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Patient Satisfaction Drops After Ambulatory EHR Is Rolled Out

Posted on June 4, 2018 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

In theory, EHR implementations are supposed to not only make providers’ jobs easier but ultimately, improve patient satisfaction too. The idea is that EHRs will eventually add something beneficial to physician routines and ultimately improving care processes. Of course, there’s a lot of question as to whether EHRs can now or will ever do so, but researchers continue to look at different use cases.

For example, new research published in JAMIA has concluded that while they weren’t too thrilled by the ambulatory EHR they were using, a group of OB/GYN practices showed some enthusiasm once the outpatient EHR was attached to the one collecting data on their related inpatient perinatal unit.

The purpose of the study was to look at how the installation of the ambulatory EHR within the OB/GYN practices and subsequent connection to an inpatient perinatal EHR affected providers’ attitudes toward sharing of clinical information. It also looked at the impact all of this had on patient satisfaction.

To conduct the study, researchers collected data on both provider and patient satisfaction. They assessed provider satisfaction by conducting four surveys staged across the phased implementation of the EHR. To measure patient satisfaction, meanwhile, they drew on data from Press Ganey surveys managed by the healthcare network using the usual process.

Their ultimate goal was to determine how provider and patient perceptions changed as the EHR system enabled greater information flow between the OB/GYN practices in the hospital.

What the study found was that the outpatient OB/GYN providers were less satisfied with how the EHR affected their work processes than other clinical and non-clinical staff. On the other hand, they grew more satisfied with their access to information once the inpatient perinatal triage unit offered useful functions. Specifically, they were happier with their access to information from the inpatient system once its capabilities included the ability to send automatic data flows from triage back to the OB/GYN offices.

On the other hand, overall patient reactions to the project appeared to be negative. Patient satisfaction fell after the installation of the ambulatory EHR, and researchers could find no evidence that patient satisfaction rebounded after the information sharing process began between inpatient and outpatient settings.

In summary, the study concluded, if providers are dissatisfied with their EHR system, and those difficulties undercut patient care, the process could negatively impact patient satisfaction. The authors recommended that healthcare organizations take extra care to maintain good communication with patients during this process.

EMR-Based Alert System Can Identify Possible Child Abuse Victims

Posted on February 21, 2018 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Sometimes, it’s pretty easy for a physician to tell that a child might be experiencing physical abuse at home. However, sometimes physicians are rushed and may not do an adequate screening for abuse, the signs of which aren’t always available at first glance.

However, a group of researchers has developed an algorithm, drawing on patient records in the EMR, which it says can improve screening rates for physical abuse and identify such cases earlier.

The project, the write-up of which appears in the Journal of the American Medical Informatics Association, coded triggers to identify children less than two years old at risk for physical abuse into the EMR using a freestanding pediatric hospital with a level 1 trauma center. The researchers embedded 30 age-specific triggers in the EMR.

During the test, the system ran a “silent mode,” in which study personnel saw data on children whose clinical symptoms triggered the alert system but physicians did not. During the period between October 21, 2014 through April 6, 2015, 226 children triggered the alert, the mean age of whom was 6.5 months.

During the pilot the system detected 98.5% of children less than two years of age with signs of probable or definite child abuse, according to the study authors.

If these algorithms are that successful in identifying at-risk children, one would hope that the system moves from pilot to widespread rollout fairly soon. In theory, the system should help clinicians who encounter children in potential danger, especially ones presenting with serious injuries in the emergency department, be better prepared to identify these children and take appropriate action.

Ultimately, this study suggests that even if such clinicians are alert and careful, triggers generated by an EMR might be more effective at detecting these cases. After all, while clinicians must juggle multiple patients in an extremely hectic environment, especially in the ED, EMRs don’t get tired and they don’t need to check a signs and symptoms list manually to detect signs of trouble.

