Dr. Haugen presents how the economic, political and social pressures on the healthcare will inevitably change the shape of this industry. Topics include how the HITECH Act provides us with an opportunity, but requires significant changes in how we implement Electronic Medical Records (EMR) to ensure the transformation results in increased healthcare quality, error prevention, reduced healthcare costs and increased efficiency. The terms implementation and adoption are often used interchangeably, but the outcomes from them are very different. Moving from an EMR implementation focus to an EMR adoption focus requires a significant overhaul in how we think, how we lead, and how we behave.

1. A Prescription for Achieving
Long-Term EMR Adoption
Heather Haugen PhD
November 4, 2011
Corporate VP Research, The Breakaway Group
Instructor & HIT Co-director, University of Colorado
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San Luis Valley Health Information Technology
Symposium, November 4, 2011

2. San Luis Valley AHEC Legal Notice
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3. What is the single most significant
barrier to end-user adoption in
your organization?
Lack of resources
Prohibitive expense
Applications are not intuitive
IT owns the project
Inadequate training
Competing priorities
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4. “There is no more delicate matter to take in hand, nor more dangerous
to conduct, nor more doubtful in its success, than to set up as a leader
in the introduction of changes. For he who innovates will have for
enemies all those who are well off under the existing order of things,
and only lukewarm supporters in those who might be better off under
the new.”
~Niccolo Machiavelli 1532
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5. Physician Adoption Research
• Background
– Recognized physician adoption as significant challenge to
adoption of EMRs
– Less than 17% of physician practice groups have adopted
today (DesRoches). Approximately 1.5% of hospitals have
comprehensive EHR (HIMSS Analytics, 2009)
– Current literature doesn’t differentiate between installed
system and a system being used for clinical benefit.
• Research
– Interviewed physician leaders representing 3575 physicians
and 496 ambulatory sites
– Our objective was to identify the barriers to adoption and
develop strategies to overcome them
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6. Physician Adoption Research
Conclusions
1. Implementation is not adoption. The implementation of an EMR
is only a milestone on the journey toward full adoption.
2. Physician adoption is highly dependent on having engaged
leaders.
3. Traditional training methods are ineffective for achieving
proficient users.
4. Most organizations are not tracking meaningful metrics.
5. Sustainment of EMR adoption requires significant resources and
must be maintained for the life of the application.
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7. The Promise of an Electronic Medical Record
“Has the potential to transform healthcare
by providing clinicians access
to comprehensive medical information
that is secure, standardized and shared.”
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8. Our Current Reality…
• Fewer than 2% of hospitals believe they can meet the meaningful
use criteria today (Jha, 2010)
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9. EMR Implementation: Hospitals
• Survey of 3049 hospitals (63% of acute hospitals)
• 2% had comprehensive EMR, 11% had basic EMR
• 17% implemented CPOE
• 75% lab and radiology reporting
• More likely to have EMR if: large institution, major teaching
institution, part of large hospital system, urban area
• No correlation with ownership status- public versus private
• Barriers: 74% capital, 36% lack HIT resources
• Facilitators: 82% additional reimbursement from EMR
Jha et al., Use of Electronic Health Records in U.S. Hospitals, NEJM, 2009.
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10. EMR Implementation: Physician Practices
Practice Size Adoption
• Smaller practices lag larger practices
• Significant increase in adoption in last All U.S. practices 40.4%
3 years Solo practices 30.8%
• 60% of hospital and health system 2 physician practice 41.6%
owned practices use EMR, 40% of 3-5 physician practice 51%
independents use EMR.
6-10 physician practice 63%
• Specialties leading the pack: dialysis,
pathology, nuclear medicine. 11-25 physician practice 71.6%
Laggards: psychiatry and holistic
medicine. 26+ physician practice 75.5%
SK&A, Bi-Annual Survey, Physician Office Usage of Electronic Healthcare Records Software, Oct 2010
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11. What Is Causing The Gap Between the Promise
and Reality…
“The difference between the promise and our real-
world experiences is borne in the assumption
that implementing an EMR and adopting an
EMR are the same objective.”
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12. Consider the marriage not just the wedding!
Consider the marriage, not just the wedding!
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13. Implementation Versus Adoption
Implementation Adoption
Emphasis Go-live (Event) Outcomes (Process)
Ownership Technical / IT Clinical / Executive
Success Criteria Technological Integrity Role-based Performance
Management Focus Project Milestones & Cost Quality Of Care
Workflow Expectations Repair Redesign
Clinical Involvement Negligible – Short Term Critical – Long Term
End User Attitude Apathetic Or Prejudiced Adaptable
Metrics Project Milestones Outcomes
Training Design Demonstrate Feature Role-based Simulation,
& Function Task Completion
Sustainment Post Go-live Left To Chance Primary Management Focus
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14. Peter Senge: Systems Thinking
Archetypes:
Limits to Growth
Fixes that Fail
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15. Understanding The System
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16. Physician Adoption Research
Conclusions
1. Implementation is not adoption. The implementation of an EMR
is only a milestone on the journey toward full adoption.
