Joy Chesnut, MD

For most physicians, using an EHR is no longer optional. At a cognitive level, we understand this. At an emotional level, this can be one of the most challenging aspects of our jobs. Insult becomes injury when placing an order takes a minimum of 15 clicks or when documenting an office visit takes twice as long as the actual visit.

Resentment of the EHR is not a symptom of physician technophobia. It is a natural reaction to being forced to work with inefficient EHR workflows. Over the years working with physicians going through EHR implementations, I have learned that resentment is not the beginning and should not be the end of the story. When faced with problematic EHR workflows, providers initially react with incredulity: “Surely, this is not working as designed.” How physicians (and healthcare organizations as a whole) react to that initial observation will ultimately determine the success of the implementation.

There is a subset of physicians that keep their incredulity to themselves. They see the problem and they identify a workaround. They quietly adapt, not to the EHR, but around the EHR, establishing electronic workflows that are incompatible with the original design. There is another subset of physicians that react quickly and loudly to declare the EHR the worst they’ve ever seen. These two groups tend to be the first to progress from incredulity to resentment. But there is another, admittedly smaller, subset of physicians that are so genuinely convinced that the system is not working as designed that they become curious and wonder, “so how exactly is this supposed to work?”

I identify with this latter group. I was less than 2 weeks into a new job when I approached an administrator truly convinced that the electronic medication ordering process had not been implemented correctly. I was referred to IT and discovered that the ambulatory medication dictionary had not been built at all and therefore every end user had to individually build out common drug strings. Once we identified the problem, I volunteered to build the dictionary strings. This project took weeks, and along the way providers started to “bump” into these nice pre-built strings. In recognition of the work, the organization offered to compensate me for the time I put into the project.

My curiosity enabled me to give the EHR the benefit of the doubt but even more importantly, the organization enabled me to seek out answers to my questions. So there is a dynamic of how the individual provider responds to EHR challenges and how the organization responds to the provider. The improvements we made to the system were a result of the access and opportunity I was given to learn about the EHR and work with stakeholders to better represent physician interests. Projects from small parameter tweaks to deployment of new functionality produced results that built support for the project among my peers. Over time, I became more and more involved in the administrative aspect of our EHR optimization and my role evolved to what eventually became Chief Medical Information Officer.

Since then, I have worked with many hospital systems in every stage before, during, and following an EHR implementation. I have learned that one of the most important keys to EHR success is investing in effective physician involvement. Organizations that create physician EHR leadership opportunities are in a better position to implement EHRs in a way that improves care delivery and preserves physician morale.

A successful EHR implementation hinges on the organization’s ability to shift the focus of the EHR dialogue from its failures and shortcomings to the identification of opportunities for improvement. How do we as physicians accomplish this?

Approach providers with one goal in mind: to create workflows that adapt to their needs. Make it clear that the implementation team can’t achieve this goal without fully understanding physician workflows. Engage providers and IT staff through workflow analysis and shadowing opportunities starting at the earliest stages of the implementation.

Recruit as many physician super users as possible. Physicians from all specialties should take part in enhanced training leading up to implementation. These physicians can be a voice for their colleagues’ needs as the product is introduced and optimized, and can build enthusiasm and support for the project.

EHR education should not end at implementation. Too many organizations see the Go Live date as the finish line. In many ways it is just the beginning. In order for an EHR to be a successful tool, it must be optimized for its workforce. Small adjustments can result in significant improvements. The EHR is updated regularly and organizations need a standard process for introduction of new and changing functionality. Maintain a group of staff invested in the EHR that convene regularly to share ideas, seek solutions, and spread EHR best practices among their peers. Provide a regular opportunity for employees to meet with an “EHR expert” and ask questions.

EHRs are here to stay. They are not perfect but they are not hopeless either. As the people using EHRs, we need to invest our time and our insights into finding ways to leverage the EHR’s strengths and mitigating its weaknesses. A successful implementation is possible if you ask questions, build support, and educate yourself and your peers throughout the process.

Joy Chesnut, MD, is a former CMIO at Marietta Memorial Hospital and MEDITECH physician consultant.

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