According to an audit of electronic health record systems by Zynx Health in Los Angeles, a clinical decision support content provider, many U.S. hospital and health system EHRs barely earn a passing grade for implementing clinical best practices, especially when treating heart failure and pneumonia. The missing processes are standardized clinical best practices, which reduce mortality, readmissions and costs. EHR systems that have updated clinical processes may remind physicians and clinicians of important steps for improving a patient's care and recovery. Without them, the best possible outcomes may not be realized.
EHRs lack clinical best practices
According to Scott Weingarten, MD, CEO of Zynx Health, the audit was conducted to determine if hospitals and health systems were receiving the best benefits possible from their EHR systems. "Unfortunately, we found out they weren't," says Dr. Weingarten. The data to inform the audit was collected from 79 hospitals and health systems across the nation. The report focused on heart failure and pneumonia because of the high incidence of the diseases. They are also among the conditions CMS will no longer reimburse hospitals for when patients are readmitted within 30 days of a previous discharge.
"We did an exhaustive literature review of randomized clinical trials, meta-analyses, meta regressions, systematic reviews and practice guidelines," says Dr. Weingarten. "We found that almost all hospitals and health systems were missing many clinical processes. It showed us there is a real opportunity for the healthcare industry to improve." On average, hospitals had implemented only 67 percent of possible clinical processes within their EHR systems for pneumonia and only 62 percent of the clinical processes for heart failure. Additionally, the brand or EHR vendor did not make a difference. The missing practices were a result of the EHR user's implementation processes and the hospital's EHR optimization practice.
Edmundson, Mo.-based Ascension Health participated in the audit. According to James Nolin, MD, director of clinical excellence and informatics for Ascension Health, the audit gave Ascension hospitals the knowledge to improve their EHR systems and their health outcomes. For example, some Ascension hospitals were missing the clinical best practice to verify that a patient schedules a follow-up appointment within seven days of discharge. "If there is not a reminder, then the patient and the clinical staff member may forget. If the patient does remember, they may not schedule a timely appointment. As a result, the patient's condition could deteriorate, increasing the likelihood of readmission. The audit helped us realize which best practices were missing, so we could remedy the problem and improve," says Dr. Nolin.
Ascension Health is not alone. Evidenced by the prevalence of low scores in the audit, there are many hospitals and health systems missing key clinical practices in their EHR systems. According to Dr. Weingarten and Dr. Nolin, a few factors have caused the problem.
1. A sole focus on "going live." Since hospitals are implementing EHR systems to meet meaningful use and improve the delivery of healthcare services, they may place a large focus on quickly "going live." For this reason, many hospitals overlook important foundational elements. "Hospitals are focusing on going live quickly and for good reason. However, they go live and their governance processes may not ensure that they include all of the clinical processes that improve mortality, readmissions and costs," says Dr. Weingarten.
Dr. Weingarten compares the difficulty to cleaning out a garage. "Often, hospital executives intend to revisit the EHR system and add the clinical processes after the system "go live," but it does not always get done. Homeowner 'to do' lists are similar. When you first move into a home, you may keep the garage very clean. However, as time goes on the garage becomes cluttered. You keep saying you will clean it out on the weekend, but you do not get around to it even though you know you should. The same can be said of hospital EHR systems," says Dr. Weingarten. A major difference is that a cluttered garage does not jeopardize quality healthcare outcomes like absent clinical best practices could.
2. Physician culture. Physicians develop treatment habits and patterns, which can be hard to break. For this reason, physicians may find it hard to adopt new clinical processes, says Dr. Nolin. However, when there are constantly new best practices and treatment protocols, rigid habits and patterns can be disadvantageous. "Physicians like to keep habits because they support workflow and improve efficiency. As a result, [physicians] forget that they need to adhere to changes in best practices for better outcomes," says Dr. Nolin. "Sometimes physicians are expected to be all knowing. That mentality infuses the culture and is hard to change. Just because someone told a physician a method is better doesn't mean he or she will readily adopt the protocol. They need evidence to support that change," says Dr. Nolin.
3. Breadth of literature. If physicians and clinical staff could stay current with clinical best practices, the need for reminders and protocols built into an EHR system could lessen. Unfortunately, it is nearly impossible to keep up with medical literature because the volume is overwhelming, says Dr. Nolin. In order to identify all the clinical best practices, Dr. Weingarten and his colleagues combed through hundreds of journal articles, meta-analyses and studies. A physician or clinical staff member may not have the time or energy to do that work independently.
4. Focus of medical education. Best practices to reduce mortality, readmissions and costs are not widely incorporated into medical education. Dr. Weingarten remembers learning pathophysiology and the science of heart failure in medical school. However, he does not remember learning how to reduce readmissions safely. "When I was trained, cost was not a key part of the medical education and residency training," says Dr. Weingarten. "When I was in practice, I was probably not aware of all the ways to safely reduce costs."
Build clinical processes into EHR governance
According to Dr. Weingarten, one of the best solutions for all of the above causes is for hospitals to ensure that the appropriate clinical processes are built into an EHR through the system's governance process. This increases the likelihood the EHR will stay up-to-date. Hospital executives may assume that physicians will always solve the problem. "We have found that assumption to be wrong," says Dr. Weingarten. "Physicians are very intelligent. However, when they are engrossed in patient care they are not always thinking of including clinical processes to reduce mortality and reduce costs. There needs to be a method of governance to remind physicians and clinical staff what clinical processes to include.
EHR systems can be an effective means for coordinating and improving care. However, the benefit of an EHR system decreases if the critical clinical processes are not included. Due to physician culture, the breadth of medical literature and an emphasis on "going live" with EHR systems, clinical processes may be overlooked. In Zynx Health's audit, many hospitals and health systems received a grade equivalent of D for the inclusion of clinical best practices. To begin remedying the issue, hospitals and health systems should ensure that the governance of their EHR systems requires inclusion of best clinical practices.
