• EHR
  • EHR’s financial benefits may be elusive

    Acfee’s stance on EHRs is that they’re an investment in health and healthcare, not an initiative to increase healthcare organisations’ income. The Acfee eHealth Impact Database contains over 60 evaluations. A common theme is that the extra cash needed for eHealth exceeds its cash savings. Healthcare quality and productivity are the main sources of benefits. The affordability planning and management lessons are clear for Africa’s health systems.

    It seems that US healthcare may see it differently. An article in Modern Healthcare says hospitals and health systems each spent millions and sometimes billions of dollars on EHRs. Examples are: 

    Trinity Health reported a US$107.8 million asset impairment charge in 2018 to switch to a single version of Epic EHR and revenue cycle management software over four years and undisclosed costsMayo Clinic spent US$1.5 billion on Epic HERPartners HealthCare spent $1.2 billion on an Epic HERScripps Health reporting weakened financial results when started an EHR conversion budgeted at US$300 million over ten years, with estimated operating costs of US$360.5 million, 20% more than the non-recurring costsBanner’s US$45 million project contributed to a US$92 million hit to university delivery operations 2017 when it spent US$24.3 million on EHR conversion.

    Modern Healthcare says the promised clinical and financial benefits have been elusive. Some healthcare organisations have suffered financial problems when eHealth has worked against them. In particular, hospitals and health systems have faced financial stress when implementation costs drive up operating costs, a Capex Opex imbalance.

    Doctors and other clinicians have been wary of embracing eHealth too enthusiastically. Concerned that they may feel held back by it and causing clinician burnout.

    A literature review in the Journal of the American Medical Informatics Association said it revealed evidence that “Data entry requirements, inefficiently designed user interfaces, insufficient health information exchange from outside institutions, information overload, and interference with the patient–physician relationship are … factors associated with physician stress.”

    Some explanations are: 

    There’s going to be some disruption when implementing EHRs so budgeting and financial planning, including contingencies helps to avoid financial crisesTo ensure successful EHRs may need extra resources after implementation to mitigate financial risksLooking at EHRs in the long-term, rather than two- or three-year returns, can be helpfulIt’s inevitable that new eHealth, especially large-scale EHRs, will slow patient volume temporarily as providers learning to use them, so are less productivePlan for eHealth complexities that diminish returns from EHRs, including procurement costs, deployment and increases in higher ICT operating costs, higher departmental operating costs and lower productivity and lower employee satisfaction. 

    Africa’s health systems can’t afford these outcomes. Rigorous business cases, an emphasis on health and healthcare benefits and top class eHealth leadership can help to avoid them.

     

  • Can duplicate records be eliminated?

    Operational and health analytics benefits from EHRs can be diminished by duplicate records. Minimising them’s a step forward, but can they be eliminated. Northwell Health in New York State thinks they can. Its case study, available from Health IT Analytics, describes its plan.

    Eliminating Duplicate Records Once and for All says after implementing its Master Patient

    Index (MPI), it still had a large and growing queue of potential duplicates in over two million records that needed manual reviews to resolve. It tied down health workers’ time. Northwell’s solution was to deploy Verato Auto Steward™ which:

    Reduced task queue by 87%Shifted staff from tedious task review to higher-value projects.

    A significant benefit is staff liberated from resolving duplicate records are now redeployed to training other people on creating accurate records and preventing duplicates. The case study doesn’t estimate when the lower, 13% duplicate rate’ll be eliminated, but it does show that it it needs two initiatives.

    As Africa’s eHealth programmes expand EHRs, Northwell’s lessons are:

    Include a patient matching systemBegin to redeploy staff from patient matching to training staff dealing with patient identification and managing EHRs. While duplicate records may not be eliminated for some time, or maybe not at all, the two initiatives will enhance the benefits from EHRs. The longer it’s deferred, the bigger the removal task will be.

  • Managing and mapping EHRs after implementation's essential

    While EHRs may be a solution, implementing them’s not enough. They need managing effectively to sustain their benefits. A white paper from ServiceNow describes a way to do it.

    Because EHRs are complicated, mission-critical and support high quality patient outcomes, visibility of their reach into all healthcare’s parts enables effective and efficient EHR management. Service visibility: A road map for IT Operations and managing your EHR system says healthcare ICT teams need an EHR  map that shows its infrastructure and the services that rely on it. A service-level view’s needed to. This should show how EHR modules, features and hospital and clinical services are routed over the ICT infrastructure. 

