0 Common Issues and Concerns Associated with E-Health

Section0.4 Overview

Section 0 Overview—Common Issues and Concerns Associated with e-Health - 1

Common Issues and Concerns Associated with e-Health

Many of us have a number of concerns about implementing and using e-health. Many are based on reality, and others are misconceptions. Use this tool to learn about these concerns, and increase your openness to and knowledge about the fullest possible use of e-health tools.

How to Use

Check off the concerns that you think members of your organization may have. Use the write-ups that follow to learn more and help staff members be more open and informed about these topics.

Therapist/User and Client Concerns

Concern: Behavioral health clients will not accept a therapist using an EHR during the interview.

• Reality: This may be true for some clients; however, it has been observed that this is more often a perception of the therapist than the client. Overcoming the barrier: Training is key to using the EHR effectively with a client—and to recognizing when it is becoming a barrier. Training must include screen navigation, as well as strategies for introducing the EHR to the client, using it to engage the client, and perhaps even getting the client to use a portal to enter some of their own data.

Concern: EHR and HIE are not secure. They do not ensure the privacy of sensitive behavioral health information.

• Reality: An EHR and HIE can provide a greater level of security—and privacy protection—than paper. Modern EHR systems have safeguards to prevent un-authorized users from view protected health information.
• Overcoming the barrier:
• From a technical standpoint, there is a very simple way to prevent confidentiality breaches: encryption. It may cost somewhat more and require one or two more “clicks” on a keyboard, but the risk reduction is enormous.
• Overcoming perceptions about lack of security and privacy is more difficult. Making security practices top priority is essential. Security should be 100 percent transparent. Every user and every client should know when security measures have been applied to the information being collected, maintained, accessed, and transmitted. For example, a user should state: “I am logging on now to access your last visit record.” A user can ask a client if they have any questions about the security of their information. State: “I am encrypting your file and logging off so it will be maintained in a secure manner” when you close a client session. If a therapist or other staff senses concern about the computer, ask the client if they have any questions about the use of the computer. If a client asks a user to stop using the computer, honor that request but find a way later to revisit the topic. Explain that notes must be taken and reiterate that the computer is safer than paper.

Concern: The challenges of 42 CFR Part 2 are too great to overcome for clients or agencies that deal with substance abuse/chemical health issues – therefore, we can’t implement and EHR or exchange data electronically with other organizations.

• Reality: 42 CFR Part 2 does require additional privacy controls for individually identifiable patient (client) information. That said, a number of solutions exist to enable BH and Chemical Health agencies to identify this type of data and to apply appropriate security permissions to it.
• Overcoming the barrier: Acknowledge the very real concern staff have for protecting the privacy of clients. Hold inservices to demonstrate how EHR/HIE technology can actually ensure that clients complete the proper permissions before data is exchanged. Get staff to brainstorm ways to help clients by get correct information to other agencies and care providers. Refer to the previous Concern regarding security. Involve clients in discussions about security and privacy, and increase their comfort by making it clear that security and privacy are an absolute top priority of your organization (as it was before EHR/HIE and as it will continue to be).

Productivity and Use Concerns

Concern: Acquiring an EHR that has a lot of document imaging and dictation support will help us transition those who are resistant to EHR and don’t know how to type.

• Reality: These bridge technologies can be helpful, but they can also be crutches that some never give up. The result can be an expenditure that yields little return.
• Overcoming the barrier: Reduce dependence on paper to the greatest extent possible, or your facility will not derive the best value from the EHR. Educate users on how to introduce the EHR to their clients, how to use it during a client interview, and how to engage the client in reaping the benefits of EHR.

Concern: We have heard that there is a huge loss of productivity with EHR and it is never fully gained back.

• Reality: Despite all the upfront planning and preparation for change, there will be an initial loss of productivity. But most EHR users find that they can regain or even improve productivity through attention to planning, workflow and process improvement, training, rollout, reinforcement, and optimization.
• Overcoming the barrier: Addressing change (i.e., engagement of users, planning, workflow and process improvement, training, etc.) and adopting strategies to use an EHR with easy-to-use templates and clinical decision support functionality are keys to preparing for go-live. Go-live is the terminology given to the event of when the users first use an HIT solution in a production (real life) environment.
• It can be helpful for users to pre-load some of their own data, spending time each day entering a small amount of key client information into the computer without the client present. Pre-load helps users get acclimated to where data is located and how to find results in a partially populated system, so that less data entry is required during an initial client visit.
• Lighten users’ schedules by one or two clients per day during the initial period of EHR use, or require use of the EHR for just one or two clients for the first few days, then increase it gradually.
• Monitor progress on returning to full productivity; if it does not happen as expected, investigate why. There may be a legitimate workflow issue, training need, or template redesign requirement.
• The leadership team’s approach and expectation setting also go a long way toward productivity improvement. Even a little healthy competition—such as rewarding the person who first uses the EHR for half of his or her clients in a day with free coffee for a week—can be helpful.

