Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

3 Barriers (and 1 Solution) to Successful EHR Adoption

1/27/2015 3:11:15 PM | 3 comments

I’m a scribe trainer, which means I train people — usually scribes, but also doctors, physician assistants and nurse practitioners — on electronic health record (EHR) systems.
 
Now to a lot of you, that probably sounds like one of those nightmare jobs akin to crime scene cleanup or sewer diving. But in many ways, being a scribe trainer is a bit like being a first responder—like an EMT or firefighter. Everyone hopes that won't need to call us, but when we show up, they're usually grateful. We get appearance requests at all hours. And sometimes once we’re on the scene, it’s tough to turn around and leave.
 
Case in point: a head scribe I know was recently awakened at 3am by a call from one of the emergency physicians she worked with. The department was transitioning to a new ED contract, and during the turnover, this doctor had worked five shifts in a row without a scribe. The physician was now so far behind that her documentation backlog had become an emergency unto itself. “Please,” she pleaded, “could I have a scribe on her next shift?
 
That desperate physician was on my mind as I read a recent post on the EP Monthly blog by W. Richard Butaka, MD. Like many of us, Dr. Bukata acknowledges the positive intent behind EHR incentives. However, he notes that despite early hype, the EHR literature has yet to demonstrate substantive benefits for doctors and patients.
 
Many of Dr. Bukata’s concerns echo what I hear from providers every day. Here are some of the pain points he addresses flavored with a few of my own observations:

1. Productivity

EHRs have become ubiquitous, but that doesn’t mean they’ve integrated neatly into providers’ workflows. Productivity generally nosedives in the adjustment period following implementation. And while some departments manage to claw their way back to pre-EHR productivity, the providers may still end up with three to four hours worth of unbillable entry after every shift.
 
While the literature on EHRs and productivity is sparse, Dr. Bukata does cite two single-site studies on the topic. One hospital showed some gains in throughput after a tumultuous post-implementation adjustment. However, it also cut unit clerk hours by 33 percent as many administrative burdens shifted to the providers. Meanwhile, providers at the second hospital spent a whopping 44 percent of their time on data entry and only 28 percent on direct patient care.

2. "Cookie-Cutter" Documentation

Chart cloning (or what I like to call cookie-cutter documentation) is perhaps the most serious issue precipitated by EHR implementation. Inappropriate use of macros and pre-completed notes can create the impression that complex, life-saving care was provided when really the patient presented with an earache or minor wound. A New York Times analysis found that between 2006 and 2010, Medicare reimbursements at ED Level 4 and 5 increased by 47 percent among hospitals that implemented EHRs versus just 32 percent among those that did not.
 
News stories tend to lay the lion's share of blame at physician's feet. If only they'd stop shortcutting, this wouldn't be a problem! Of course, this reasoning ignores the larger productivity issues that place providers between EHR and a hard place. Education is also a perennial issue. While scribes receive regular continuing education on the changeable rules surrounding record creation, physicians may be entirely unaware of the nuances involved.

3. Order Sets

Cost-containment is a driving force behind the EHR incentive program. However, research suggests cost effects have been paradoxical, especially in the area of medical testing. One study abstracted by Bukata found a 60 percent increase in medication administration, lab testing and ECG orders following EHR implementation.
 
Dr. Bukata attributes this phenomenon to the growing use of order sets, and his theory squares well with my own experience. Order sets certainly have their good points. They can be ordered in triage, which should expedite the care process and enhance throughput.
 
Except it doesn't always work that way. According to Dr. Bukata:
 
"I can just see how order sets are created. A bunch of doctors get around a table and start throwing out tests for the 'chest pain' order set. Before you know it you have all sorts of tests that one doctor or another likes … Everybody gets to add their favorites. The next thing you have is a 60 percent increase in testing."
 
Now I don't have any personal knowledge of this process, but I can vouch for the fact that many doctors consider these order sets as overkill. And I can also assure you that at many hospitals, it's a giant hassle to customize the chart so that only the necessary tests get ordered. (In many cases, the physician must actually chase down someone from the IT department to get the job done.) No wonder busy providers sometimes throw up their hands and order the laundry list of tests, despite the high costs and drain on resources.

Solution: Scribes as a "Game Changer"

So given that EHRs are here to stay, what's a frazzled provider to do? A possible solution raised by Bukata is the utilization of scribes. And of course, that's a suggestion I can enthusiastically support. Having worked on a number of EHR implementations, I don't think it's possible to overstate the positive effect scribing can have on a struggling department.
 
Case in point: I recently worked on a scribe program startup at an ED that had just implemented a new EHR. Productivity was suffering, and the providers were putting in long hours on data entry. When the scribes came on the scene, they were practically ecstatic. You could almost see the weight lifting from their shoulders. They joked about not knowing what to do with all of their free time. One of the doctors called the scribe program a "game changer."
 
Administrators sometimes worry that scribes will make patients uncomfortable. However, sitting at a computer terminal battling with a keyboard doesn't exactly advance the provider-patient relationship. In my experience, patients love the idea of a scribe, so long as the person's role is explained up front. And even more, they love having their provider's undivided attention.

Parting Thoughts

Okay, maybe it's a little self-serving for a scribe trainer to extoll the benefits of scribing. But when you hear story after story from stressed out providers who want nothing more than to be there for their patients, you tend to form strong opinions on this topic.
 
Just the other day, as I was leaving my shift, I ran into our hospital's newest emergency physician. "You're not leaving, are you?" she asked with genuine panic in her voice. "I've never used an EHR in my life! Please, I need your help."
 
So I hung up my coat, and within a few hours, she'd made remarkable progress. I drove home tired, but confident that she'd now be more available for her patients and colleagues.
 
And honestly, until we have smarter, user-friendlier EHRs, I think I better resign myself to being a first responder of sorts. Or at least a lot of long shifts and crock-pot dinners.
 
[Image credit: "Dr. Danny Sands with his patient e-Patient Dave deBronkart" by Jerry Berger, Beth Israel Deaconess Medical Center licensed under CC BY-SA 4.0]


Comments
Anne Bruce
Scribes are "Heroes on Duty!"
2/1/2015 12:36:26 AM

Cyndy Flores
Clearly our scribes are the best. By handling the difficulties of the EMRs, the scribes allow the providers to focus more on our patients. Without the work of the scribes, our workload would be significantly increased an dour ability to treat our patients would be decreased.
I hope all our scribes know the important part they play in caring for our patients!
1/31/2015 7:58:56 PM

Do Kim
Great article, Nic. I agree with you that scribes are such a vital part of enhancing the patient-provider relationship in addition to helping to prevent physician burnout. Scribes are a great ROI!
1/28/2015 5:47:21 PM