The following is a guest blog post by Heather Haugen, PhD, Managing Director and CEO at The Breakaway Group (A Xerox Company). Check out all of the blog posts in the Breakaway Thinking series.
Healthcare leaders and clinicians continue to be disappointed with the value Electronic Health Record (EHR) technology provides in their organizations today. The challenges are real, and it will take some time and effort to improve. The technology will continue to evolve at the pace we set as leaders, vendors and healthcare professionals.
When Free Is Expensive
Several years ago, a reputable IT vendor offered us free use of their software, which provided monitoring of equipment that would be valuable to us. Initially, we were excited; the functionality perfectly aligned with our needs, and the application was robust enough to grow with us. We had a need and the software fulfilled the need. We couldn’t wait to have access to the dashboard of data promised by the vendor.
Months after the implementation, we were still waiting. The “free” price tag was alluring, but we quickly recognized the actual maintenance costs and labor required to make the application truly valuable to our organization were far from free. This story drives home a concept that we all understand, but often overlook. Underestimating the “care and feeding” required to maintain a valuable investment puts the entire project at risk. We all need to remember the importance of sustainability even when we are initially excited about a new investment.
EHR systems are expensive and require tremendous resource investment, but the effort is ongoing and we need to plan accordingly.
The Key to Long Term Behavior Change
The difficulty of moving from implementing an EHR to maintaining high levels of adoption over the life of the application is strikingly similar to weight loss and weight management efforts. The percentage of overweight adults in the U.S. is staggering and continues to rise. Today, over 66 percent of adults in the United States are overweight and 59 percent of Americans are actively trying to lose weight. But the problem isn’t weight loss – it’s weight maintenance. Many of us have successfully lost weight, but can’t keep the weight off. As a matter of fact, we regain all the weight (and often more) within 3-5 years.
This isn’t a complex concept: dieting doesn’t incent long-term lifestyle change, thus we re-gain weight after we settle back into old habits. To be successful in the long-term, we need to practice weight management behaviors actively – for years, not months.
We’ve taken the dieting approach to implementing new software solutions in healthcare for too long. We prepare for a go-live event, but fall back into our comfortable old habits afterwards – resulting in work-arounds, regression to ineffective workflows, insufficient training for new users, poor communication and errors. The process of adoption requires a radically different discipline, and the real work begins at go-live.
Instead of checking the project off your to-do list after a successful implementation, you need to create a plan to sustain the changes. A sustainment plan addresses two critical areas:
- It establishes how your organization will support the ongoing needs of the end users for the life of the application. This includes communication, education and maintenance of materials and resources.
- It establishes how and when your organization will collect metrics to assess end user adoption and performance.
Lack of planning and execution in these two areas will lead to a slow and steady decline in end user adoption over time.
Effective sustainment plans require resources – time and money. Keep in mind that adoption is never static; it is either improving or degrading in the organization. A series of upgrades can quickly lead to decreased proficiency among end users, completely eroding the value of the application over time. Leadership must plan for the investment and fund it to achieve improved performance.
Most organizations only achieve modest adoption after a go-live event, and it takes relentless focus to achieve the levels of adoption needed to improve quality of care, patient safety and financial outcomes. Sustainment plans are most successful when they are part of the initial budgeting and planning stages for EHR.
Metrics Make the Difference
Metrics are the differentiating factor between a highly effective sustainment plan and one that is just mediocre. End user knowledge and confidence metrics serve as a barometer for their level of proficiency, providing the earliest indication of adoption. Ultimately, performance metrics are powerful indicators of whether end users are improving, maintaining or regressing in their adoption of the system. If we get an early warning that proficiency is slipping, we can react quickly to address the problem. These metrics ensure the organization is progressing toward high levels of adoption, overcoming barriers and gaining the efficiencies promised by EHR adoption. Metrics act just as the scale does in long-term weight management; they are the first indicator that we are falling back into old behaviors that are not consistent with sustainable adoption.
Metrics also keep us on track when performance does not meet expectations. Two potential scenarios in which the go-live event is successful but performance metrics fail to reach expectations help illustrate this idea. For instance, performance metrics could not be achieved because the system is not being utilized effectively. This may be due to inadequate training and therefore lower proficiency, or a problem with the actual performance by end users in the system. Measuring end user proficiency allows us to identify “pockets” of low proficiency among certain users or departments and make sure they receive the education needed. Once users are proficient, we can refocus our attention on the performance metrics.
A second scenario is less common but more difficult to diagnose. Users could be proficient, but specific performance metrics are still not meeting expectations. In this case, we need to analyze the specific metric. Are we asking the right question? Are we collecting the right data? Are we examining a very small change in a rare occurrence? There may also be a delay in achieving certain metrics, especially if the measurements are examining small changes. A normal delay can wreak havoc if we start throwing quick fixes at the problem. In this situation, staying the course and having confidence in the metrics will bring desired results.
Like sustained weight loss, EHR adoption is hard work. Commit to a sustainment plan and a measurement strategy to ensure your EHR continues to provide the long-term value that was promised at go-live.
Xerox is a sponsor of the Breakaway Thinking series of blog posts. The Breakaway Group is a leader in EHR and Health IT training.