Of course, while these triggers can be very helpful in investigating signs of abuse, clinicians would be ill-advised to rely on them entirely, as there’s no substitute for experience and medical judgment. Also, there’s always a risk that adding another alert to the cacophony of existing alerts could lead to it going unnoticed. Still, it seems certain that if nothing else, this is a promising approach to protecting children from harm.

Alert Fatigue: It May Be Worse Than You Thought

Posted on November 3, 2017 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Until recently, I didn’t take the problem of clinical decision alert fatigue that seriously, or at least not as seriously as I should have. After all, it’s just an alert, right? You can just shut it off if you don’t like hearing it. Or so it seemed to me, admittedly a naïve pundit from the peanut gallery who’s never treated a patient in her life.

But despite my ignorance, researchers have continued to unearth evidence that alert fatigue may be one of the worst safety hazards afflicting medicine today. After all, this fatigue comes from a deadly one-two punch: the excess noises camouflage the alerts clinicians really need to hear while distracting them from what they’re doing with useless sounds. (If you put me in a situation like that I’d get booted out the door for throwing particularly noisy devices out the window.)

Sadly, alert fatigue is far more than a nuisance. The latest evidence to this effect comes from the Journal of the American Medical Informatics Association, where an article published last month underscored how often alerts cause clinicians to ignore important information.

To conduct their study, a group of researchers conducted a cross-sectional study of medication-related clinical decision support alerts. They collected data at a 793-bed tertiary-care teaching institution, measuring the rate of alert overrides, the reasons cited for overrides and the appropriateness of those reasons.

The results of their analysis were disquieting. On the one hand, they found that roughly 60% of overrides were appropriate overall. In particular, 98% of duplicate drug overrides, 96.5% of patient allergy overrides and 82.5% of formulary substitution overrides were appropriate. That’s the good news. On the other hand, they concluded that 40% of physician alert overrides were inappropriate.

All told, overrides of alerts in certain categories were inappropriate greater than 75% of the time. Let’s take a moment to think about that. Seventy. Five. Percent. Now, I know that “inappropriate” doesn’t mean that the patient would’ve died if the error was corrected, or even that they incur serious harm, but this still isn’t great to hear.

Not surprisingly, researchers said that future studies should optimize alert types and frequencies to improve their clinical relevance so clinicians don’t slap them down over and over like a snooze alarm.

The truth is, studies have been drawing this conclusion for quite some time now, and from what I can see little has changed here.

My assumption is that vendors keep doing what they do because nobody has pressured them enough to make them rethink their CDS logic and drop needless alarms. I’m also guessing that some misinformed health leaders might be reassured by the sound of alerts going on and equating it with higher safety ratings. If so, let’s hope they get disabused of this notion soon.

Medical Groups Can Use EHR Data To Analyze Clinical Workflows

Posted on October 17, 2017 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Typically, ambulatory care organizations don’t do workflow studies, as leaders assume they have neither the time nor the data available to make it happen.

They may have more options than they think, however. A group of researchers has concluded that timestamp data found in their EHR can be used to predict ambulatory workflow.

The research article, which appears in the Journal of the American Medical Informatics Association, notes that workflow studies typically require large amounts of timing data which are too expensive to collect through observation or tracking devices. Historically, ambulatory care organizations have had to make do with observation and intuition rather than sophisticated interventions.

In fact, the relationship between health IT and ambulatory care workflow redesign hasn’t been a friendly one. A 2015 study by the Agency for Healthcare Research and Quality concluded that health IT implementations could make a mess of existing workflows. Problems included “a redistribution of clinicians’ and clinic staff’s time on different clinical tasks, repurposed usage of workspace, increased level of interruptions, multitasking, and off-hours work activities.”

According to the current group of researchers, however, these organizations may have the data they need at their fingertips. The study, which used EHR timestamp data to predict ambulatory workflow timings, suggests that this approach is valid.

To conduct the study, the researchers studied the workflow at four outpatient ophthalmology clinics associated with the Oregon Health and Science University, observing their workflows and timing each workflow step. They then mapped the EHR timestamps to workflow steps to see how they compared.

