EMRs: Reaching the Holy Grail
January / February 2009
The electronic medical record (EMR) is the Holy Grail for most hospital executives. Some industry experts think it is the panacea for ills plaguing the industry. By integrating all aspects of the care delivery system — from ambulatory care to the emergency department, to the inpatient setting, to post-acute care providers — hospital systems are hoping to reduce costs and improve outcomes. In 2005, Hillestad et al. estimated industry savings of $81 billion annually, with that number possibly doubling once the data captured by EMRs is fully used in the prevention and management of chronic disease.
Yet, despite the healthcare community’s consensus that the EMR is the next great leap forward, many hospitals and health systems struggle to find real benefit. Physicians, nurses, and other caregivers complain that electronic charting reduces productivity. Administrators scratch their heads in wonder as their organizational inefficiencies prior to EMR go-live only seem bigger and more problematic afterward. Even CFOs are affected, as they struggle to calculate a hard-dollar return on investment (ROI) for the technology that was supposed to boost the bottom line.
Still, there is little doubt that implementation of an EMR is an opportunity to transform healthcare in terms of clinical outcomes, patient safety, access, affordability, and customer satisfaction. However, to date, many of these efforts have failed to meet these lofty expectations, and, in the end, the EMR has become just another IT project. Sure, there is improved functionality, perhaps a few productivity enhancements, mixed reviews from the user community, but very little true value creation to patients and their families.
The question is, why?
The answer is simple and often painfully obvious. Broken or non-performing processes can’t be fixed with an overlay of technology. In fact, that approach only serves to magnify the deficiencies, not correct them. Yet, in their haste to implement an EMR solution, many hospitals overlook this simple fact: Poorly designed manual processes that receive a technology infusion don’t morph into highly efficient and effective workflows. Technology simply turns poorly designed manual processes into poorly designed electronic processes.
For example, if a medical center’s pathology department struggles to report test results in a timely manner, implementing electronic order entry will not improve cycle time. After all, the workflows associated with collecting and testing specimens and then reporting the results are highly reliant on the people doing the work and the processes they are using to complete the job. While electronic order entry will change how lab tests get ordered (which does not necessarily mean that the ordering process will be any easier for physicians), it will not actually change the processes within the lab. What the electronic order entry system will do, however, is give the hospital administrator excellent data for demonstrating just how inefficient the lab testing and reporting process really is.
Process Improvement or Process Redesign?
All is not lost. By focusing on process redesign prior to implementing the EMR, hospitals can maximize the benefits technology has to offer. Two large health systems — Sutter Health in Northern California and Presbyterian Healthcare Services in Albuquerque, New Mexico — are taking this approach, using Lean Six Sigma design tools. They are first redesigning processes and workflows to eliminate waste, redundancy, and variation, and then automating these newly improved processes with EMR technology.
Both health systems are using a methodology called Design for Six Sigma, also known by the acronym, DMADV, which stands for Define, Measure, Analyze, Design, and Verify. Design for Six Sigma has yet to break into the mainstream, perhaps because the list of improvement opportunities is already daunting. However, the basic premise of Lean Six Sigma is that before you can improve a process, it has be stable and in control. More often than not, healthcare processes don’t meet these criteria, which is why many improvement projects are unable to sustain real gains for more than a few months. How often have hospitals devoted valuable resources to performance improvement, only to see those improvements slip away in less than a year?
Rather than try to improve processes that are broken and beyond repair, a better approach is to start from scratch and redesign the processes using Design for Six Sigma’s five-phase methodology:
Define. The organization defines design goals that are consistent with customer demands and organizational strategy.
Measure. The process redesign team measures the critical-to-quality needs of their customers through a process known as voice of the customer, which is a methodical approach to understanding customer requirements. Customers include key external and internal stakeholders — patients, families and family caregivers, payers, physicians, staff nurses, ancillary staff, and case management, to name just a few.
Analyze. A high-level design is created, using various analysis tools to develop and design alternatives that can improve quality and reduce costs. High-level design features are selected that can deliver the level of performance demanded by the project’s customers. These design features are formally evaluated against the critical-to-quality criteria specified in the Measure phase.
Design. Detail-level design is completed, including detailed workflows, policies and procedures, facilities plans, equipment and supply plans, change management plans, and risk assessments. Additionally, if necessary, simulation may be conducted to test the new design prior to launching pilots. What’s more, the IT plan is created in this phase, which directly impacts the design of the EMR.
Verification. Once a design has been analyzed and tested, it is verified through one or more pilots. Following successful verification, it is ready to be spread throughout the organization.