    It’s a considerable project. Automated mapping services can help. A solution should:

    Automatically map complete services within a few hoursDoesn’t need significant input from your domain expertsTraces hospital business services across entire ICT and clinical environments, not just a few technology domainsMaps custom-built business services, not just standard services such as email or Enterprise Resource Planning (ERP) systems. 

    Benefits of EHR mapping include:

    Pinpointing disruptions to EHRs that affect critical hospital and clinical servicesIdentifying root causes of hospital service issuesInstantly seeing the impact of planned changes to specific EHR environments, reducing the time needed for manual analysis Easily optimising architecture of EHR-related hospital and clinical services, saving time, reducing costs and improving reliabilitySecuring and simplifying major transformation initiatives, such as data centre consolidations, upgrades, new modules and migrations. 

    These combine into sustained support for benefits realisation and embedding them into daily clinical and working practices. It’s an essential part of EHR investment that Africa’s health systems should consider to ensure that EHR implementation isn’t the end, but the start of improved healthcare. 

  • Duplicate patient records keep turning up

    Achieving accurate patients’ IDs’s a constant theme of managing EHRs. Duplicate records just won’t go away. University of Washington (UW) Medicine based in Seattle regularly reviews and improves the reliability and accuracy of its EHRs. Cleaning duplicate records is an important part of the task. 

    Its latest initiative, available from EHR Intelligence, is  with Just Associates,  a consultancy that identifies and resolves patient data integrity problems, reveals some critical lessons for Africa’s eHealth. It found that the duplicate rate was significantly higher than the 10% to 20% it usually finds. The main cause was inadequate information. Many records contained only four of six ID components. They’re last name, first name, middle name, gender, fate of birth and social security number. 

    The review identifies the source of ID issues and issues that create duplicates. This information has helped UW Medicine to develop its strategy and planning to control duplicate rates.

    There’s a long-standing ID challenge. It’s an “uphill battle to dedicate the appropriate resources.”

    Sustaining appropriate staffing levels for ID management’s a challenge. Part of the solution’s relying on ICT tools. An objective’s to using technology to improve efficiency and reduce staff time manually accessing and matching records. It means that staff can then deal directly, efficiently and successfully with awkward ID cases and records.

    A valuable lesson for Africa’s eHealth’s that EHRs alone are not enough. Extra resources are needed to ensure the value of data in EHRs. With a typical duplicate rate of 10% to 20%, any drift in ID management seems to lead to higher rates, so greatly diminished value of EHRs’ data.

  • Five main insights on the impact of EHRs can help investment plans

    While EHRs provide the most comprehensive, up-to-date patient information, more details about their impact’s needed for investment decisions. eHealth investment challenges are:

    What benefits to they bringHow are they realisedHow long does it takeDoes their value exceed their costs.

    Spectralink describes insights into some of these in its technical brief Five ways EHRs improve healthcare delivery. It’s available from EHR Intelligence. The five generic ways are:

    Access to critical data, anytime, anywhereImproved care coordinationMore accurate diagnosticsIncreased work flow efficiencies and cost savingsBetter patient participation.

    Within these five, ten benefits are identified across two groups:

    Physician workflow              

    Accessed patient chart remotely - 74%Alerted to critical lab value - 50%Alerted to potential medication error - 41%Reminded to provide preventative care - 39%Reminded to provide care meeting clinical guidelines - 37%Identified needed lab tests - 28%Facilitated direct communication with patient - 25%

    Patient-related outcomes   

    Enhanced overall patient care - 74%Ordered more on-formulary medications  - 41%Ordered fewer tests due to lab results availability - 29%

    Three other activities show large impacts: 

    Note practice functions more efficiently - 79% Receive lab results faster - 75%Report enhances in data confidentiality - 70%. 

    While these are large increases, there’s no information about how much more efficiently, fasters of enhancing these changes were. These estimated values are important in evaluating EHRs’ impacts. 

    None of the benefits refer to increased patient access as part of Universal Health Coverage (UHC). This needs resources liberated by efficiency gains to be redeployed to communities with no or limited UHCs. Acfee reviews reveal that these seldom happens on a large scale with EHRs. It has to be linked to specific UHC initiatives. 

