Eliminating the disconnect

Eliminating the disconnect Strategies that Bridge EHR Systems and Outcomes December 2015 Contributors Michael Beaty, Principal, Advisory Lisa Steen, Director, Advisory Lynn Eckendorf, Manager, Advisory kpmg.com Eliminating the disconnect 1

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The disconnect between clinicians and systems Providers still struggle with using clinical systems to enhance productivity and improve patient outcomes. The government has invested billions of dollars in promoting Electronic Health Record (EHR) implementation. And yet, eligible healthcare systems and providers still struggle with using clinical systems to enhance productivity and improve patient outcomes. A significant obstacle to getting incremental value from healthcare IT investments like EHRs is provider dissatisfaction. According to recent research, providers report that EHRs burden them with poor usability, time-consuming data entry, limited interoperability, and interference with the patient/provider relationship. 1 It is worth noting that the widespread contention that EHRs suffer from poor usability may be due to a surprising finding from the Office of the National Coordinator for Health Information Technology (ONC), as reported in JAMA: Sixty-three percent of EHR vendors participating in the ONC study are not using the requisite number of participants in the usability testing they conduct before implementing these systems with providers organizations. 2 Usability testing, along with standards enforcement, is considered by industry experts to be critical to ensuring that EHRs ultimately function as useful tools for managing patient safety and well-being across the continuum of care. Eliminating the disconnect 3

When it comes to the impact on care delivery: 20 % The percentage increase from 2013 to 2014 of physicians who report spending more than one day per week on paperwork because of workarounds to EHR documentation, according to a report in Medical Economics. 7 48 minutes The average number of minutes spent daily on struggling with EHR use, according to a report cited in Healthcare IT Analytics. 8 Percentage of physicians 25% across the country who sustained productivity losses in their ability to care for patients since instituting EHRs, according to the Institute for Healthcare Improvement (IHI). 9 What is at stake? As organizations shift to value-based reimbursement, it will be difficult to achieve the triple aim improving outcomes, enhancing the quality of patient care, and reducing costs without maximizing the use of clinical systems. EHRs, along with analytics and clinical decision support tools, must be aligned with provider workflows and patient care. Without this alignment, it will be more and more difficult to identify target populations for intervention, stratify risk, and ensure continuity of care both inside and outside the hospital. Given the mandate to reduce hospital readmissions and decrease emergency department visits, clinicians can no longer afford to work with ineffective tools. Instead, they must continue to optimize their clinical environments and EHRs to achieve these goals. When it comes to the EHR technology itself: Provider satisfaction with EHRs 34 33 % % has plummeted to Out of the largest physician practices, particularly given the increase in spending, according to the American Medical Association and American EHR Partners. 3 73 % said they would not purchase their current EHR software again. 4 Inefficient and less fulfilling work content, inability to exchange health information between EHR products, and degradation of clinical documentation were the most-cited 67 challenges by 67% % of respondents to a recent KPMG survey. 5 Most providers were concerned that lack of data standardization would prevent them from meeting Physician Quality Reporting System requirements and ultimately lead to lower Medicare reimbursements. 6 4

What is Clinical Optimization? More than Just an IT Fix Clinical optimization involves more than installing upgrades or adding eyecatching new applications to existing systems. 10 It is about improving clinical processes and enhancing healthcare IT systems to be as efficient and functionally effective as possible, in order to provide better patient care and improve outcomes. Achieving better patient outcomes and lowering costs should drive technology upgrades, not the other way around. In addition, evidencebased practices, decision support, patient safety, and regulatory guidelines should also be top of mind as systems are evaluated during search and selection and/or enhanced after implementation. Since significant investments in healthcare IT have already been made, provider organizations are seeking to avoid costly and time-intensive system overhauls and/or new implementations by optimizing their current systems. These efforts can be challenging as they require integration of multiple existing systems that may not interoperate easily with each other. Further, efforts must be dedicated to solving usability and functionality challenges in order to derive value from these systems, such as: It will be difficult to achieve the triple aim without maximizing the use of clinical systems. Integrating formerly siloed solutions that do not support patient-centered care processes Aligning IT solutions that are out of sync with clinical workflows Upgrading the user experience and interface to more closely align with both the clinician s and the patient s journey Promoting organizational accountability for driving change Cultivating clinical staff education and communication Devoting sufficient time and effort to change management Measuring clinical systems impact on productivity Eliminating the disconnect 5

