Tuesday, March 19, 2013

An Epic narrative

My professional life at Johns Hopkins has been largely consumed in recent months by preparations for the implementation of the Epic electronic health record (EHR) system. Our so-called "Ambulatory First" go live for all outpatient Hopkins clinics in the Baltimore-DC area begins 4/4/13 with the scheduling and registration system and then swings into full gear with the clinical roll-out of the EpicCare EHR at Green Spring (where I practice) on 5/16 and in East Baltimore at Johns Hopkins Hospital clinics on 6/27. If you've ever been part of a major EHR go-live at a hospital, clinic, or office, you know what a monumental undertaking this is and why "consumed" doesn't really do the experience justice. For Hopkins, we are transitioning from many years of doing things a certain way using a huge variety of legacy and/or best-of-breed electronic systems for data capture and analysis, including some homegrown ones and in some cases paper records, to a single, enterprise-wide, vendor system. It will impact every aspect of our clinical operation and touch everyone who works here, not just those in patient care. While I'm confident we will emerge in a much better place, I am not looking at the coming months with much joy.

Hopkins is doing this for all of the right reasons, many of which are listed at the link above. The most important reason is, of course, the patients, so that we can improve the safety, quality, and efficiency of the care we deliver. A single EHR will enable us to collaborate better with other physicians and engage patients by giving them greater access to their records and treatment team. In some ways I am most looking forward to the implementation of the patient portal myChart, since I think it will revolutionize access. As a patient of a Hopkins physician myself, I received an email today touting the benefits of the portal and encouraging me to sign up (yep, got that one covered).

Sounds great, right? Well, not always. The reality is that many physicians are not very fond of EHRs, for a lot of complex reasons. To put it bluntly, many truly can't stand using them for patient care and rarely find much good to say about them. And it's not that physicians are inherently technophobic - quite the opposite, as virtually every physician I know owns a smartphone and tablet - but as a profession we are deeply skeptical of anything that slows us down and changes our workflow. A major EHR implementation like this has a huge impact on productivity for weeks if not months. And it's not just about the change process. The reality is that most EHRs, including this one, leave a lot to be desired in terms of usability (how easy it is to navigate and get through your work) and interoperability (how well these systems share data with each other). Physicians have to spend more and more time entering data at the point of care through menus, drop-down lists, and checkboxes, and - as many point out - less and less time interacting with and looking at the patient in the exam room instead of the computer. And in spite of the multimillion dollar investment this requires for a large health care system like Johns Hopkins, these systems still don't talk well with other non-Epic systems (true for other vendors as well). 

Certainly, there is another side of the story. For the first time ever, Hopkins physicians, nurses, pharmacists, and other allied health professionals will be able to access clinical information about a patient from any one of our clinics and hospitals, something that was virtually impossible to do before this. The reduction in duplicate labs and imaging tests should be immediate, as so often in the past, labs were repeated simply because we didn't have access to prior results. Electronic prescribing will be uniformly implemented, and medication reconciliation will finally become part of our everyday clinic workflows. And while it won't happen right away, Epic's data mining capabilities will allow us to track many aspects of care with ease, analyze trends across populations of patients with similar clinical characteristics, and hopefully soon link these routine clinical data with personalized genomic markers being identified in our labs. 

I hope to write some future posts on this blog about different aspects of EHRs, like the Federal meaningful use incentive program and whether it is still "meaningful," why many doctors are disappointed with their existing systems (here's a teaser), why cost-savings and efficiencies EHRs were supposed to bring have, to date, not yet materialized, and why, in my opinion, greater penetration and implementation of EHRs is mandatory for the dysfunctional U.S. health care system to truly make our care patient-centered, something it obviously is not much of the time right now. Here's the take-home message for today: No industry in the U.S. in the 21st century is as dependent on paper-based record-keeping as health care historically has been. Even the most strident critic of EHRs would have to acknowledge that there is no justification for continuing to use antiquated, analog workflows based on the classic paper hospital or office chart, a place where data go to die, locked in a single vessel that cannot be viewed by more than one user at a time and not manipulated, analyzed, or transmitted (sorry, your 1980s fax machine doesn't count). U.S. health care has no choice but to adopt a fully digital infrastructure to achieve the goals of what some call the Triple Aim: higher quality and greater patient satisfaction, better population health, and lower cost. Clinicians must lead from within, by being fully engaged in system selection, design, and implementation, and not defer to the "IT team" or administrative managers. At a higher level, the physician voice must be heard by vendors and policymakers. I disagree with those that claim our input is useless. I acknowledge that it's difficult to move along a monolithic, billion dollar vendor when you're a single voice but it's not hopeless. Frontline clinicians are the only ones who really know what it takes to take care of patients. We should be the ones who are in the front leading change in health IT. Sniping from the sidelines, griping anonymously in comment sections on NY Times articles, or tagging tweets with #EHRbacklash may feel good momentarily but isn't going to help our patients or make our lives easier.

To be clear, I'm not talking about my colleagues at Hopkins who have generally been open to this implementation, even though they have been understandably apprehensive about the impact on clinic throughput and efficiency. I know they will rise to the occasion and do the right thing since that's our culture. But bashing health IT and meaningful use has become fashionable in the blogosphere and popular press these days, and it is becoming relentless. So here's my call to action: Physician colleagues, step up and engage. I understand your reservations, but I think our patients deserve better. They deserve our professionalism and resolve to make an impact on the current state, not skepticism and griping. They need us to take ownership of this transformation, so it happens with us and by us...not to us.

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