    Uploading information with mHealth links are in place in about two-thirds of EHRs. This offers scope for further investment. It’s an essential feature for Africa’s eHealth

  • US EHR solution judged not up to the job

    eHealth has risks. A report from the US Office of the Secretary of Defense, and available from EHR intelligence, highlights some of these. They provide valuable themes for Africa’s health systems to use in their EHR assessments and procurements. Is says “a partial  IOT&E [Initial Operational Test and Evaluation] was adequate to determine that MHS GENESIS was neither operationally effective nor operationally suitable.” It raises an important challenge: how could this have been established before procurement? 

    Inappropriate performance included: 

    MHS GENESIS is neither operationally effective nor operationally suitable. DOT&E recommends that the Under Secretary of Defense for Acquisition and Sustainment delay further fielding until JITC completes the IOT&E and the PMO corrects any outstanding deficiencies. Detailed recommendations are included in the main body of this report;

    It doesn’t demonstrate enough workable functionality to manage and document patient care in 56% of the 197 tasksof performance Poorly defined user roles and workflows increased the time needed for health care providers to complete daily tasks, including overtime and seeing fewer patients a dayUsers questioned information accuracy in exchanges between external systems and MHS GenesisPoor usability of 37%, on the System Usability Scale (SUS), well below the 70% thresholdInsufficient trainingInadequate help desk supportSystem unplanned downtime outages indicated that the end-to-end system and supporting network didn’t have sufficient availability to support operations at the four IOT&E locationsUsers reported increased lag times when other IOT&E sites went live, suggesting the supporting network configuration wouldn’t support the hundreds of additional planned sitesSurvivability is undetermined because cybersecurity testing isn’t complete. 

    This salutary experience shows the importance of rigorous assessment processes before procurement. Across the global eHealth community, it’s not the first time, and it’s not likely to be last. Africa’s health systems can afford this type of risk exposure experience. 

  • Apple health app stores personal medical information

    Giving patients access to their medical records is an increasing priority. It can help them to manage their conditions and comply with medication and treatment requirements

    Apple is determined to make people’s lives easier. It’s created a new app that people can use on their iPhones to access, view and store their medical records on their person. Data on the app includes; allergies, test results, prescription drug list, immunization records or general health histories. Patients can also add files to the menu, provided they comply with Clinical Documented Architecture (CDA).

    Medical records information’s transmitted electronically from participating providers to patients’ iPhones. It needs patients to opt into the service via the health app and be able to browse through their data as well as receive new notifications when updated.  

    Jeff Williams, Apple’s chief Operating Officer (COO), assures that the app’s data is password protected an encrypted. It even denies Apple access to the information unless it is shared by patients.

    An announcement by Apple says patients with multiple chronic conditions will probably have considerable benefit.

    There’s a tricky bit about portals and patients accessing their medical records. A study reported on eHNA found for some patients, access made no difference to their health outcomes compared to patients who didn’t have access.

  • EHRs can be more efficient, with better quality

    Better efficiency and quality are two main eHealth benefit groups. They don’t stand alone. Benefits in one group can lead to benefits in the other. Imprivata  emphasises two lessons in its white paper, available from EHR Intelligence.  Saving time, improving care Two lessons to remember when integrating a new EHR sees efficiency gains liberating resources for better quality. 

    Its proposition’s that clinicians can waste 13 seconds waiting unnecessarily with the time they log into EHRs. Aggregating these across all clinicians’ logins can create a valuable chunk of their time, about 13,000 hours a week for a typical hospital. On this scale, clinicians’’ time, can be redeployed to improving health care quality. This simple arithmetic looks appealing, but it’s consistent with an EHR challenge of redeploying each clinician’s small time savings and efficiency gains. It’s an essential, but not an easy activity. 

    Three important findings from a study by American EHR illustrate the difficulties:

    42% of professionals who found it difficult to improve efficiency with EHRs72% found it difficult to decrease workload with EHRs54% said EHRs increased total operating costs.

    These confirm the need for eHealth to be highly usable. It’s a prerequisite for benefit realisation. 

    Imprivata suggests early types of EHRs incorporate these constraints. Modern versions can overcome them, and more benefits will result. It points Africa’s health systems to the need to test the efficiency and performance of EHRs that they’re considering in their procurements. Better EHRs offer better benefits. It looks encouraging for Africa’s healthcare.

