shifting competitive landscape, mergers and acquisitions and divestments are driving the need to implement, configure and reconfigure electronic health record systems faster and with shorter implementation cycles.
This is challenging, but also offers multiple opportunities for EHR optimization, chances to improve they systems for better clinical quality and cost efficiencies.
The term “optimization” in this instance typically is used to describe a variety of different classifications of post go-live improvement. In fact, EHR optimization should have its own strategic course – one that is separate from routine operational activities such as system upgrades, system maintenance and platform hygiene items.
The intent of EHR optimization should be viewed as an ongoing performance improvement program, working to get the most benefit possible for an organization’s EHR investment.
Here, five EHR experts offer best practices and tips for making EHRs run optimally so that healthcare provider organizations can make sure the complex healthcare information systems are meeting their specific needs.
Perhaps the best place to start with EHR optimization is around definition of terms, said Dan Kinsella, managing director, healthcare and life science, at Deloitte.
“Optimization includes the thoughtful tailoring of installed software components to better align with the workflow of a specific person or function,” he explained. “Optimization is not break-fix, nor should it be confused with unfiltered work orders that are processed across the enterprise, often without supervisory approval. Unfortunately, many healthcare providers have 25-50% of their IT capacity absorbed in ‘answering the mail’ as requests come through the help desk or ticketing system.”
"When optimization is done well, the technology changes are driven by consideration of the related business function, workflow and people."
Dan Kinsella, Deloitte
The best ideas about what requires optimization come from the user departments or customer groups, working in collaboration with business partners from IT, Kinsella said.
“Optimization efforts generally are projects with a beginning, middle and end,” he explained. “When optimization is done well, the technology changes are driven by consideration of the related business function, workflow and people. Optimization then takes some time.
“It also takes a village,” said Kinsella. “Skill sets on a hybrid agile POD for optimization include subject matter expertise from the business with decision rights to drive a solution that aligns with standard work of the enterprise in addition to the technical and application team members.”
Change management techniques, including journey maps depicting how work will get done after the optimization effort is complete, reflect leading practice, he added.
As a best practice for EHR optimization, once an approach has been determined – broad or time-boxed project focused, for example – key sources of information to feed the optimization roadmap should come from multiple outlets, the first being the organizations’ end users, who experience challenges on the front-line, said Laurie King, a managing director at Accenture, where she leads the provider technology services practice for the North America health and public service industry group.
“Other sources of ideas are with third parties, such as IT vendors, and consulting firms with broad clientele networks and technology experience, and even health systems that share a similar profile,” she said.
"Problems that may be discrete, isolated problems that are part of ongoing themes can all be addressed by strategic, well-coordinated solutions based upon data-driven, root-cause assessments."
Laurie King, Accenture
“Our clients also look to data to help isolated pain points through key performance indicators, data mining, and to identify and resolve problems. Problems that may be discrete, isolated problems that are part of ongoing themes can all be addressed by strategic, well-coordinated solutions based upon data-driven, root-cause assessments.”
At the very heart of every high-performing EHR is a rigorous engine, purpose built to record, maintain and manage data concerning the most essential components of an individual’s well-being, King said.
“That group of data is contributed to by a myriad of care professionals who use multiple technology solutions to curate the slice of the patient record that they are accountable for,” she explained. “These multiple data slices must be choreographed as part of the overall EHR optimization, with the essential electronic health information for an individual patient comprising data across multiple technology systems.”
A well-optimized EHR is designed to integrate and interoperate those multiple slices of data into a contiguous, logical, semantically normalized whole that is available wherever and whenever the patient record is required, she added.
“Increasingly, the plurality of information systems that may hold, or be required to access, information about a patient sit inside multiple organizations,” she cautioned. “This trend is one embraced by emerging ONC and CMS defined regulations – and we believe defines the future of healthcare in the U.S. and globally.”
As part of this best practice, governance is essential, and the CIO, CTO and CDO should be fostering a sense of shared decision-making, not in isolation, King suggested.
“For instance, establish a multi-disciplinary team comprised of accountable leaders; product experts; those who understand the business needs and those who are focused on human aspects of change such as training and change enablement functions,” she said.
“Also of importance is to dedicate budget and resources by creating a clear distinction of resource and financial allocation EHR optimization in order to avoid prioritization and planning conflicts with competing strategic initiatives.”