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EHRs lack clinical best practices
According to Scott Weingarten, MD, CEO of Zynx Health, the audit was conducted to determine if hospitals and health systems were receiving the best benefits possible from their EHR systems. "Unfortunately, we found out they weren't," says Dr. Weingarten. The data to inform the audit was collected from 79 hospitals and health systems across the nation. The report focused on heart failure and pneumonia because of the high incidence of the diseases. They are also among the conditions CMS will no longer reimburse hospitals for when patients are readmitted within 30 days of a previous discharge.
"We did an exhaustive literature review of randomized clinical trials, meta-analyses, meta regressions, systematic reviews and practice guidelines," says Dr. Weingarten. "We found that almost all hospitals and health systems were missing many clinical processes. It showed us there is a real opportunity for the healthcare industry to improve." On average, hospitals had implemented only 67 percent of possible clinical processes within their EHR systems for pneumonia and only 62 percent of the clinical processes for heart failure. Additionally, the brand or EHR vendor did not make a difference. The missing practices were a result of the EHR user's implementation processes and the hospital's EHR optimization practice.
Edmundson, Mo.-based Ascension Health participated in the audit. According to James Nolin, MD, director of clinical excellence and informatics for Ascension Health, the audit gave Ascension hospitals the knowledge to improve their EHR systems and their health outcomes. For example, some Ascension hospitals were missing the clinical best practice to verify that a patient schedules a follow-up appointment within seven days of discharge. "If there is not a reminder, then the patient and the clinical staff member may forget. If the patient does remember, they may not schedule a timely appointment. As a result, the patient's condition could deteriorate, increasing the likelihood of readmission. The audit helped us realize which best practices were missing, so we could remedy the problem and improve," says Dr. Nolin.
Ascension Health is not alone. Evidenced by the prevalence of low scores in the audit, there are many hospitals and health systems missing key clinical practices in their EHR systems. According to Dr. Weingarten and Dr. Nolin, a few factors have caused the problem.
Causes
1. A sole focus on "going live." Since hospitals are implementing EHR systems to meet meaningful use and improve the delivery of healthcare services, they may place a large focus on quickly "going live." For this reason, many hospitals overlook important foundational elements. "Hospitals are focusing on going live quickly and for good reason. However, they go live and their governance processes may not ensure that they include all of the clinical processes that improve mortality, readmissions and costs," says Dr. Weingarten.
Dr. Weingarten compares the difficulty to cleaning out a garage. "Often, hospital executives intend to revisit the EHR system and add the clinical processes after the system "go live," but it does not always get done. Homeowner 'to do' lists are similar. When you first move into a home, you may keep the garage very clean. However, as time goes on the garage becomes cluttered. You keep saying you will clean it out on the weekend, but you do not get around to it even though you know you should. The same can be said of hospital EHR systems," says Dr. Weingarten. A major difference is that a cluttered garage does not jeopardize quality healthcare outcomes like absent clinical best practices could.
2. Physician culture. Physicians develop treatment habits and patterns, which can be hard to break. For this reason, physicians may find it hard to adopt new clinical processes, says Dr. Nolin. However, when there are constantly new best practices and treatment protocols, rigid habits and patterns can be disadvantageous. "Physicians like to keep habits because they support workflow and improve efficiency. As a result, [physicians] forget that they need to adhere to changes in best practices for better outcomes," says Dr. Nolin. "Sometimes physicians are expected to be all knowing. That mentality infuses the culture and is hard to change. Just because someone told a physician a method is better doesn't mean he or she will readily adopt the protocol. They need evidence to support that change," says Dr. Nolin.
3. Breadth of literature. If physicians and clinical staff could stay current with clinical best practices, the need for reminders and protocols built into an EHR system could lessen. Unfortunately, it is nearly impossible to keep up with medical literature because the volume is overwhelming, says Dr. Nolin. In order to identify all the clinical best practices, Dr. Weingarten and his colleagues combed through hundreds of journal articles, meta-analyses and studies. A physician or clinical staff member may not have the time or energy to do that work independently.
4. Focus of medical education. Best practices to reduce mortality, readmissions and costs are not widely incorporated into medical education. Dr. Weingarten remembers learning pathophysiology and the science of heart failure in medical school. However, he does not remember learning how to reduce readmissions safely. "When I was trained, cost was not a key part of the medical education and residency training," says Dr. Weingarten. "When I was in practice, I was probably not aware of all the ways to safely reduce costs."
Solution
Build clinical processes into EHR governance
According to Dr. Weingarten, one of the best solutions for all of the above causes is for hospitals to ensure that the appropriate clinical processes are built into an EHR through the system's governance process. This increases the likelihood the EHR will stay up-to-date. Hospital executives may assume that physicians will always solve the problem. "We have found that assumption to be wrong," says Dr. Weingarten. "Physicians are very intelligent. However, when they are engrossed in patient care they are not always thinking of including clinical processes to reduce mortality and reduce costs. There needs to be a method of governance to remind physicians and clinical staff what clinical processes to include.
EHR systems can be an effective means for coordinating and improving care. However, the benefit of an EHR system decreases if the critical clinical processes are not included. Due to physician culture, the breadth of medical literature and an emphasis on "going live" with EHR systems, clinical processes may be overlooked. In Zynx Health's audit, many hospitals and health systems received a grade equivalent of D for the inclusion of clinical best practices. To begin remedying the issue, hospitals and health systems should ensure that the governance of their EHR systems requires inclusion of best clinical practices.
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