They found that workflow times generated by EHR timestamp analysis were within three minutes of observed times for greater than 80% of the appointments. What variance they did observe between observed times and timestamps seems to have been due to EHR use patterns.

Even giving these variances, ambulatory care organizations can get a lot of value out of EHR timestamp data, researchers said. “EHR timestamps…can be used to create simulation models, analyze HR use, and quantify the impact of trainees on workflow,” they concluded.

Even given this option, few ambulatory care organizations are likely to conduct formal workflow studies unless they’re backed by a deep-pocketed health system. Most medical practices have their hands full collecting what they’re owed by health plans and managing operations on a day-to-day basis.

This isn’t to suggest that they are unsophisticated, but rather, that workflow studies may require a level of time, commitment and resources that smaller practices simply don’t have. Most U.S. medical practices are small businesses.

Still, it’s good to know that if they choose, medical groups can use data already available in their EHR to make meaningful workflow improvements. Perhaps it’s time for vendors to step forward and support the use of EHRs for this purpose.

Some Methods For Improving EMR Alerts

Posted on June 25, 2015 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

A new study appearing in the Journal of the American Medical Informatics Association has made some points that may turn out to be helpful in designing those pesky but helpful alerts for clinicians.

Making alerts useful and appropriate is no small matter. As we reported on a couple of years ago, even then EMR alert fatigue has become a major source of possible medical errors. In fact, a Pediatrics study published around that time found that clinicians were ignoring or overriding many alerts in an effort to stay focused.

Despite warnings from researchers and important industry voices like The Joint Commission, little has changed since then. But the issue can’t be ignored forever, as it’s a car crash waiting to happen.

The JAMIA study may offer some help, however. While it focuses on making drug-drug interaction warnings more usable, the principles it offers can serve as a model for designing other alerts as well.

For what it’s worth, the strategies I’m about to present came from a DDI Clinical Decision Support conference attended by experts from ONC, health IT vendors, academia and healthcare organizations.

While the experts offered several recommendations applying specifically to DDI alerts, their suggestions for presenting such alerts seem to apply to a wide range of notifications available across virtually all EMRs. These suggestions include:

  • Consistent use of color and visual cues: Like road signs, alerts should come in a limited and predictable variety of colors and styles, and use only color and symbols for which the meaning is clear to all clinicians.
  • Consistent use of terminology and brevity: Alerts should be consistently phrased and use the same terms across platforms. They should also be presented concisely, with minimal text, allowing for larger font sizes to improve readability.
  • Avoid interruptions wherever possible:  Rather than freezing clinician workflow over actions already taken, save interruptive alerts that require action to proceed for the most serious situation. The system should proactively guide decisions to safer alernatives, taking away the need for interruption.

The research also offers input on where and when to display alerts.

Where to display alert information:  The most critical information should be displayed on the alert’s top-level screen, with links to evidence — rather than long text — to back up the alert justification.

When to display alerts: The group concluded that alerts should be displayed at the point when a decision is being made, rather than jumping on the physician later.

The paper offers a great deal of additional information, and if you’re at all involved in addressing alerting issues or designing the alerts I strongly suggest you review the entire paper.

But even the excerpts above offer a lot to consider. If most alerts met these usability and presentation standards, they might offer more value to clinicians and greater safety to patients.

Simpler EMRs Lower Physician Stress

Posted on September 23, 2013 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

When it comes to EMRs, simpler may be better, according to a new study. 

Researchers have concluded that doctors who use EMRs with a moderate number of functions are more stressed out and have a lower level of job satisfaction than those who use EMRs with fewer functions.

The study also suggested that doctors who used highly functioning EMRs are especially challenged providing care if they feel the time allowed to do so isn’t adequate.

The study, which was reported in Healthcare Informatics magazine, originally appeared in the Journal of the American Medical Informatics Association. In the study, researchers examined variables including doctor-reported stress, burnout, satisfaction and intent to leave the practice, then used these variables to compare decisions before and after EMR systems were implemented.