Luis Sayago, manager of the healthcare technology practice at consulting firm Dacarba, says that having access to the standard interfaces for an EHR will provide a healthcare organization with greater visibility into its data either directly or via connected apps.
“As a result, a great optimization opportunity arises by being able to easily identify data quality gaps in the EHR, like physician documentation, or problem/medications list maintenance,” he advised. “Although data quality optimization in the EHR can take many forms, like directly in the EHR through build or training, we can now focus on technology solutions enabled by standard FHIR interoperability.”
"A great optimization opportunity arises by being able to easily identify data quality gaps in the EHR, like physician documentation, or problem/medications list maintenance."
Luis Sayago, Dacarba
With HL7 FHIR, healthcare provider organizations can easily grant access to clinical data, and increasingly financial data, to applications that can analyze it in real time and output suggestions to existing workflows, he advised.
“One way a FHIR app can accomplish this is by ingesting EHR patient data via FHIR and subscribing to notifications using the CDS Hooks standard that will display within the EHR,” he said. “For example, a use-case may involve allowing a more sophisticated, and perhaps more up to date, medication decision support app to provide information instead of the EHR tools, thus improving documented medication names.”
Facilities also can improve the quality of their patient demographic and history data by using FHIR apps, he added.
“For example, scheduling applications that connect patients to their upcoming visits and allows them to fill out paperwork electronically, avoiding transcription errors,” Sayago said. “Also, there are more and more apps out there that allow patients to access and analyze their EHR data via FHIR, which should give them more visibility into any potential errors.”
On the personnel front, many CMIOs have helped lead their healthcare organizations through the initial implementation of the enterprise EHR as driven by the meaningful use incentive program, said Kinsella of Deloitte.
“As valuable as these clinical leaders have been during the initial project, they are even more valuable as a partner to the CIO as the focus shifts to optimization,” he said. “Highly effective CMIOs understand the EHR solution framework as well as the process used by IT to select and deliver on high-priority projects. CMIOs can promote ‘systemness’ across the enterprise and help other clinical leaders understand multiple right answers to the questions around what they are trying to accomplish.”
The most effective CMIO with whom Kinsella worked also had the trust and respect of the medical staff.
“He was able to engage with specialists who wanted their version of a workflow that was not consistent with the enterprise view,” he explained. “Optimization does not mean that you only say yes. Organizations who do this well seek to understand what is trying to be accomplished and then come back with multiple answers that are architecturally sound and practical to implement.”
Historically, the biggest challenge when optimizing an EHR has been the existence of data in third-party systems, said Sayago of Dacarba. Now, with EHRs increasingly taking over functionality from other systems, some of these silos have moved to modules inside the EHR.
“An important EHR optimization strategy that helps mitigate this is to implement all standard interoperability functionality provided by your vendor out of the box,” he suggested. “Having all standard interfaces enabled will facilitate the real-time exchange of data within the EHR or third-party systems when needed without going through a lengthy integration cycle.”
Many EHR vendors now include many standard specifications for HL7 v2, FHIR, and even health information exchanges. Not all of these standard specifications will address all required interoperability workflows, but they can be a great base, if needed, Sayago advised.
Also, EHR vendors have made the specifications to these standard interfaces publicly available, which can enhance the speed of development and quality of another connecting system interface, he added.
The two main advantages of this EHR optimization, he said, include: 1) Helping physicians tap into the booming clinical decision support apps market, without the high cost of custom integrations; and 2) Opening the door for organizations to easily implement specialized analytical solutions and tools that can complement their existing data warehouse and revenue cycle investments without the need for additional FTEs.
Paul Black, CEO of Allscripts, says optimizing an EHR really means ensuring caregivers have the right information at the right time to make the best possible decisions for patients. This is made possible, he said, when clinicians are leveraging an EHR built on an open platform.
“For healthcare practices, optimizing practice performance and enhancing your EHR starts with an understanding for strengthening the four corners of your practice,” he said.
"It’s important to upgrade to the latest version in order to improve your organization’s efficiency to achieve the outcomes you desire."