Linking Process Transformation to the EMR
The IT plan developed in the Design phase is the blueprint for a successful EMR implementation. By aligning the EMR build with newly-designed processes that are designed to meet specific customer criteria, the likelihood of achieving real benefits is increased. However, not all design features are created equal, and by understanding the different categories of design features, the health system can often begin to achieve benefits long before EMR go-live. To illustrate, consider a project that is chartered to redesign the flow of patients through the emergency department (ED). As part of the new design, the project team may have selected the following features:
Core Measure Patient Flagging. A product and process feature that begins with the identification of a patient who is eligible for a core measure protocol, such as AMI and pneumonia. The patient is flagged electronically with built-in order sets and time-sensitive countdowns.
Discharge Nurse. A dedicated nurse who performs the discharge process for all appropriate patients.
Primary Triage Nurse. The first contact for patients arriving through the main entrance of the ED. The primary triage nurse designates the patient pathway based on their initial chief complaint.
STAT Mini-Registration. The primary triage nurse greets the patient and performs a brief registration to include the patient’s name, date of birth, and chief complaint. This includes the generation of an armband, face sheet, and labels.
Immediate Bedding. Once patients have gone through the STAT Mini-Registration process, they are sent directly to the care delivery area for the MD/RN secondary triage and assessment.
Patient Priority Tracking (eWhiteboard). A real-time visual management tool that provides patient updates and status reports for location, diagnostic results, orders, medications, and length-of-stay status. The feature also provides alerts and flags for time-sensitive metrics and targets.
Rapid Admission Process. An expedited bed request for possible admission based on patient’s primary assessment and potential eligibility based on InterQual criteria.
Standardized Protocols and Nursing Interventions. Medical-staff-approved order sets that allow nursing to begin treatment and diagnostic testing for certain disease states prior to the physician assessment.
It is important to note that not all of these design features require a technology solution. Indeed, at least half of these features could easily be implemented manually, without the need of any EMR solution. Understanding which design features are technology-enabled, which are technology-enhanced, and which are purely process transformative in nature will allow the organization to implement technology-independent improvements well in advance of the EMR itself, and begin to realize benefits.
Technology-enabled design features are those that require an IT application, such as Patient Priority Tracking. Technology-enhanced features can be implemented in a manual environment, but are greatly enhanced by the EMR. For instance, Standardized Protocols and Nursing Interventions can be implemented without technology, but having those same protocols and interventions automated with an electronic feed into the medical record certainly enhances the process. Finally, process transformation features, such as Immediate Bedding, represent revolutionary changes in the current process that have no impact on the EMR build, but are capable of achieving early benefits.
Once the technology-enabled and technology-enhanced design features are isolated, the EMR can be configured to take advantage of these new workflows. While the EMR build is underway, the process transformation features can be implemented — many times, months in advance of EMR go-live — thus expediting the return on investment.
Calculating the Benefits
In today’s IT world, implementing an EMR is typically part of a broader strategy to transform care delivery, achieve a competitive advantage in the marketplace, and deliver hard savings to the bottom line. However, benefits realization rarely evolves past the point of justifying the capital expenditure with an internal rate of return and ROI. Once the project has been funded, the hope is that the functionality of the system and the good intentions of the implementation team will deliver a bounty of benefits to be shared by all. To go beyond this, a true benefits realization process requires a pyramid of metrics, consisting of three levels:
Level 1. Total cost of ownership and return on investment. These are the metrics that the board of trustees and the executive management team care about most. At Level 1, the organization strives to understand not only the costs of the EMR, but also the expected financial benefits that will result from the combination of process redesign and technology implementation. It includes expected cost savings that will result from reductions in average length of stay, pharmacy costs per adjusted discharge, payer denials, etc.
Level 2. Business and/or transformation dashboards, including key outcome measures, such as improvements in medication errors, core measure compliance, and adherence to admission criteria. These are often the hard project measures that are monitored by the EMR governance team.
Level 3. People and process metrics. Process redesign, coupled with the EMR, will have a dramatic impact on resource requirements. This is where the real benefits are realized, as the new process designs and workflows impact staffing levels, productivity, supply budgets, space requirements, and more.
Implementation of a sound benefits realization strategy is not a complex discipline, like project management, but it is hard work. Organizations typically fail to allocate dedicated personnel whose job it is to eat, live, and breath the measurement and achievement of desired results. Who does this work will vary from organization to organization — Lean Six Sigma Black Belts, decision support analysts, process engineers, informatics staff, management engineers, or benefits analysts, to name just a few. Regardless of who is given the assignment, process ownership and accountability for both the design and realization of benefits should be clearly established with both metrics and milestones included in the EMR charter and work plan. Pre- and post-implementation metrics at all three benefits levels should be closely monitored.