Cost and Payback Concerns

Concern: All EHRs cost a lot of money.

• Reality: EHRs require considerable resources in terms of money to purchase or license, costs of hardware upgrades, staff time to implement and learn, and often an initial period of lost productivity.
• Overcoming the barrier: There are alternatives to stand alone packages. EHRs applications are offered by application service providers or as software as a service solutions that offers a lower entry cost. See 3.3 EHR and HIE Vendor Selection and Understanding the Marketplace for more details. Plan thoroughly with respect to workflow and process changes. While you want the fullest support possible from the vendor for implementation, make sure you assume responsibility for leadership, workflow and process improvement, and other aspects of implementation to garner a faster return on investment.

Concern: There is no return on investment for an EHR.

• Reality: Although EHRs were conceived 50 years ago, it has only been since the Meaningful use incentive program in 2011 that there has been a significant uptake in adoption. There is not yet much scientific evidence about EHR return on investment. There is anecdotal evidence that—when used properly—EHRs do improve productivity and quality of care. When they are not implemented and used properly, EHRs can introduce new risks in these same areas.
• Overcoming the barrier: There is increasing evidence that EHRs—properly selected, implemented, and used—are beneficial. They are also being recognized as a cost of doing business for which there may not be a lot of direct monetary return, but other important benefits. For example, the ability for community mental health centers to complete assessments and bill on time improves cash flow. Chasing down paper, clients, schedules, etc., traditionally has led to staff frustration, and potentially, has made client sessions less effective. The ability to access data when needed, remind clients of upcoming visits, manage therapy schedules, and complete documentation at the point of care often means more clients can be seen each day and improves staff satisfaction. These are two examples of EHR’s value in behavioral health.

Selection Concerns

Concern: Success depends mostly on acquiring the best EHR.

• Reality: “Best” is a subjective term, and everyone has a different view of what it means. Furthermore, even with the “best” EHR—that which is most expensive or highly recommended—poor implementation will not produce desired results. A “good” (i.e., lower cost, lesser known, or more basic) EHR, on the other hand, that is very well implemented, can achieve excellent results.
• Overcoming the barrier: Work to achieve success rather than solely focusing on selecting the “best” product. The five “rights” of EHR include: right data, right presentation, right decisions, right work processes, and right outcomes. Right product is not one of the rights! The key to success is engagement of all stakeholders in determining which data is “right” (i.e., of good quality), which templates support the workflow, which clinical decision supports are meaningful, which workflow and process changes optimize use of the EHR, and ensure that the right outcomes (as measured by pre-established goals for improving the quality and cost of care) are being achieved. A good plan that involves many people in the organization and the selection process is key.

Concern: We heard that Facility A had a bad experience with Vendor X, so we should not consider Vendor X.

• Reality: A bad experience may not reflect the quality of the product. Poor planning and inappropriate implementation may also have caused problems.
• Overcoming the barrier: Perform thorough due diligence. If the product is of interest, consider asking Facility A for an informal demonstration of its product. Learn about how that facility implemented it. Require the vendor to demonstrate the capabilities you need. Contact other facilities on the vendor’s reference list and learn about their approaches. Discern the differences and decide whether you can avoid Facility A’s implementation mistakes. It is widely known that poor EHR implementation contributes to poor results more than any other factor.

Concern: We should acquire an EHR product that is certified under the federal meaningful use (MU) incentive program.