2. Physician adoption is highly dependent on having engaged
leaders.
3. Traditional training methods are ineffective for achieving
proficient users.
4. Most organizations are not tracking meaningful metrics.
5. Sustainment of EMR adoption requires significant resources and
must be maintained for the life of the application.
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17. Having Engaged Leaders is Unconditional
• Tone at the top
• Governance
• Importance of clinician
leaders
• Staying engaged for
the life of the application
A “reinforcing” system
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18. Physician Adoption Research
Conclusions
1. Implementation is not adoption. The implementation of an EMR
is only a milestone on the journey toward full adoption.
2. Physician adoption is highly dependent on having engaged
leaders.
3. Traditional training methods are ineffective for achieving
proficient users.
4. Most organizations are not tracking meaningful metrics.
5. Sustainment of EMR adoption requires significant resources and
must be maintained for the life of the application.
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19. Revolutionize “Training”
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20. Focus on Proficiency Not Training
Training: Proficiency:
• One time event • Accumulation of experience
• Classroom/Scheduled • In work environment
• Scheduled • Anytime/anywhere
• Goal: mastery • Goal: fluency
• Generic content • Role-based content, 80/20 rule
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21. Precise and Fast, Simulators by Role and Task
Flight Simulation & The Breakaway Method™
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22. Proficient by Role- Fast
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23. Physician Adoption Research
Conclusions
1. Implementation is not adoption. The implementation of an EMR
is only a milestone on the journey toward full adoption.
2. Physician adoption is highly dependent on having engaged
leaders.
3. Traditional training methods are ineffective for achieving
proficient users.
4. Most organizations are not tracking meaningful metrics.
5. Sustainment of EMR adoption requires significant resources and
must be maintained for the life of the application.
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24. Metrics
• End user adoption
- Knowledge and certification
• Utilization metrics
• Performance metrics- clinical and financial outcomes
- Quality and safety
- Meaningful use
- Productivity
- Cost of ownership/maintenance
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25. Utilization Metrics
Survey of CHIME CIOs
• n = 45
• Hospital characteristics
• 89% >100 beds, 40% >400 beds
• 60% fully or almost fully implemented EHR
• Adoption defined as 75% of physicians using the functionality
according to prescribed best practices
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26. Utilization Metrics
Functionality Installed Physician Adoption
Clinical Documentation 91% 40-55%
Testing & Imaging Results 91% 90-100%
Clinical Decision Support 84% 41-65%
Computerized Provider Order Entry 73% 16-64%
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27. Performance Metrics
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28. Physician Adoption Research
Conclusions
1. Implementation is not adoption. The implementation of an EMR
is only a milestone on the journey toward full adoption.
2. Physician adoption is highly dependent on having engaged
leaders.
3. Traditional training methods are ineffective for achieving
proficient users.
4. Most organizations are not tracking meaningful metrics.
5. Sustainment of EMR adoption requires significant resources and
must be maintained for the life of the application.
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29. Lifecycle of Adoption
Optimization ADOPTION
Fluency
Threshold
Proficiency
Readiness Implementation Utilization Upgrades/Additions
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30. Sustainment
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31. This Just In…Clinical Outcomes
• Review of current literature
• 1995-2004 Chawdry et al
• 2004-2007 Goldzweig et al
• 2007-2010 Blumenthal et al
- 154 studies
- 96 (62%) positive improvement in one or more aspect of care
- 142 (92%) positive or mixed positive (overall positive, at least
one negative conclusion.
Blumenthal et al. The Benefits of Health Information Technology: A Reviwe of the Recent Literature Shows
Predominately Positive Results. Health Affairs, March 2011.
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32. Factors Influencing Negative HIT Results
• Lack of clinical leadership
• Staff skepticism
• Leadership turnover
• Unrealistic schedule
• Vendor products not ready on time
• Workflow issues
Blumenthal et al. The Benefits of Health Information Technology: A Reviwe of the Recent Literature Shows
Predominately Positive Results. Health Affairs, March 2011.
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33. EHR- A Competitive Advantage
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34. Please fill out your evaluations on this talk and
leave the completed form in the box next to
the door before you leave today.
Please send any questions or comments to:
hhaugen@thebreakawaygroup.com
THANK YOU!
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