7/21/03
Multiple Visions Undermine Success of EHRs
Leslie Ann Fox, MA, RHIA, and Patty Thierry, MBA, RHIA, CCS
Thank you to Advance Magazine for permission to use this article

Patty: We have talked about the importance of vision before in our column but not necessarily in the context of the electronic health record (EHR). Leslie, why do you want to spend time talking about this topic?

Leslie: It's apparent that within organizations, there simply isn't a unified vision of what the EHR should look like and do. This results in several concurrent technology projects that don't seem to line up into an integrated vision of the EHR.

Patty: Well that's true. It's really unfortunate, for example, that little thought is given to the printing of online data. Those leading the EHR effort are often focused on developing a paperless environment and don't seem to realize that the printed copy or a document set of the record is still needed to fulfill outside authorized requests.

Leslie: I understand this is a common problem. Printing the record may require going to more than one system and often the data is not formatted for printing as a document. This usually results in a voluminous document set with sometimes just a few lines of text per page.

Patty: This could be the result of a "best of breed" approach, which is not necessarily a bad approach, but if you don't have a strategy to manage and access the data residing in various systems, then best of breed solutions just seem to compound data management problems.

Leslie: I think that CEOs are often frustrated by the multitude of technology projects that don't seem to return the investment or bring the organization closer to the Institute of Medicine's (IOM) vision of the computerized patient record (CPR). Departments have their own goals. Nursing may want to increase efficiency through certain types of automation; radiology may want to improve the quality and accessibility of stored images. It takes an overarching EHR vision, however, to reduce medical errors, increase the quality of care, make access to up-to-date health information easier for health care providers, reduce full-time equivalents (FTEs), or to maximize the organizations return on investment. It's really time for strong leadership from the CEO to help create the vision of the EHR and focus the organization's information technology (IT) strategies to stay the course and reach that vision.

Patty: That is an interesting perspective because often it's the chief information officer (CIO) who has been charged with setting the EHR vision through the creation of IT strategies. But the CEO is ultimately responsible for setting the course for their organization so why not be more involved in the creation and active sponsorship of the EHR vision.

Leslie: I guess it begs the question then, who owns the EHR vision? Like any project, you need an owner. Is that the CEO, CIO or the health information management (HIM) director?

Patty: Good question. I don't know the answer to who should own the vision. But we do know from reading the John Kotter books on project management that creation of the vision, a sense of urgency and a sponsor are critical to the success of any project. It would seem that the CEO would create the urgency and establish a multidisciplinary group consisting of major stakeholders to define the vision. The director of planning and decision support, for example might provide input that results in a vision that includes being able to pull together certain types of data from various systems. The HIM director could make sure that processes that must be performed in order for the record to serve as a legal document were present in the system(s) selected. Physicians would make sure the information they need is provided in a format that is easy to use and remotely accessible.

Leslie: As we perform our consulting work, we often encounter different EHR visions within the system. Often these visions are not brought together, resulting in a fragmented EHR vision. Typically, at minimum, there are four different visions of the EHR.

Patty: That is so true. It is very common for physicians, nurses, IT and HIM to all have a different vision. Each of these groups has different needs and will envision the EHR from their perspective and workflow. Add to that, the vision that a risk manager might have or the vision held by hospital attorney's regarding what the legal record must look like. And the list of users and perspectives goes on.

Leslie: Sometimes it might appear that the vision is the same only to find out after implementation that the visions weren't the same.

Patty: Do you have an example?

Leslie: Electronic signature functionality is a good example. The clinical, IT and HIM representatives each have a vision of signing documents online. It sounds like a great idea to all parties. After some time, a system is purchased but the HIM director was not involved in the selection. When the product is tested, test scenarios of clinicians signing and cosigning doesn't go well. The HIM professional doing the testing realizes the product doesn't work the way she envisioned it would. Physicians can sign documents but can't edit or append them if there are any errors or they want to add something. In addition, the e-signature workflow doesn't support routing to attending physician's once residents have signed the report. And worse yet, physicians have to access a separate system to sign their reports. And they don't really want to do that.

Patty: And I bet there are no interfaces to the deficiency system either.

Leslie: Of course not. How did you guess? Another issue is that more electronic monitoring technology is available now and was not necessarily part of a paper record before. This information, however, is often part of a stand-alone system. Organizations must think about the fact that this can and perhaps should be part of an organization's EHR.

I guess the most startling aspect regarding the vision of the EHR for me, is that it usually does not include workflow to support the uses of the health record after the patient is gone. Retrieval of data and printing of that data as documents, as we discussed earlier are usually afterthoughts.

Patty: Crafting a vision is quite challenging. No wonder a unified vision is often lacking in organizations. It is a daunting task to bring everyone to the EHR table for this discussion, especially if there are conflicting visions. It also appears that this group doesn't just get together once to develop a vision, but must continue to meet as the EHR evolves.

Leslie: We've suggested that many organizations lack an EHR vision, or they have an incomplete vision or a fragmented vision of the EHR. We've also suggested that organizations need one comprehensive vision if they are to optimize the return on technology.

Patty: HIM professionals can help facilitate the awareness of different perspectives. They can also bring examples to the table of the poor outcomes created by fragmented visions. I find when HIM steps up to the table they are a welcome addition, provided they add value with their HIM expertise and problem solving skills.

Leslie: In the Hands-On Help article titled "The CPR and the Role of the HIM Professional," (April 1, 2002) we outlined steps HIM professionals can take to get a seat at the table.

Patty: HIM professionals can bring their vision to the table and help organizations understand the uses of the health record post encounter. HIM must play a lead role in bringing the fragmented visions together if they hope to evolve from HIM to e-HIM.

Leslie Ann Fox is president and chief executive officer and Patty Thierry is vice president of operations and chief information officer, Care Communications Inc., Chicago. They invite readers to send their thoughts and opinions on this column to lfox@care-communications.com or pthierry@care-communications.com.