Workarounds Persist As EMR Systems Evolve

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With frustrated end users finding shortcuts, changes in workflow and training offer a longer-term solution to adoption problems

Government incentives have been a catalyst for the rapid adoption of various health IT initiatives, especially electronic medical records (EMRs) and electronic health records (EHRs). But as with any new technology, there are shortcomings and challenges.

One of the ways end users are addressing obstacles posed by immature or inefficient EMR systems has been to develop workarounds – either paper-based or electronic.

“Workarounds are a challenge,” said Dr. Paul Dexter, chief medical information officer for Wishard Health Services, based in Indianapolis. “Our first priority is to address those identified as potentially adversely impacting clinical care.”

The American Medical Association has been paying close attention to workarounds and their impact on productivity and patient care.

Dr. Steven Stack, the association’s chairman, said that to address these glaring inefficiencies, various shortcuts and tools are used in the EHR.

The most common of these are templates, macros and using the cut-and-paste function. While Stack considers none of these inherently bad, he said the risk is that they could be misapplied – accidentally or intentionally.

“Cut and paste becomes bad and is appropriately criticized as `cloning’ when clinicians reproduce information created by themselves or others, either without attribution or without attention to its accuracy,” Stack said.

Workarounds a Symptom, Not the Problem

A recent study conducted at Indiana University found that “consistent workarounds across institutions suggest common challenges in outpatient clinical settings and failures to accommodate these challenges in EHR design.”

The study’s authors determined that an examination of workarounds provides insight into how providers adapt to limiting EHR systems. Data revealed that part of the design process for computer interfaces should include user-centered methods specific to providers and healthcare settings to ensure uptake and usability.

Dr. Brad Doebbeling, a professor of medicine and informatics at Indiana University who co-authored the workaround study told HealthBiz Decoded the results argue for an extensive redesign of EHRs systems in general and improvements in clinical decision support.

“Workarounds are more of a symptom (than) a problem,” he said. “It’s a symptom that the work that’s involved in using the EHRs is not optimal, that it’s inefficient. As we create workarounds, we do those individually, we each do them our own way, and it has the potential for introducing errors.”

Dan Stewart, vice president and practice partner in strategic consulting and advisory services at Xerox, agrees that workarounds are a symptom of a bigger problem, with the industry generally more focused on implementation than adoption.

“The health systems in many cases are not adopting an EHR because they are not engaging leadership and they are not educating the stakeholders in developing the proper governance structure,” said Stewart. “The vendors contribute to this by implying that once an EHR is implemented, the health system will be able to use it in a meaningful way.”

Much of it has to do with organizational change management, he says, with keys to adoption being to focus on process workflow, content development, training, and policies and procedures.

Too Much Focus on Primary Care?

Some industry insiders contend that one of the reasons for workarounds is that many EMR products were built for primary care physicians at the expense of a specialist’s workflow.

“The workflow has to match a physician’s specialty workflow, and many of these products are not designed for that,” said Mark Anderson, chief executive of the AC Group, a Montgomery, Texas-based health IT consultant firm.

Anderson, a former hospital chief information officer, said that while most top-tier vendors’ products are designed to address specialists, the majority of the mid-level products are not.

The lack of interoperability has also been a “huge” problem for EMR adoption and implementation, said Xerox’s Stewart. The good news is that, under Stage 2 of government Meaningful Use requirements beginning in 2014, software vendor systems will have to adhere to new certification standards that are designed to move the industry closer to interoperability.

What do the next generation of EMR vendors need to do in order to reduce the need for workarounds?

“To better address the problem of workarounds, we have to get to where there’s many more choices in the market. Striving for both modularity and interoperability are important to this effort,” said Wishard’s Dexter.

Stewart said that while there are some systems that need to be redesigned, it’s more about internal organization and change management.

“The health systems that are the most successful in utilizing electronic records have been the ones that have focused a significant amount of time on organizational change management,” he said.