How to bring innovation into commercial EMRs

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BOSTON—After years of developing their own EMRs and innovating within those systems, many healthcare institutions are leaving their homegrown systems behind and turning to commercial EMRs. In a session on “Homegrown Innovation in Commercial EMRs” at the AMDIS 2014 Fall Symposium, Jonathan Teich, MD, PhD, CMIO at Elsevier, posed the question: “How do we take some of the actual philosophy and spirit and innovative work in this homegrown environment and bring it into a commercial EMR?”

In 1993, Brigham and Women’s Hospital in Boston implemented the Brigham Integrated Clinical System (BICS), which has since been regarded as one of the most functional information systems in healthcare.

According to Adam Wright, PhD, associate research scientist in the Division of General Internal Medicine and Primary Care at Brigham and Women’s Hospital (BWH) in Boston, and senior medical informatician in the Clinical and Quality Analysis Department at Partners HealthCare, the feeling at BWH over the years was that there was really no need to consider transitioning to a commercial system because “there was nothing that had CPOE quite as good as BICS.”

“You can imagine my nervousness when there started to be rumblings that we were about to do something different,” Wright told his AMDIS audience. It turned out that there were several different options on the table—either continue to develop BWH’s own EHR or go with a commercial system like Epic.

BWH has decided to go with Epic, leading Wright to ask himself, “How am I going to do informatics research and innovation in this system?” Over time, he said, as he learned more about Epic, he has become “increasingly optimistic” that there are “neat” ways to do innovation within the Epic system.

Wright said that BWH and Partners have taken several steps—beyond getting software in place—to encourage innovation within the Epic system.

The first step, he said, was the creation of an innovation council as one of the four councils governing the implementation of Epic. “What was neat to me was that innovation was one of the top level committees or principles, so that at least from the leadership there was a serious desire to continue to innovate within the system,” Wright said.

Among the recommendations that have come out of the committee, Wright said, was one creating a dedicated innovation copy of Epic—a separate copy of Epic that will allow innovators who want to prototype a new idea in the system to build the idea out and test it in a laboratory setting in real time. “This will sort of prove there is value in it before we decide to make an investment to move it into our main environment,” Wright said. “We think that will be a tool that will be helpful for allowing a sandbox for innovation without interfering with the very aggressive timeline we have to do the production and implementation of Epic."

In addition, Wright said, BWH and Partners have devoted a substantial number of technical and analytics personnel who will be working on innovative activities and approaches.

“We’ve also created a set of areas we call fertile fields,” Wright said. “These are areas where we think there are significant opportunities to innovate. We are trying to create a zone where people who are interested in innovating but may not have all the technical skills needed to do an innovation could work.” For example, Wright explained, if a nurse or physician comes forward with a new paradigm for clinical documentation, he or she could approach this fertile field management group and get the technical and analytics resource support necessary to develop this new innovation.

Adam Landman, MD, CMIO of health information innovation and integration at BWH, pointed out that while EHRs are being widely implemented, “there are tons of opportunities to innovate outside of the electronic health record.”

“We are really seeing the emergence of tons of novel health IT tools,” he said. “And the staff I work with, the clinicians, the researchers—our innovators—are very excited about this technology, and come in daily with new ideas.”

The challenge, Landman said, is that many of these innovators and vendors are unfamiliar with implementing health information systems. It can be a particular problem when it comes to issues of privacy and security, he pointed out, since many of the innovations proposed by physicians don’t deal adequately with those issues and won’t meet the privacy and security requirements of an organization like BWH.

What BWH has done, Landman said, is use tools and resources to assist these innovators. For example, BWH has instituted an innovation review process to make it easier for innovators to meet the organization’s requirements and, eventually, to support operationalization of these projects.

BWH is particularly interested in research projects and small pilot programs, Landman said. “All of this starts in the grass roots,” he said. “You have to start small and fail often, and we want to support those small projects, which is very different from our typical IS, where we are usually focused on operations and implementations across the entire hospital.”

BWH created a process where innovators can fill out a short form and then engage in a review session with technical experts to discuss and review the project technically, get connected with the IS resources they need, and eventually get permission to go ahead with their pilot.

“Much of this is education,” Landman said. “Educating the innovators how to use health IT safely, and educating some of our vendors. We’re in Boston and we’re seeing lots of MIT [Massachusetts Institute of Technology] grad students coming up with great ideas, but they’ve never done this in a healthcare setting.”

Since launching this process in July BWH has had 14 innovative pilots in progress.

"There are clearly rich opportunities for innovation outside the EHR,” Landman said. "As CIOs, CMIOs and IS staff, we play a critical role in supporting this innovation.”

The Regenstrief Institute in Indianapolis developed one of the “seminal” computerized physician order entry systems—the Medical Gopher—about three decades ago, but, according to John Duke, MD, senior scientist and chief innovation officer at the institute, by 2010 it was clear that system had grown “stale” over the years and that it needed to be upgraded.

The upgraded system, rolled out in 2012, was developed based on three principles, Duke said.

First, he said, there is no real need to invent new interface paradigms. “Anything you need to do in an EMR system has been done, studied and evaluated,” he said. “If there is some sort of solution you need on how to approach something, the chances are somebody has already done it.”

Second, Duke said, is the need to “constrain and innovate.” Twitter is an example of this, he pointed out, as the development of things like URL shorteners and hashtags were generated from the constraints created by limiting “tweets” to 140 characters.

So what Regenstrief did was constrain the real estate on its new EMR by setting aside an area of the screen for future use, such as non-interruptive alerts, order sets and clinical recruitment—“all based on the idea we needed to preserve this space and work within it,” Duke said.

Finally, Duke said, there is the need to “set gravity in the right direction,” meaning that EMR developers want to make it easy for users to do the right thing and difficult to do the wrong thing.