  • Is eHealth mature enough for healthcare?

    Two opposing views of eHealth could be optimism and cynicism. An article in Fierce Healthcare identifies a view in between. It sees eHealth as a maturing endeavour that’s in an adolescent stage. While it’s a view of US eHealth, if it’s right, it has implications for Africa’s eHealth strategies too/

    It starts from a position where basic ICT infrastructure’s in place, such as EHRs, analytics and population health tools. This has created lots of data, but healthcare organisations don’t seem to know what to do with it. They’re entering a phase of trying to pull it together into a cohesive unit. Doctors are taking a core role in this, such as the Integrated Health Model Initiative (IHMI) reported on eHNA. 

    EHRs aren’t as communicative as they could be, and doctors don’t like the extra time they have to commit to eHealth’s demands. This extends to data entry too.

    Wearables can be full of potential for better health and healthcare. Unresolved challenges include designing effective service models and creating appropriate reimbursement arrangements. Reimbursement for telehealth remains elusive too, which doesn’t augur well for rising investment trajectories. It’s especially disappointing when over half of healthcare executives plan to expand their current programmes based on improved patient satisfaction and healthcare coordination achievements. 

    Recent huge global cyber-attacks, WannaCry  and Petya/NotPetya. revealed healthcare’s vulnerabilities. WannaCry breached several hospital systems in the UK’s NHS. For many weeks after the attack, the US Department of Health and Human Services was dealing with it’s operational aftermath for two multi-state health systems.

    Petya: 

    Damaged a US-based drug companyForced a West Virginia hospital to replace its entire computer systemCost Nuance some US$68 million by shutting down it’s medical transcription services.

    Repairs weren’t confined to technical cyber-security matters. They had to address a severe lack of ICT security talent too. 

    In this setting, US eHealth investment’s up. For Africa, it’s eHealth strategies need recognise and deal with both the challenges and opportunities. A wide range of resources need deploying to drive through eHealth’s complexities that extend beyond ICT. 

  • Successful EMR switching lesson from Scotland’s Fife

    Implementing EHRs from scratch is challenging. Switching from one set of EHRs to another is more daunting. NHS Scotland has been developing its latest Patient Management System (PMS) version over several years. Marianne Campbell, eHealth senior programme manager at NHS Fife, a health board in Scotland, has described provided five essential lessons in Connected Care Watch. An overarching requirement’s “Grace under fire … keeping a cool head in times of stress.”

    They five are:

    Early stakeholder engagementFull dress rehearsalClear leadership and delegationStick to the scopeUnderstand priorities.

    An connecting thread running under these is the long timescales needed for success. PMS has been many years in development. Implementing it extends across several too. It’s consistent with finding from Acfee’s eHealth evaluation database 

    Switching needed intensive preparatory efforts lasting over a year. Over 700,000 records were transferred from the existing system to PMS, and change management introduced new processes and procedures across ten acute, mental health and community facilities. More than 3,000 health workers completed the training programme. It also needed teething problems addressing. 

    Fife’s PMS project is part of a broader initiative across Scotland, promoted by the devolved Scottish government. There are 14 regional and eight specialist Sottish Health Boards. Twelve, covering 92% of the population, now use PMS.

    Engagement focused on internal stakeholders, reflecting PMS’s change management requirements affecting almost all health workers. A Fife lesson’s that more engagement was needed, especially regular immersive workshops. These started five months before go live. 

    The full dress rehearsal enables a seamless go live. It revealed troubleshooting actions in a controlled test environment. They were addressed in advance.

    and iron out any kinks before the big day.

    Two leaders dealt with and technology and business in parallel. They weren’t the only ones, Decentralised leadership from each area were empowered to make effective decisions quickly. Two technical teams from of NHS Five and InterSystems worked as a cohesive unit. 

    Sustaining the scope required strict discipline. It had to deal with some robust debates to balance the requirements of services with the go live timeline goal. Being controlled and systematic was the only way to a project of PMS’s scope could succeed. 

    The numerous stakeholders had many competing priorities. Clarity about critical activities was a daily discipline. 

    Success’s attributed to careful planning by many people over a long period. As Ms Campbell points out successful implementation doesn’t preclude issues arising down the track.

    eHNA’s looking forward to her next report on  PMS’s realised benefits compared to the previous system. Lessons from the realisation timescales and activities are as valuable as implementation lessons.