From Meaningful Use to meaningful care

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 - William F. Bria, MD
William F. Bria, MD

BOSTON--When it comes to the adoption of health information systems, the nation’s health IT leaders have certainly caught the attention of healthcare providers and patients alike. The question, though, according to William Bria, MD, is whether the adoption of these systems is being accomplished in a way that these healthcare stakeholders believe will truly benefit the practice of medicine.

Bria, along with Annabaker Garber, RN, PhD, director of clinical informatics at Massachusetts General Hospital, delivered his comments at a session on “Meaningful Use to Meaningful Care” at the 2014 AMDIS Fall Symposium.

As a way of approaching that question Bria, who is president of AMDIS and CMIO at the HCI Group, referenced a recent study in Health Affairs that found that while more than half of U.S. hospitals have at least a basic EHR, less than 6 percent are able to meet all Stage 2 Meaningful Use criteria.

“From the perspective of bang for the buck, return on investment, happiness from pain, we still have a great deal [of work] ahead of us,” Bria said. “That’s a depressing thought, but it’s also a call to arms.” Something that needs to be addressed, he said, is the possibility that these systems are obstructing “age old dialogues, and age old synergy between nurses and doctors and our patients” which serve to reduce any of the benefits that should be realized with health IT.

The urge to require EHRs to “be all things to all people” diminishes the ability of the technology to perform what should be its most critical function, said Bria: “helping physicians care for their patients.”

“We have this great tool and we’ve tried to make it do too many things and tried to make it represent too many other players besides those folks who are intimately involved in care,” said Garber, adding that this dilutes health IT’s ability to serve those caregivers like physicians and nurses who deal with it on a daily basis.

“Until we realize that we can’t serve all masters and we’re willing to make a stand on making sure it is representing the work it is supposed to do, it’s going to continue to diverge away from the job it’s supposed to do,” she said.

In looking at the barriers to meaningful care, Bria focused on the failure to design appropriate workflows for clinicians and the idea of process redesign, and suggested that health IT leaders need to start addressing those “elements of workflows prior to automation that have now been disconnected as a result of introducing these systems.”

Nurses spend a lot of time thinking about workflow, handoffs and putting the right information in the right place in order to free up physicians to do their clinical work, Garber pointed out, and “the EHR should really be the last piece of your workflow design, making sure all of the other pieces fit well and then captures what you did or creates a very precise point within that workflow.

“But it’s not a catch-all for fixing those problems that are broken around it,” she added. “We’ve tried to make it do all those things, so we have to design a process and then see how it fits into that process, and the more of that we do the more efficient clinicians are, the more satisfied they are, and paradoxically, the simpler your EHR design becomes because it’s designed to do that thing that supports the work.”

Bria and Garber also touched on the recent situation at the Texas Health Presbyterian Hospital in Dallas when the first case of Ebola ever diagnosed in the United States was only diagnosed after it was missed the first time around, leading to questions about why important clinical information in the hospital’s EHR wasn’t communicated effectively.

“You tend to think that as soon as you put something into the EHR it is being communicated,” said Garber, recalling that a CMIO colleague of hers called that phenomenon “fire and forget” in the sense that one puts the information in the EHR, “fires” it off, and then forgets about it, assuming that someone else will access it.

“We have to be extremely overt in creating processes . . . that emphasize person-to-person communications,” she said. “We have to go back and build those in. The collaboration that used to happen around the chart rack is gone—now we have to institutionalize the opportunity for those conversations.” Part of that is a process, she added, but part of that also involves fostering a culture that allows that communication to happen."

“We really have to work on that piece to surround and support that technology appropriately,” she said.

The consequences of having things evolve the way they have, Bria added, “ends up not with just inconvenience.”

Going forward, he said, health IT leaders should pay attention to process redesign at it impacts safety and quality, the effectiveness of communication among members of the healthcare team, and care coordination over the continuum.