Sunday, March 15, 2009

Get Ready for Electronic Health Record Failures, But Don't Blame the Software

Computerized medical records are an old dream and sometimes work well enough within an individual medical practice. On a large scale, however, they seem likely to remain a dream. Britain has spent around 30 BILLION dollars in setting up such a system to cover all its hospitals -- with very poor results so far. It is common for governments and large businesses to spend many millions on custom software only to have to abandon it eventually as a failure. The article below makes the additional point that even if the software is working well, there are still large human factors making its implementation very difficult.

I have been writing scientific computer programs since 1967 so I am not anti-computer. I have however been around long enough to see a lot of very expensive failed attempts at computerization. Just as one example, the Australian government recently spent $300 million on a program to run its new submarines -- only to end up scrapping it all and buying in existing American software instead

With the Economic Stimulus Bill signed and available to subsidize EHR purchases (for more information see "The Stimulus Bill and Meaningful Use of Qualified EHRs/EMRs"), we are seeing a dramatic increase in electronic health records (EHR) buyer interest. Assuming these buyers make use of the stimulus subsidy to buy an EHR, we expect to see a lot of EHR failures over the next couple years.

Don't get us wrong! We are HUGE advocates of EHR technology. Doctors should be using EHRs. The stimulus subsidy is great. EHR software programs (and software companies) are not the problem.

Our concern is that the subsidies won't change healthcare providers' late adopter mindsets about information technology. Providers may jump at "free software" and try to avoid penalties (starting in 2015), but will they:

* Truly believe in the value of an EHR over traditional paper charts?

* Take a leadership role in advocating adoption of the new EHR in their practice?

* Change their old workflows to match the best practices in leading EHRs?

* Take part in intensive training to learn the new system?

* Ride out the difficult stages of new software adoption and change management?

Traditionally, the substantial costs of EHR systems keep the luddites from buying technology in the face of these challenges. But with "free" EHR software, we expect more than a few providers to throw caution to the wind, buy an EHR and overlook the critical implementation and change management practices that are critical to success.

The best things in life are free, but that doesn't refer to healthcare IT. We think providers would be far more serious about implementation and adoption if they had to pay dearly for the technology. Accordingly, here are our thoughts on why IT projects fail and how providers can avoid that fate while still capitalizing on this once-in-a-lifetime subsidy.

When and why do IT projects fail?

In 2007, the U.S. Office of the National Coordinator for Health IT reported that about 50% of EHR implementations failed. IT industry analysts widely agree that software implementations fail because of the customers. It's too easy to point the finger at software vendors or at the software itself, but failure usually is the buyer's fault. In a recent survey, one group identified the following top reasons for IT implementation failures:

* ~40% attribute failure to poor planning and communication;

* ~20% cite mismanagement and rejection by end users; and

* ~15% blame overspending.

Very few doctors use EHRs. In fact, most predictions put EMR market penetration at 10%-15%. We all know why this figure is so low: doctors don't want to use them, practice staff is stuck doing things "the old-fashioned way," etc. Now that Uncle Sam is willing to pay for EMRs (and telling us we had better buy!), a lot more practices are going to adopt them. The scary thing, however, is that the same feelings that have slowed the adoption of EMRs are still prevalent. Here let me present what I think are 5 critical steps for a smooth, successful EMR implementation:

1. Become a project manager. If you're a physician, you may not consider yourself a business person. However, for this project, you need to become a project manager. If you're lucky, you may have a staff member or consultant that can play the role for you, but don't count on it. First, create a project plan. Outline all the steps of your implementation so you know what changes need to occur by certain deadlines. Stay on top of the plan and hold your team accountable.

2. Rally everyone else. Recall that poor leadership and lack of user adoption are frequently cited as contributing factors to IT failures. You need to express confidence in the technology and get your staff on board before the implementation. Show how much easier their lives will be. Get them excited about it. Tell your patients that next time you see them, you will be a computer whiz with a slick EHR.

3. Buy the best training you can. The government is paying for it (laugh). Seriously though, you will need the help. It's too easy to skimp on adequate training and ongoing support. Don't risk failure of an investment because you want to save a few thousand bucks. It's worth it. Get trainers in the office, send the staff to training, implement a train-the-trainer program.