Eight System Optimization Considerations that Enhance Clinical Outcomes Overcoming common clinical system usability and functionality challenges requires a strategic and integrated approach to addressing an organization s operational, financial and clinical requirements. Following are eight strategies for optimizing EHRs and improving clinical functionality: 1. Institute an effective governance model. All efforts should have executive-level sponsorship and include input from key stakeholders on clinical system requirements and design. Stakeholders can include a wide range of individuals from C-suite executives to clinical department leaders, managers, physicians, nurses, social workers, care coordinators, and home healthcare clinicians. Since establishing accountability is essential to driving progress, a formalized change control process should be in place. This is critical to maintaining clinical system consistency and continuity and ensuring that adjustments are made by designated staff. Many organizations still lack change control methods and need to put greater focus on codifying policies and procedures related to their healthcare information systems. 2. Evaluate clinical information needs and gaps throughout the enterprise. In addition to conducting an IT inventory assessment, interview C-suite executives, specialty department leaders, and clinical end users to understand their clinical information needs and workflows. It s important to give clinicians access to the information they need, when they need it so that they can improve patient outcomes, instead of providing what others outside of direct patient care think they need. By identifying gaps, the tools should enable clinical effectiveness and maximize efficiencies. Finally, it is critical to address requirements driven by changes in the business model, including accountable care organizations, patient-centered medical homes, and other population-health-driven models. The more far-reaching goal is that these solutions contribute to the transition to value-based healthcare. It s important to give clinicians access to the information they need, when they need it. 6

3. Consider the Patient Journey. We have now entered the age of the empowered patient. Therefore, provider organizations need to consider the patient s perspective at all touch points where they interact with them. EHRs are no exception. Throughout the healthcare journey, providers need a better understanding of what makes their patients tick. One way that providers can go about this is by using a technique called patient journey mapping. By discovering the problems and opportunities that customers see in EHRs, providers can focus on why they are occurring and how they can help change the experience as they optimize their systems. 4. Determine data analytics needs, particularly as they apply to population health management. Identifying clinical data analytics needs, as well as short and long-term reporting requirements, is critical to establishing desired outcomes and benchmarks. In particular, population health management platforms should be able to aggregate data across multiple sources and distill information at a granular level. The goal is to stratify a population s risk to determine appropriate interventions and care strategies. Visualizing data on dashboards that graphically represent information enables clinicians to monitor key performance indicators and measure outcomes. Clinical decision support tools, which incorporate evidencebased diagnostic protocols and provide performance feedback, can expedite decision-making and alert clinicians to situations needing immediate attention. 11 5. Balance physicians current workflow needs with a vision of a preferred future state. Given EHRs clinical use, it is counterintuitive when clinicians are left out of healthcare IT strategy planning and decision-making. The physician perspective should be given equal weight to that of CMIOs and IT professionals from the beginning, as they will ultimately be the drivers of change. Ideally, financial, IT and clinical perspectives can be integrated to ensure that technology becomes more of a help than a burden. Further, expecting clinicians to change how they provide and document care all at once is a recipe for dissatisfaction and inefficiency. If clinicians across different departments and facilities participate in the IT build process, they will be invested in the solutions as they evolve over time. 6. Collaborate with vendors to identify technology that meets longterm goals. Make sure that system implementations and upgrades are not just band-aids. Work with vendors to develop systems that can evolve to support your organization s long-term vision. When purchasing modules and applications, make sure that the vendors are working toward adding functionality and usability over time, such as integrating and aggregating data from multiple systems. Eliminating the disconnect 7