To gauge how physicians react to EMR features, the study authors looked at 379 primary care physicians, along with 92 managers at 92 clinics from New York City and the upper Midwest.

The physicians and managers were participating in the Minimizing Error, Maximizing Outcome study, a 2001 – 2005 study assessing relationships between the structure and culture of the primary care workplace, physician stress and burnout, and the quality of care experienced by their patients, Healthcare Informatics reported.

The researchers actually found the job stress went down slightly for physicians using sophisticated EMR system compared to physicians with moderately complex EMRs. However, time pressure during examinations was more highly associated with adverse physician outcomes in the high EMR function group, the study authors wrote.

It’s worth remembering, however, that EMR complexity isn’t the only factor which determines how comfortable physicians are with their system.

Ultimately, seeing to it that doctors are comfortable with EMR features and functions before they’re installed and set in stone is the best way to see to their satisfaction, according to health IT expert Mark Olschesky.

Getting Personal with EMRs and Women’s Health

Posted on October 18, 2012 I Written By

As Social Marketing Director at Billian, Jennifer Dennard is responsible for the continuing development and implementation of the company's social media strategies for Billian's HealthDATA and Porter Research. She is a regular contributor to a number of healthcare blogs and currently manages social marketing channels for the Health IT Leadership Summit and Technology Association of Georgia’s Health Society. You can find her on Twitter @JennDennard.

It’s that time of year again. Like my mother, I’ve taken to scheduling any sort of annual event around the time of my birthday. So, now my birthday cake is accompanied by a trip to get my emissions done, a jaunt to the tag office, and a visit to my primary care doctor for an annual physical and any other female-related health services I might need. (Timely, considering that October is also Breast Cancer Awareness Month.)

I tend not to schedule my well visits months in advance, and so was a bit apprehensive earlier in the week as I dialed in to get an appointment. I’ve read quite a few patient horror stories lately of appointments not being available for months due to lack of staff. Thankfully, this was not my experience. I was able to pick the date and time of my choosing, with the only insurance-related caveat being that I had to wait until one day after the date of my exam in 2011.

When I was at the doctor’s office last year, they were in the process of launching a patient portal. Digging around on their website while speaking with their receptionist, I noticed the portal is indeed available. The patient-centric portal offers online bill pay, appointment scheduling and pre-registration services and a personal health record. I’ll be interested to see if they mention its availability when I am seen in a few weeks. I’ll definitely ask who was involved with the implementation, and if they’re looking to Stage 2 Meaningful Use quotas when it comes to electronic patient engagement.

But enough about me. The reason I bring all this up is because the Journal of the American Medical Informatics Association recently made available research on “The effect of electronic medical record system sophistication on preventive healthcare for women.” A quick look at the abstract relates that 29.23% of providers (culled from those in the National Ambulatory Medical Care Survey from 2007-08) had no EMR system, 49.43% had minimal EMRs, 15.97% had basic EMRS, and 5.46% had fully functional EMRs.

“For breast examinations, pelvic examinations, pap tests, Chlamydia tests, cholesterol tests, mammograms, and bone mineral density tests, an EMR system increased the number of these tests and examinations,” according to the abstract. “Furthermore, the level of sophistication increased the number of breast examinations and pap, Chlamydia, cholesterol and BMD tests.”

The JAMIA’s point being that “the use of advanced EMR systems in obstetrics and gynecology was limited. Given the positive results of this study, specialists in women’s health should consider investing in more sophisticated systems.”

I’m going to play devil’s advocate here for a minute.

First of all, the fact that not even 5.5% of providers surveyed had a fully functional EMR is dismaying, but perhaps I don’t understand the underlying financial reasons for their lack of adoption. And the fact that the survey was taken more than four years ago could play a part. It would seem to me that there would be much to gain clinically and financially in having a fully function EMR especially in obstetrics, where women are often seen at a number of facilities throughout their pregnancies.

