Teaching old docs new e-health tricks proves difficult

Younger physicians are more likely to gravitate to automated systems

Before the rollout an all-electronic health records (EHR) system about a year ago, only about half of the doctors and nurses in West Virginia's state hospitals were familiar with medical computer systems. So when technology rolled in, staffers pushed back.

"We actually had some nurses who were completely computer-illiterate. They didn't use a computer at work, and they had no use for it at home," said Jerry Luck, director of facilities systems administration at the West Virginia Department of Health and Human Resources.

West Virginia is not alone. Hospitals across the country are feeling pressure to implement more efficient IT systems in light of President Barack Obama's plan to establish a nationwide EHR system in the next five years. Under the Health Information Technology for Economic and Clinical Health Act (HITECH), physicians would be eligible for between $40,000 and $65,000 if they show they are using IT to improve the quality of care.

EHR systems are expected to streamline health care workflow, improve the quality of care and cut costs, according to experts. But medical facilities could also find themselves at loggerheads with some of their own staffers, which are far more familiar with pen and paper than a keyboard or tablet PC. Adding to the problem: the bulk of HITECH money will be awarded beginning in 2011, according to current legislation pending in the House. That doesn't give hospitals much time to prepare, and organizations that aren't ready won't receive funds.

West Virginia is a rarity: Its state government health care system has an all-electronic record-keeping system spread across seven medical facilities.

Younger docs prefer tech

"Probably the most difficult part of our technology rollout was teaching the old doctors new tricks," Luck said. "With younger doctors, we did not experience a problem at all. In fact, [using technology] was their preference. [For] the older and more senior doctors, who for years only dealt with paper, it was a far more difficult transition."

West Virginia began rolling out OpenVista, an open-source software version of the Vista medical records system from U.S. Department of Veterans Affairs (VA), about two and a half years ago. OpenVista, from Medsphere Systems Corp. in Aliso Viejo, Calif., was the brainchild of two physicians who submitted a Freedom of Information Act request in order to get the source code for Vista, which is used at 1,300 VA facilities to maintain health records for 5 million veterans. Vista is seen as the most advanced EHR system in use because it has been around for 20 years.

Luck said all personnel were offered basic computer training. They took a two-hour course in using the new EHR technology and had to pass a test ensuring they knew how to use a keyboard and mouse. Getting doctors and nurses to adopt the technology, however, required more than a bit of peer pressure from younger doctors, interns or trainees who readily accepted its use.

At private medical facilities, getting physicians, nurses and clinicians to accept the move from paper to pointer, often required finesse -- and sometimes finance.

David Whiles, director of information systems at Midland Memorial Hospital in Midland, Texas, said he still hears complaints from doctors and nurses trying to warm up to the 70 new wireless mobile computer carts that came with the facility's $6.5 million, three-year EHR project. The rollout was completed exactly a year ago.

A common complaint: mouse clicks

"We still have common complaint today -- too many clicks," Whiles said. "It's been a challenge to streamline the system, even through it's very well designed. Just making it more efficient is probably one of the biggest complaints still. And, it does take time [to enter information]."

Midland, a community hospital with about 200 physicians on staff, also used Medsphere's OpenVista system because most doctors have to perform a stint at the VA at some point in their education. As a result, Vista is familiar to them. Using open-source software cut costs by two-thirds and the implementation time in half, Whiles said.

Even so, getting doctors involved and trained on the new system "was probably hardest part of the rollout -- overcoming their resistance to change," Whiles said. "It just turned their world upside down, because doctors had to go use a computer to access patient chart information. We underestimated the level of computer literacy our staff didn't have. So there was a challenge getting them up to speed on basic computer skills."

Midland trained four or five doctors at a time to ensure that they had one-on-one time with instructors. "They had to demonstrate their proficiency after using it for a month to get paid for that. They had to enter their own orders and sign electronically for documents."