Paul Black, Allscripts
In understanding how health IT helps one be successful, Black said to ask these questions:
“In addition, and especially for hospitals and health systems, EHR optimization often means updating to the latest, greatest technology offered by your vendors,” Black said. “It’s important to upgrade to the latest version in order to improve your organization’s efficiency to achieve the outcomes you desire. This enables you to meet the needs of patients who, increasingly, require care occurring outside the four walls of a hospital. Further, as regulatory requirements and your goals change, so does the software you will need.”
Kinsella of Deloitte, more abstractly, advises CIOs and others trying to optimize EHRs to not nibble at the apple but to devour it.
“CIOs should not overlook the content that comes from their core EHR vendors as a flavor of ‘optimization,’” he said. “The quarterly releases that come from some of the leading EHR vendors in the market reflect the concentrated effort of their dedicated development teams, and the requirements as understood by a broad customer base.”
If a healthcare provider organization is at all concerned about not knowing what it does not know, this is a great area of focus, he said.
“Who is to say that the ‘factory-engineered’ new feature is not as good or better than what your in-house team would have developed on their own?” he asked. “Even if it was only 70% of what you were seeking, you get it with the upgrade and then need only to work on the configuration, testing and adoption – not trivial, but not from scratch either.”
Too many organizations “nibble at the apple” of optimization as they are concerned about the impact of significant change across the enterprise, he contended.
“Over time, this risk can be mitigated by a commitment to standard work,” Kinsella said. “What if your enterprise project management system had all of your customer group requirements cataloged and prioritized? What if you could then cross-walk those requirements to the quarterly upgrade documentation provided by the EHR vendor? Organizations who do well with this practice have their application teams defend why they are not implementing a new feature provided by the vendor. They devour the apple.”
One of the best practices for CIOs and health IT professionals seeking to optimize their EHR is to put a focus on the intake forms and clinical forms that the medical team uses when seeing patients, said Daniel Kivatinos, COO and co-founder of DrChrono.
“Intake forms take vast amounts of time during entry for patients and staff,” he said. “With online optimized medical forms on iPad, iPhone and web, patients and staff enter all of the information quickly. Clinical forms, the forms the doctors use, take vast amounts of time to create and optimize, but if the forms are optimized, a company can scale fast, saving providers, patients and staff time.”
"Clinical forms, the forms the doctors use, take vast amounts of time to create and optimize, but if the forms are optimized, a company can scale fast, saving providers, patients and staff time."
Daniel Kivatinos, DrChrono
The provider should be able to enter in all of the information as quickly as possible, allowing them to do what they were hired to do, which is to take care of patients, he insisted.
“Enabling physicians to document as fast as possible allows CIOs and other health information specialists to do their jobs as well, making sure the medical institution is able to submit medical claims as fast as possible, get paid the right amounts and be able to report on this information,” he advised.
Clinical forms can be complex, but if one optimizes them and makes them simple, with only a few taps or clicks, one can have medical professionals, whether that be physician, nurse or other provider, see a patient chart and finalize a note very quickly, he said.
“Be sure to leverage macro buttons, medical speech to text, and take advantage of any billing features triggered by clinical note entry,” Kivatinos suggested.
In clinical forms, there are sometimes great bells and whistles like medical form branching, which allows a caregiver to change medical forms dynamically on the fly to whatever is happening within a patient encounter, he added.
“These are complex things to set up but they save countless hours for providers,” he explained. “The CIO’s team also can connect billing events into some EHR companies that trigger based off of events in the medical record. Setting these up can also save time with charting and with entering billing information.”
Kitavinos, whose DrChrono software is tailored for iPhones and iPads, points out that physical hardware is always important in using electronic health records.
“Making sure you have the latest and greatest devices can help speed up work due to faster processors and better technology,” said Kivatinos. “When I go into a medical facility, some of the time I see providers charting on older devices that do not support some of the latest technology. For example, newer iPads and iPhones have Touch ID and Face ID. It is shocking how much faster a provider can log in simply by using one of these devices.”
Leveraging integrated cameras from iPhones and iPads is enormously helpful when documenting or taking profile pictures of patients; be sure to take full advantage of iPads and iPhones and laptops that have camera integration, he said.
Another EHR optimization best practice from King of Accenture is to look beyond the EHR.
“We find that clients with a broader lens often are looking outside clinical information technology as part of their optimization roadmap,” she said. “They commonly need to continually evaluate how the business strategy can be further enhanced or extended using technology.”
Other opportunities, she advised, are to implement complementary functionality in areas such as: