Helping End Users Guide EHR Improvements

I often hear versions of the following complaint across the healthcare IT market: “This EHR’s developers have no idea what clinicians need in order to do their jobs.” An exaggeration? I think so. But the fact remains that no one knows what clinicians need better than clinicians do.

I’m confident that most healthcare IT leaders believe this. We want the EHR to be as usable as possible for our providers. But I think many of us could give our providers a bigger role in change management and help them mold the EHR to their own needs.

Looking Through the End Users’ Eyes

At Northwestern Memorial Health Care, some of our EHR frustrations were caused by a failure to consider what would make life easiest for our end users. Let me illustrate with an example.

Originally, we set up the EHR with hard stops that ensured each step in an encounter had been completed before the bill was sent. Great intentions, right? However, that setup meant that when a vaccination was ordered and delivered but not documented by the delivering nurse, the physician couldn’t close the encounter.

As you can imagine, this frustrated our physicians. In setting those encounters aside until the nurses’ documentation was complete, the physicians often forgot to come back later to close the encounters.

Some of the physicians complained that they were kept from doing their jobs because of other peoples’ unfinished tasks.

When we stopped to consider this, we realized they were right. We had put a blockage in front of the doctors that they had little control over. So we thought about the steps that actually had to be completed before sending a bill and considered ways that we could alter the EHR workflow.

In the end, we decided to remove a hard stop. A physician can now sign off on an encounter before the nurse has documented the delivery of a vaccination. The encounter then goes to a different workflow to ensure that the documentation does get done. Today, accountability is appropriately shared, and physicians can move more quickly between encounters.

This instance shows that considering the end users’ point of view when setting up or changing the EHR can increase efficiency and satisfaction. For this reason, our organization has chosen to make our providers an integral part of our EHR governance.

Creating Provider-Led Work Groups

While Northwestern Memoria Health Care has had EHR work groups for some time, we have more recently repurposed these groups so that each one has support from the the analytics, performance, PI, quality, safety, and informatics sides. We call these work groups collaboratives.

Including the right people in these collaboratives sets us up for success. We try to balance the academic and the community voices in the collaboratives by having co-leads: one from the academic side and one from the community side.

We also look to the presidents of the different operating units and ask questions like the following:

• “Who in your unit is respected by his or her peers? Who has the most influence on people?”
• “Which of your providers are good listeners and have the ability to see the big picture?”
• “Are any members of your units already working on process or quality improvements? Which providers have roles that would align well with the work of our collaboratives?”

Once we had added the most promising candidates to our collaboratives, we make sure they are well supported and put them to work. Their charge? To represent the clinical side while dissecting the EHR’s problems and steering change management.

Of course, the end users’ wishes must be aligned with the needs of our institution, but we’ve found that when those sides come together, real work gets done and helpful changes are pushed through. Best of all, our clinicians adopt the changes because they drove them.

Rolling Out a New EHR

We used the same principles of provider inclusion as we prepared to go live on our new Epic platform this year. Our message to all of our employees was that the transition to Epic was not an IT project. We wanted the physician and clinical leaders to guide the entire implementation process.

I led a project team that was made up of seven physicians from across the organization, as well as a clinical nurse informaticist. The team worked with our IT department, project management department, and consultants.

We asked our clinicians what they wanted and needed from the EHR, and then we considered their feedback. Some decisions required a “tiebreaker” from one of our governance groups, but most were resolved at work-group meetings led by our advisory committees. In the end, 65%-70% of our implementation decisions were made by the end users.  

We also communicated with our providers throughout the implementation process. We met with 55 physician advisors once per month to walk them through the things that would impact their peers. We then had the advisors relay this information to the rest of our organization.

After our successful go-live, the 55 advisory people involved in planning the rollout of our Epic platform remained involved in the guidance of our collaboratives. We also added some nurse analysts from the project team to our informatics department.

Every new project has its naysayers, but I’m grateful that we followed through on our decision to give our end users a greater say in the system they use every day. Our clinically led approach to EHR optimization has paid and is still paying great dividends.

Create Your Own Success

It’s true that many EHRs leave a lot to be desired in terms of usability, but I think some healthcare leaders and providers are too quick to grumble in their EHR vendor’s direction.

Wouldn’t it be more effective to look inward? As my organization has learned, the best way for healthcare IT leaders to help their clinicians is to guide the clinicians in helping themselves.