• Reality: First, it is important to remember that as of this writing (2014) the Meaningful Use incentives do not extend to most behavioral health care providers. That said, in general, selecting certified products is good advice. At a minimum, the product will meet the standards needed for interoperability and will include other important features and functions. However, there are some important caveats.
• The Minnesota Mandate for Interoperable Electronic Health Records does require that mandated providers (including home health care providers) implement either a Federally Certified EHR or a “qualified EHR”. You can find definitions of these here:
• A certified EHR may have more functions than you need—potentially making it more expensive and difficult to learn.
• A vendor whose product is not currently certified but who claims it will become certified is not the same as a vendor who has a certified product. It also is important to understand at which level in the MU program the vendor’s product is certified. In 2013, there were 1,767 general ambulatory EHRs certified under the MU Stage 1 criteria, while only 112 were certified for MU Stage 2. The criteria for MU Stage 2 are much more stringent from a technical feature/function perspective, and many vendors certified for MU Stage 1 are having a very difficult time meeting them. In addition, and according to the Centers for Medicare & Medicaid Services (CMS), only 30 of the 1,767 products certified for Stage 1 are being used by 80 percent of physicians earning the incentives; the remainder used by only 414 other vendors. That means that 1,323 products either have not been sold at all or are being used by physicians who aren’t earning incentives. A large percentage of these vendors probably will go out of business.

• Overcoming the barrier: If acquiring a certified product is where you want to start, you still need to conduct due diligence. Remember to carefully determine requirements and check out the vendor’s viability. Certified or not, never assume that a stated feature will perform as you desire. We can’t stress buyers beware enough! For example, one clinic reported that its vendor indicated it had security access controls in its product; while it did require each user to have a userID and password, all users had access to all information.

Concern: If we don’t like the product, we can stop using it or acquire a different product.

• Reality: You can stop using a product or acquire a different one, but the first option is not very feasible and the second is not easy, for these reasons:
• Even users who struggle to learn an EHR or find fault with it will not want to revert to paper. There are significant benefits from any EHR, even if the one you chose does not work to your fullest expectations.
• If you are unhappy with the product and think another one could be better, it is essential to consider all aspects of what might have gone wrong in the first product’s selection, implementation, and optimization. These are steps over which your organization has control and have little to do with the product itself or the vendor.

• Overcoming the barrier: Most organizations that have already acquired an EHR suggest the following:
• Do not consider your first foray into EHR as a pilot or your “first” EHR. This can be an expensive and frustrating self-fulfilling prophecy. Remember that there is an initial learning curve inherent to implementing any new system, but consider the EHR a permanent addition to your process.
• Do the very best you can to select the EHR that is right for your organization’s future needs. Conduct full due diligence, take your time and assume responsibility for a comprehensive implementation process. View the EHR as an ongoing program that requires constant reinforcement, optimization, and acquisition of additional modules, services, and enhancements.

Concern: Behavioral health facilities, general hospitals, and medical clinics in a given community should use an EHR from the same vendor.

• Reality: This concern reflects the legitimate hope for interoperability. In a few cases, the hope is fairly close to reality; but in most cases it is not. Even the same vendor can have very different data structures for EHR products aimed at behavioral health, general hospitals, and medical clinics. This results in barriers to interoperability. Check very closely (demand full blown demos with real data!) before your community accepts a vendor’s claims of interoperability.
• Overcoming the barrier: If the hospital(s) and clinic(s) in your community do share a common EHR, consider this product. If they do not share a common EHR, you should look for EHR products that follow technical and semantic interoperability standards (see Section 1 Interoperability for EHR and HIE) that will facilitate communication across these provider settings.

Implementation Concerns

Concern: We’re concerned that our transition to e-health will cause a major disruption in how we do business and that staff will become very dissatisfied with their jobs.

• Reality: This concern is based on horror stories that folks love to tell. There always is some disruption to the agency or clinic associated with e-health. That said, there are many successful implementations where the disruption is short and staff benefits arrive on time.
• Overcoming the barrier: Most important in overcoming concerns of disruption are leadership and planning. Laying a solid foundation is a critical first step when building anything. Everyone must be engaged, starting from the board of directors and administration, through the project manager and IT support, to every end user. The leadership team must believe in the value of e-health in general, assure that a strategic planning process is applied, and be committed to supporting e-health through appropriate resources. Leaders must establish expectations and policy for achieving results, and remain accountable for the investment in e-health.

• People, policy, and process are the most important elements of implementing technology. To succeed make sure that:
• Plans are in place
• Leadership support is strong and visible
• Change management and communication initiatives start early and remain consistent
• Workflow changes are identified and communicated
• Everyone is trained in the new way of working.

The tools in this toolkit focus on helping you with all of the above.