily operations.
- Strive to aid user memories with reminders. Resist the temptation to try to control behavior with the computer. Computers are generally much more stupid than humans. People know when you are trying to control their behavior and resent it. On the other hand, when a computer acts as a valued memory aid and reminder, we tend to look on the technology far more favorably. This simple lesson can be lost in the enthusiasm of using all the bells and whistles of a shiny new EMR system. The consequences can be tragic, with group rejection of a system, thus missing the opportunity of reaping its benefits. On the other hand, improvements in patient care can be realized by utilizing consistent care reminders.3
The Patient/Personal Health Record
What About My Patients? What Can AMI Do for Them?
As was shown in part 1 of this series4 on AMI, the emerging concept of the electronic health record has now changed from a hospital-centered or provider-centered view to more accurately encompass the cycle of clinical information from a patient-centered point of view, with the use of the patient or personal health record (PHR). Patients’ interest in electronic medical information has, in many ways, outpaced the involvement of the medical profession in EMR adoption. The fact that, as of this writing, a search of the term "health" on Google yields > 1.7 billion citations is just one indicator of the interest and pervasiveness of health issues in the digital landscape today.
The authoritarian model of the medical establishment has transitioned to one in which patients are using the power of the World Wide Web to equip themselves with health information and to actually engage in a dialog with their health-care provider, which has moved from being the exception to being the rule. Recent reports5 have shown that 8 in 10 Internet users are seeking health information online on subjects including everything from medications and fitness to doctors and hospitals. Today patients are more likely to prepare for their office visits and to demand involvement in their health-care decision making. This all comes down to information and communication. The PHR is a component of the EMR that is not only centered on the patient, but is created, audited, and managed by the patient!
The opportunities for secure, structured, regular physician-patient communications, often using Web-based tools, is already resulting in benefits in disease management, prescription management (e-prescribing), and health-care scheduling.67 When the PHR allows the patient to access multiple systems (eg, EMR, scheduling system, or prescription refill/management systems), the term patient portal is now commonly being used.
What’s Next?
One of the most exciting next-step developments in AMI is the virtualization of medical practice. This domain includes such diverse technologies as remote radiograph interpretation, electronic office visits, and, most recently, the virtual ICU. All of these applications have in common the application of fast Internet-based networks, remote multimedia (eg, video, audio, and telemetry) displays, linkages to a functioning EMR system, and the real-time collaboration of medical professionals in the delivery of patient care.8 The next generation of critical care systems is also enabling the enhanced implementation of complex care guidelines, improving outcomes such as glycemic control, compared to paper-based ordering and decreasing the number of medical errors.910 Hence, we can think of the next steps in AMI as stepping stones from our initial conception of the results reporting systems of the past, to CPOE, CDS, and finally the virtual electronic diagnosis and treatment environments of the future.
Conclusion
We are at the threshold of launching a new era of AMI-enabled American health care. The failure of the health-care information technology industry has been discussed in this and many other articles over the past 30 years. Strategic action in health information technology is straining at the bit: but why has the obvious taken so long to implement? Today the United States is poised to achieve what has been sought and anticipated for at least 3 decades.11
With regard to AMI, business as usual will not work. As a profession, we need to be more knowledgeable, demanding, and involved with the introduction of information tools and systems into health care. Most urgently, there must be a greater emphasis on medical knowledge incorporated into new systems. Only in this way will the realization of the improvements of patient care be achieved. Only clinicians working hand in hand with technical experts can make this happen. The building of information systems that learn is needed, adding actual valuable clinical information with each implementation (rather than starting with a clean slate each time). Software that better reflects an understanding of the complex relationships and workflow between clinicians is long overdue.
Finally, the timeline for change, with initiatives from the federal, state, local, payer, and provider worlds of American health care are now beginning to take shape. It really seems that our grasp is finally coming a little closer to our reach.
Footnotes
Abbreviations: AMI = applied medical informatics; CDS = clinical decision support; CPOE = computerized physician order entry; EMR = electronic medical record; PHR = personal health record
Received for publication January 31, 2006.
Accepted for publication February 1, 2006.
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