EHR Implementation-My first thoughts

It is time for some reflection about the EHR system I have been using since go-live at the beginning of May. These impressions are uniquely my own but I think they mirror those of many on the medical staff. The most surprising conclusion (though it shouldn't be) is that I am finding that change is especially hard to accept. The question I pose is: Is change hard because it is innately so or were there design, training, and implementation flaws that exacerbated the situation? Introspective IT professionals would be wise to revisit these possibilities on a regular basis.


Going counter to my natural inclination, I will discuss the positives first. One of the most positive elements of the implementation was having well-trained EHR specialists easily available during the first few months of use. These folks, some internal, and some with special training with the EHR, were generally very knowledgeable and could answer most questions. They had access to resources to get quick answers when they were stumped. The hospital administration wisely extended its short-term commitment to keeping these people around when they recognized how much the service was needed even 6 weeks after go-live.

The most positive aspect for the inpatient EHR from my point of view is that I don't have to search the ward looking for a patient's chart. I can assess the record from any computer on the hospital network as well as remotely from home. It is a lot easier to locate incomplete charts that need additional documents or signatures. I have helped develop two operative report templates for a colleague does a few procedures over and over. He can now complete the operative reports just as accurately in about one third the time it would take to dictate. This doesn't work as well for me because I do so many different types of procedures. I will have more to say about my documentation difficulties later.

I have spoken to a few nurses about the system. Their assessments of the EHR seem generally much more positive than that of physicians.

Now I will discuss some of my criticisms. I don't the same as a lot of physicians that I have read about in EHR case studies. For a lot of things I do, I don't feel the EHR is an indispensable step forward and that I would never go back. A lot of my complaints stem from poor overall engineering of the system where usability and attention to clinician workflows could not have been high priorities of the design team. The system is clunky, makes us do things that don't make sense in a way that does not seem natural and that does not follow customs and patterns many have come to expect when using computer systems. A laundry list of my complaints would be too long for this post.

Patient Safety: I have run into the problem many times where a patient's medications cannot be fully documented. Only medications in the EHR data base can be used. That data base is not exhaustive by any means. For example Combivent inhaler is not on the list either generic or by trade name, as far as I can tell. Furthermore, that is no work around to enter a medication not in the data base by free text so that at least it shows even if it is not in structured format. True, you can enter the drug in a patient care note but unless someone searches for and finds this specific note it will not be apparent that the patient is taking the medication. To reiterate, it does not show on the patient's medication list and is not available to the system for clinical decision support when drug-allergy and drug-drug interactions are being checked. Finally, as far as I know, there is no policy that has been promulgated to clinicians to explain how one goes about bringing this to the IT department's attention and correcting the problem.

Order sets available at go-live in no way reflected local preferences. They were company generic sets and had a frustrating number of inadequacies. The third CMIO in 3 years has just started working at the medical center. The governance structure to deal with order set development and maintenance does not yet exist. There is no capability for clinicians to individually modify, amend, or add to the pre-determined list of order sets. Some parameters of existing order sets can be pre-selected and saved as favorites.

Results: Access to laboratory results is essential for patient care. Our system offers several options for locating and reviewing lab results. The trouble is that I am not sure where the best place to look is. Results are presented in directory format that requires one to open sub files to see all the results. I have found that I sometimes miss results that are important to me. I hate to say this but in the old days of paper or with our previous computerized lab reporting system, I could feel secure that I was viewing all the daily labs and cumulative summaries. Now-not so much. I am not alone among clinicians in voicing this concern.

Elements such as setting up in baskets to receive and show results were not configured individually with clinicians. It took me months to learn what I did not know about my personal work space-that I had not been set up to receive results. This was potentially dangerous for my patients and for me. I cannot understand why someone from IT did not sit down with each clinician and go through a checklist of options for how to configure the system to match their preferences. This seems like EHR 101 to me. I am still making discoveries about configuration issues at four months after the initial implementation where significant discrepancies in configuration result in differences in my screen views vs. how others in my same specialty.

Ease of Use/Efficiency of Care: Clinical documentation. The plan was to offer about one third of the medical staff the use of voice recognition (VR) software for dictation, once they completed creation of user files and had training in the use of the software. Many of the hospital transcriptionists were laid off. Some clinicians were expected to develop point and click templates; others were expected to continue to use dictation until the end of the year when dictation would be phased out completely. The number of VR licenses was rapidly increased due to unexpected demand by clinicians. A separate decision was that positions for transcriptionist/editors would not be created. Sole responsibility for accuracy of dictations rests on clinicians and spell check software. At first, I was an enthusiastic supporter of this enterprise version (but not the latest version.) Then I started reading some of my previously created notes. I found the number and types of errors to be unsatisfactory. I tried to solve this by running spell check on every note. This took time but did not significantly increase the accuracy rate. Some of the errors I were such a distortion of what I said that I would not be able to correct them without listening to the original voice file to discover what was really said. I have tried taking the time to train out the errors but this is time-consuming and did not seem to be achieving the desired effect. More and more, I am resorting to typing my notes to achieve the accuracy that I feel is needed for a medical document. It is that or proofread and correct every document. That is not efficient use of my time. Isn't that why voice recorders and transcription systems were developed in the last century in the first place?

I could go on but I will stop here. IT staff say they are committed to addressing clinician concerns, optimizing the systems, correction errors, and providing on-going user training. That remains to be seen. While I don't think clinicians will reject this system, the successful implementation of our EHR is a work in progress.