4. KISS: Keep It Simple, Stupid. No office becomes paperless overnight, so don't try to do everything at once. Ease into your new workflow as much as you can. Adopt advanced features after you learn how to turn on the computer. It is OK to implement bells and whistles after the initial dust has settled.

5. Be prepared to practice differently. As much as you don't want to admit it, you will need to adjust the way you meet with patients and how your practice operates. And if you can, make easy adjustments ahead of time. Start carrying a tablet PC or dictating with voice recognition software. It pays to work out the kinks early on.

If you follow these major guidelines - and a lot more small steps in between - you'll have a much greater chance of EHR success. Most importantly, wrap your head around being tech savvy and enjoying the new system. If you don't, you'll pay for it (one way or another).


Negligent NHS doctors let teenager die of cancer

A teenager died from massive cancerous tumours after his GP repeatedly failed to diagnose the disease and told him to 'grow up a bit and stop worrying', an inquest has heard. Christopher Chaffey, 19, was so worried about his failing health that he visited his doctor's surgery half a dozen times in the 15 months up to his death. His symptoms were dismissed as minor and allegedly put down to 'panic attacks'. Even when a blood test was 'significantly abnormal', the GP thought it indicated mild anaemia instead of taking it more seriously.

X Factor contestant Mr Chaffey found the same attitude at a hospital casualty department when he was taken there by ambulance with a headache, vomiting and chest pains. A doctor at Hull Royal Infirmary believed he had an anxiety-related condition and told him to consult his GP.

But the teenager's body was gradually being ravaged by cancer and he died two months later - two days after doctors finally discovered the true nature of his condition. A post-mortem examination found tumours in his neck and skull, as well as a huge tumour affecting his heart and lungs which weighed four-and-a-half pounds.

The alleged medical blunders were revealed at an inquest in Hull. Dr Sahra Ali, a consultant haematologist who was involved only at the very end of his treatment, told the hearing that the lymphoma would have taken months to develop. The doctor added: 'It's a very sad case which is treatable and potentially curable if it would have presented at an earlier stage.'

Mr Chaffey, of Coniston, near Hull, was a music fan and had been a contestant in The X Factor two years earlier, although he failed to get beyond the first round. He was forced to postpone his A-level studies in media and law because of his health problems.

The inquest heard how Mr Chaffey's GP, Joseph Austin, ordered blood tests in July 2007 after the teenager complained of excessive sweating and hair loss. The tests showed abnormalities, but were not considered important. Repeat blood tests the following April showed his haemoglobin levels had fallen, which the GP diagnosed as a mild type of anaemia.

Independent expert Bill Holmes said these blood test results should have been 'explored more actively'. He said night sweating was a well-recognised symptom of lymphoma, although GPs usually came across more innocent causes.

Mr Chaffey's mother Patricia, 40, told the hearing that when her son went back to the GP with his taxi driver father Paul, 43, they were allegedly told 'he should grow up a bit and stop worrying there's something wrong with him'. She took him back to the GP when bouts of fainting prevented him from doing voluntary work at a charity shop. Mrs Chaffey told the GP about prominent veins on her son's chest, his voice becoming hoarse, and that she sometimes had to sleep in his bedroom, but the doctor put it down to panic attacks, the inquest heard.

Dr Austin said he never suspected his patient was suffering from anything serious. Asked by coroner Geoffrey Saul whether he had ever suggested to a member of the family that the problem was in the mind, Dr Austin replied: 'No, I never told him that.'

On July 19 last year, when Mr Chaffey was taken to Hull Royal Infirmary, tests were ordered by Dr Mohammed As'Ad, who also decided there was nothing physically wrong with him.

Later, consultant Mark Higson concluded there had been 'several' missed opportunities at the A&E department when the cancer could have been picked up.

Mr Chaffey's father got in touch with the Psychosis Service for Young People, which put him on a six-month plan to cope with anxiety, but his health continued to worsen and his weight to drop. On September 17 last, the family spotted a lump on his neck and he was seen by an out-of-hours doctor. He was admitted to hospital but by then it was too late.


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