Midland paid doctors doing the EHR systems training up to $1,000 each for 10 hours of time. "That really got a lot of physician buy-in," he said.

Monetary incentives from the government are also expected to bring more physicians on board. "It's very obvious that market forces and bravado alone will not do this," said Dr. David Brailer, former national coordinator for health IT and President Bush's health information czar from 2004 to 2006. "Putting significant money into it is really the next appropriate step."

A little sugar

On Jan. 1, the federal government enacted an incentive program for doctors to begin using electronic prescriptions for Medicare patients. Doctors are paid 1% more for every Medicare patient they use e-prescribing on, "which generates several thousands of dollars a year," Brailer said. "It's a net ROI because their cost is very small. Then beginning in 2013, there will be a penalty if doctors don't do it."

But not everyone is confident that the government will do a good job getting doctors to use EHR technology.

In the second half of 2007, both Medicare and Medicaid put into place a physician-reporting bonus system. Based on Medicare and Medicaid billing systems, physicians who simply reported treatments through electronic billing to the government would get a small bonus, according to Dr. Charles O. Frazier, vice president of clinical innovation at Newport News, Va.-based Riverside Health System, which includes five hospitals, three cancer treatment centers and two long-term care centers.

But Frazier said most doctors found the reporting system clunky and confusing. "The government didn't tell doctors to report through an electronic medical record, just through the regular claims system," he said. "So there was no incentive to use EHRs."

On top of that, Frazier said the government also added reporting codes to the system so physicians could report on more treatments. But the system bogged down when the number of codes grew to 170.

"It's so confusing and so hard to get your hands on that most people just said, 'Forget it. It's not worth it,'" Frazier said. "It's just crazy the way they do things."

Frazier also said the Medicare/Medicaid bonus system offered only up to 1.5% on top of whatever bill was submitted electronically. "If they had said 3% and said you had to report out of an electronic medical record, that would have been an incentive," he said.

Superusers

"Rewards go a long way in helping lead staff through change like this," said Chad Eckes, the CIO of Cancer Treatment Centers of America Inc. (CTCA) in Schaumberg, Ill.

Over the past three years, CTCA performed a $15 million rip-and-replace overhaul of its existing IT infrastructure in order to create paperless hospitals and an efficient EHR system. The multimillion-dollar project included a rollout of Eclipsys Corp.'s Sunrise Clinical software that cost $3.5 million. Completed in December, the effort came in $500,000 under budget.

CTCA includes four hospitals and one clinic, the bulk of the $15 million earmarked for the project was initially going to go for IT consultants, Eckes said. So he had a handful of consultants train 260 business and IT staff members, who then completed the rollout. CTCA has achieved the second highest EHR ranking -- Stage 6 -- from the Healthcare Information and Management Systems Society, a nonprofit, health care professional organization. EHR rankings run from 1 to 7, with 7 being the highest.

In order to get physician, nurse and technician buy-in, staff members spent 80 to 90 hours in mandatory training on the new systems, which included information about the benefits of EHR. If staffers needed one-on-one training, they got it. "They were being taken away from patient care, but our board recognized it was a pay-me-now-or-pay-me-later situation," Eckes said. "At the same time, the training was critical to ensure the safe use of the EHR after activation."

Perhaps most important to full staff qualification was the use of "superusers" -- 20% of the physician and nursing staff on every shift who were hand-selected to become experts on the systems. That way, if other staff members had a question, there was always someone knowledgeable to ask. The super users could also correct other staffers' bad habits.

Eckes also tapped 72 staff members to help pick the EHR system, and only two were from his IT shop. "Physicians trust physicians. And, that's where leadership of change needs to come from," he said.

"The use of the system made staff members more efficient," Eckes said. "They were no longer fumbling around looking for data. They had it at their fingertips, so it allowed them more time with the patient. Not only did it achieve greater patient satisfaction, but it also increased more efficiency, so doctors could move from patient to patient faster."

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