And finally, I have to take issue with the “positive results” the JAMIA concludes the study to have had. To me, “positive” connotes “successful,” so I wonder if there’s a hidden conflict of interest here. Increased sophistication of EMR systems would seem to equal more tests, according to the study, but no mention is made of if those tests lead to better outcomes (a win for patients) or higher reimbursements (a win for providers). I know we walk a fine line when talking about EMRs, tests and money, and that it often ends up being a chicken-and-egg situation, but it’s still a debate that needs to be had, especially in the area of women’s health.

EMR Data Often “Inaccurate” Or “Missing”, Study Says

Posted on September 17, 2012 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

EMR adoption continues to march forward, spurred not only by Meaningful Use requirements but also the need for doctors to access data remotely and the rise of cloud infrastructure to support such initiatives.  According to research firm IDC, 80 percent of healthcare organizations should adopt EMRs by 2016.  Pretty much what you might expect.

Hopefully, this will have a positive impact on clinical care. However, EMRs may be less useful than they should be for population health research, as data is often inaccurate or missing, according to a new report published in the Journal of  The Medical Informatics Association.

Researchers behind the report said that while data from EMRs can be useful, it’s prone to certain types of errors which undermine its value.  For example, EMR data accuracy varies depending on whether the patient was treated during the day or during the night, in part because patients at night are often sicker, according to Dr. George Hripcsak, a professor of biomedical informatics at Columbia, who recently spoke with eWeek magazine.

Another issue of concern is that patient symptoms are often poorly documented in EMRs before death. For example, patients with community-acquired pneumonia who enter the ED and die quickly don’t have symptoms entered into the EMR before they die. Later on, their medical records make it look as though a healthy patient died, the researchers note.

Dr. Hripcsak told the magazine that researchers in informatics, computer science, statistics, physics, mathematics, epidemiology and philosophy will need to work together to get an accurate read on EMR data and avoid biases. (Whew!)

Clearly, the kind of teamwork Dr. Hripcsak has in mind will take a great deal of resources. They’re on their way, it seems. For example, I’m betting that the new Johns Hopkins center for population health IT will serve as a model for the kind of interdisciplinary efforts he’s describing. But that’s just one effort. It will be interesting to see whether other universities follow in Johns Hopkins’ footsteps.

When Physicians Own Practice, EMR Implementation Feels Tougher

Posted on January 30, 2012 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Here’s an EMR adoption study which interested me largely because it runs counter to what I would have predicted.  The study, which surveyed physicians pre- and post- EMR implementation, found that doctors who owned a stake in their practice found their rollout to be tougher than physicians who didn’t have a stake.

I don’t know about you, but I would have assumed that the folks with more control — the owners — would have found it easier than those who have to adapt to the decisions others make.  But it seems that physician-owners simply feel the pain of change more acutely.

To conduct the study, which was published last week in the Journal of the American Medical Informatics Association,  researchers surveyed 156 physicians working with the Massachusetts eHealth Collaborative.  The surveys included a pre-implementation questionnaire  in 2005 and a post-implementation questionnaire in 2009.

Thirty-five percent of doctors who responded reported that implementation was very difficult, 54 percent said it was somewhat difficult and 12 percent not difficult. Those numbers square pretty well with what I’ve seen elsewhere. The twist here was that 38 percent of physicians with full or partial ownership stakes in their practices voted “very difficult,” versus 27 percent of non-owners. That surprised me. After all, aren’t most of the complaints coming from doctors who try to use the new systems?

According to Marshall Fleurant, MD, one of the study’s authors, the owners “probably experienced more underlying challenges associated with EHR implementation and workflow transformation” given their broader operational responsibilities.

While this study is interesting, it’s hardly the last word. Teasing out just which factors predict how doctors will react to EMR implementation, much less what it takes to support them, is still a new science.  But it never hurts to bear in mind that physicians making critical management decisions get support, too.