View from the Hospital: Reflection on Electronic Health Record Implementation


Guest post by Rishi Agrawal, MD, MPH, physician champion, La Rabida Children’s Hospital, Chicago, IL.

“Why do I have to click so many times to order something so simple?” a frustrated resident blurted out on her first day using our newly implemented CPOE system.

Having helped build order sets as a physician champion, the best I could tell her was that many aspects of the software were beyond my control, but that it will get faster and easier with familiarity.  And it did, to a point. Within a few weeks of going live, we had more than 90 percent adoption of CPOE, a source of both relief and pride. But challenges remained.

Adaption to new workflows.

Inexplicable bugs and crashes.

A lack of an interface to e-prescribing software within the current software version.

La Rabida Children’s hospital is a small hospital dedicated to the care of children with complex medical conditions. Our patients frequently have numerous medical problems, multiple specialists located in multiple health systems, and significant socioeconomic challenges.

While children like these constitute a small proportion of the population, they utilize a disproportionate quantity of pediatric health resources just as the minority complex chronically ill adults consume a large quantity of health care resources as well. Our longstanding goal to provide a medical home and care coordination to the most challenging patients is increasingly being viewed as instrumental to achieving sustainable health care in all age groups.

To that end, our trials and tribulations of implementing an electronic health record for patients with complex chronic issues may offer lessons for others. For the purpose of such systems is information management, and the more complex the patient, the more information to manage.

When we admit a patient to the hospital, for example, we have to contend with soliciting long histories that nobody remembers in their entirety, reconciling dozens of medications, and ordering multiple nursing interventions. If patients have extensive records within our hospital, the process goes relatively smoothly. But if they don’t, limited availability of information from other hospitals and providers because of a lack of health information exchange continues to challenge us substantially. The barriers to setting up a working health information exchange are numerous and it is understandable that they have yet to come to fruition in many places. Yet it is maddening that even simple generation, exchange and ingestion of a PDF of medical records from point to point is not the low hanging fruit it could be as interim step to more precise forms of exchange.

The customizability of the electronic health record has been a mixed blessing. We have been able to build documentation templates and order sets specific to our focus of practice. There were many instances in which we wished that more content had already been built or at minimum that it is easier to share templates with similar hospitals using the same system to avoid multiple wheel reinventions.

Just as often, we were frustrated by the lack of customizability of other parts of the electronic record. In particular, the summary views of a patient’s chart are excessively hardcoded. Yes, it is nice to be able to see a current list of medications, problems, and allergies. But complex patients need more than that in a bird’s eye view.

Providers need the ability to see recent encounters, special diets, providers, therapists, DME suppliers, etc. without going on clicking expeditions. If integrated care is the goal we seek in healthcare, why is it still so difficult to integrate and summarize large amounts of clinical data?

We also need customizable alerts and reminders to help clinicians keep track of information across episodes of care, not just within them. Electronic records are excellent for acute episodic care; they fall short, as does the rest of our health care system, for complex care planning and chronic illness management.

At the end of the day (or the start of the go-live), we have to play the cards we’re dealt (even if they’re Jokers). Sometimes little decisions can make a big difference. A focus on one-on-one training using adult learning principles rather than large group lectures worked well for us. We made sure desktops have wide screens because every inch of screen real estate counts when multitasking and flipping between programs. Though popular, we are holding off on tablets until the day, hopefully soon, when the software is optimized for the tablet and the tablet is optimized to fit in our pockets.

Despite the frustrations, I remain optimistic about the future of health IT. Subsequent software versions will get better. Hardware will become more usable. And health information exchange will someday become reality.

It just might take longer than we might like. But who said system transformation was going to be easy?

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