7. Reinforce behavior change with ongoing training initiatives. In many situations, organizations give staff a basic system overview without having a point person with deep IT system expertise to troubleshoot issues. For example, nursing staff might not have knowledge of how multiple system modules work together, which would prevent them from taking advantage of a system s capability to transfer patient information from admissions to the nursing department. Training can be addressed in multiple ways, e.g., by outsourcing expertise and bringing in onsite super users to support organizational self-sufficiency; via repetition and reinforcement delivered via brief standing meetings with clearly defined agendas; in experiential classroom lessons offering one-on-one skills and scenario training; and through online continuing education modules and reference guides that advance and test knowledge beyond the initial learning session. 8. Minimize go-live remediation glitches by setting expectations and developing transition plans. It is normal for some minor remediation efforts after a go-live. However, for changes that are not regulatory or associated with patient safety, clinicians should wait a trial period of four to six weeks after launch to prevent multiple fixes that will in turn require their own repairs. The next step after go-live should be the creation of a change control process with buy-in from key stakeholders. Analyzing questions, problems, and requested changes will determine the priority of future enhancements and reveal where additional training may be needed. Strategies for optimizing EHR systems Institute an effective governance model Evaluate clinical information needs and gaps Consider the patient journey Determine data analytics needs Balance current workflow needs with future vision Choose technology tools that support long-term goals Reinforce behavior change with ongoing training Minimize go-live remediation glitches Keys to Success As population health management, improved outcomes and reduced costs become more entwined with reimbursement under value-based healthcare, effective use of clinical systems will be essential. These efforts require care coordination beyond hospital walls, which necessitates tools and processes that allow the seamless collection, sharing, analysis, and clinical use of data across facilities and locations. Optimizing EHRs and other clinical systems represents an undeniably cost-effective and prudent approach to achieving these objectives. 8

References 1 Street, R.L. Liu, L., Farber, N.J., Chen Y., Calvitti, A., Zuest, D., Gabuzda, M.T., Bell, K., Gray, B., Rick, S., Ashfaq, S., & Agha, Z. (2014, September). Provider interaction with the electronic health record: The effects on patient-centered communication in medical encounters. Patient Education and Counseling, 96(3), 315-9. doi: 10.1016/j.pec.2014.05.004.Retrieved from http://1.usa.gov/1ckphca 2 Ratwani, R.M., Benda, N.C., Hettinger, A.Z., Fairbanks, R.J., (2015). Electronic health record vendor adherence to usability certification requirements and testing standards, JAMA 314(10). 3 Bresnick, J. (2015). EHR, health IT spending rises as provider satisfaction drops. Health IT Analytics. 4 Verdon, D. (2014, February 10). Physician outcry on EHR functionality, cost will shake the health information technology sector. Medical Economics. Retrieved from http://bit.ly/1jprjnd 5 Friedberg, M.W., Chen, P.G., Van Busum, K.R., Aunon, F., Pham, C., Caloveras, J., Mattke, S., Pitchforth, E., Quigley, D.D., Brook, R.H., Crosson, J., & Tutty, M. (2013). Research report: Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy. RAND Corporation and American Medical Association. Retrieved from http://bit.ly/1lwcp9f 6 Terry, K., Ritchie, A., Marbury, D., Smith, L, & Pofeldt, E. (2014, December 1).Top 15 challenges facing physicians in 2015. Medical Economics. Retrieved from http://bit.ly/1wgsit3 7 Terry, K., Ritchie, A., Marbury, D., Smith, L, & Pofeldt, E. (2014, December 1). Top 15 challenges facing physicians in 2015. Medical Economics. Retrieved from http://bit.ly/1wgsit3 8 Bresnick, J. (2015). EHR, health IT spending rises as provider satisfaction drops. Health IT Analytics. 9 Stiefel, M., & Nolan, K. (2012). A guide to measuring the Triple Aim: Population health, experience of care, and per capita cost. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement. Retrieved from http://bit.ly/1ikqcdw 10 Vincent, W. (2014, December 10). Using technology to optimize population health care coordination outcomes. Healthcare Informatics. Retrieved from http://bit. ly/1hq4svp 11 El-Kareh, R., Hasan, O., & Schiff, G.D. (2013, October). Use of health information technology to reduce diagnostic errors. BMJ Quality and Safety. 22 Suppl 2:ii40-ii51. doi: 10.1136/bmjqs-2013-001884 Retrieved from http://1.usa.gov/1g5nv6g Eliminating the disconnect 9

Contact Us: Mike Beaty Principal, Advisory T: 404-658-5063 E: mbeaty@kpmg.com Lisa Steen Director, Advisory T: 502-815-1354 E: asteen@kpmg.com Lynn Eckendorf Manager, Advisory T: 216-875-8091 E: leckendorf@kpmg.com kpmg.com/socialmedia kpmg.com/app affiliated with KPMG International Cooperative ( KPMG International ), a Swiss entity. All rights reserved. Printed in the U.S.A. The KPMG name, logo and cutting through complexity are registered trademarks or trademarks of KPMG International. NDPPS 518837