In our haste to meet budgets and go-live schedules, benefits realization becomes an easy task to overlook or postpone until later in the project. Unfortunately, without focusing on process redesign first and benefits realization second, the day of reckoning will surely come. Whose decision was it to buy this system in the first place? Things were easier before we had everything on the computer. I need more FTEs because the new system makes us less productive. The system just slows me down. I didn’t go to medical school to be a data entry clerk. Did we get our money’s worth for this multimillion dollar investment? Every healthcare CIO has heard these questions and complaints, and without good process redesign and benefits planning up front, they are destined to hear them again.
Rules of the Road
To improve your chance of a successful EMR implementation, which includes process redesign, pay close attention to these 10 rules:
Rule 1. Thou shall not disrupt clinical productivity. This is the golden rule of process redesign and clinical information system implementation. If physicians see a reduction in clinical productivity and a resulting negative impact on RVUs and compensation, acceptance will be difficult at best. It’s all about the 10 to 15 minutes with the patient during the clinical encounter. The processes and systems should not divert time and attention from a clinician’s No. 1 priority — to provide good patient care. Processes and systems should be designed around how clinicians do their work, which is what Design for Six Sigma’s voice of the customer aims to do.
Rule 2. Vision and guiding principles. The EMR build will require operational leaders to make many decisions regarding the design and functionality of the new processes and new system. Senior leaders should make the “big decisions” that will guide the process design and EMR build teams and help ensure that the finished product will meet intended goals.
Rule 3. Where’s the ROI? Benefits realization does not happen without doing the hard work to plan for intended benefits, measure processes and outcomes pre- and post-conversion, and assign ownership and the accountability for achieving them. Benefits should be measured at the three levels specified earlier in this article. Remember, the day of reckoning is never far away.
Rule 4. Take advantage of the opportunity to transform care. Redesign processes with the customers — external and internal — in mind. While it requires both process transformation and EMR technology to fully transform care, keep in mind that the majority of the benefits come from the former, not the latter.
Rule 5. Have one integrated plan. Leaders will be frustrated trying to manage multiple initiatives. Application of Design for Six Sigma should be integrated into the EMR work plan and included in the project charter.
Rule 6. Be careful what you wish for. The E in EMR means electronic. Efforts to cling to paper-based systems must be addressed directly with few, if any, exceptions. If you write it down and then enter it into the system, all you have accomplished is making highly trained providers and support staff very expensive and unhappy clerks.
Rule 7. Discipline, discipline, and more discipline. In your haste to meet scheduled deadlines, don’t take shortcuts with the basics. The project should have a detailed charter, including governance, scope, interfaces, change control process, risk assessment and mitigation, process redesign, communications, change management, and benefits realization. Use the disciplines of project management. If the vendor does not bring a mature system lifecycle development methodology to the project, you may want to consider bringing in a systems integration consultant to support this role.
Rule 8. Locally owned and operated. Remember, this is not just an IT project. The EMR touches virtually every employee in the hospital and, when coupled with process transformation, changes how they do their jobs. Governance, ownership, and enthusiasm for the project cannot be outsourced to the IT vendor.
Rule 9. Dance with the partner you came with. When building or configuring the system, 8 out of 10 decisions will default to the best practice or system standard. However, don’t become overwhelmed by functionality you don’t need. Just because the system is capable of providing certain functions, it does not mean you have to turn them on. Try to use the most important functionality most of the time and keep the design as simple as possible. You can always add additional functionality later.
Rule 10. Several humble streams instead of one mighty river. Standardized processes and standard work does not mean that the answer is always a one-size-fits-all solution. Different customers with different requirements may necessitate several standard processes — but too many is still too many. The challenge is finding the right balance. Remove unwarranted variation, but enhance the ability to respond to variation that is warranted.
As senior vice president of Juran Healthcare, Joseph Duhig leads Juran’s trainers and consultants in guiding healthcare clients to Six Sigma levels of performance. He is a certified Master Black Belt, Lean expert, and experienced in implementation of Lean Production Systems. Previously, Duhig was the practice director of quality and performance improvement at the Innovations Institute and was executive director of process excellence for Memorial Health University Medical Center in Savannah, Georgia. He also was the CEO and executive director of the University Medical Center Alliance (UMCA) in Memphis, Tennessee.
Duhig has a master of business administration degree from Wilmington College, a bachelor of science degree in industrial and systems engineering from the Georgia Institute of Technology, and a certificate in health in systems engineering from the Georgia Institute of Technology. He is a member of the Institute of Industrial Engineers, the American Society of Quality, and the Healthcare Information and Management Systems Society. Duhig may be contacted at jduhig@juran.com.
Reference
Hillestad R., Bigelow, J., Bower, A., Girosi, F., Meili, R., Scoville, R., & Taylor, R. (2005). Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health Affairs, 24(5), 1103-1117.