A decade ago, Kaiser Permanente installed the nation’s most comprehensive electronic health record (EHR). The decision was made by the health plan and medical group together. Due to the large size of our organization, implementation was challenging and expensive: The process took two years, and the cost at the time was estimated to be around $4 billion. But there is no question that the price tag and the effort required to train and motivate physicians and staff were worth it. The information the EHR provided, combined with our data analytics and integrated medical care delivery system, has helped us save countless lives.
Across the United States, few physicians have access to a comprehensive EHR that contains all of a patient’s medical information (regardless of how many doctors have provided care) and communicates care gaps and potential medical errors before they happen. As difficult and expensive as it may be to integrate this kind of system across a community, doing so is the best way to maximize quality of care for all patients. For health systems that want to make the investments in time and capital needed, here are some important lessons our experience taught us.
Make the EHR Comprehensive
In the late 1990s, and again in the early 2000s, we tried to design and build our own EHR. Both efforts failed, costing us close to a billion dollars each time. A major issue was the approach we used: To gain physician acceptance, we tried to accommodate the unique preferences of every specialty. For example, rather than having a single diagram of the body that every clinician would use to document the location of a patient’s problem, ophthalmology had its own diagram focused on the eye, while ENT had a different one for the face. As a result, a primary care physician had to review and incorporate two sets of data, sometimes with contradicting information, for a single problem.
After two failures, we made the decision to purchase a single system, EPIC, whose philosophy was not to customize the applications but to maximize the combined functionality of the system for all. In addition, we worked with the company to develop an in-patient suite fully integrated with the outpatient modules.
There will always be customized applications that are more desired by a single specialty and more specific to its practice, but the power of the EHR derives from the totality of the information it provides. Patients benefit the most through the sharing of information across specialties, rather than the depth or ease of documentation within each. Unlike many office-based stand-alone systems that focus on a single clinician’s needs, a comprehensive EHR begins with the totality of the patient, and communicates their information to every physician who provides care.
When the same data is presented to all physicians, they can spot and address any gaps, regardless of whether they work in a primary or specialty department. For example, consider high blood pressure, the most common cause of an ischemic stroke, as a quality measure. According to the CDC, it is controlled across the country only 55% of the time. In contrast, in The Permanente Medical Group (TPMG), success is achieved 90% of the time. The reason is that every physician is aware when a patient has this problem, and they can communicate easily to clinical colleagues when additional therapy is needed.
Get Physicians Onboard
Outside of large multispecialty medical groups that are paid on a capitated basis, one of the biggest challenges with EHR adoption is convincing physicians of its value. Many of the current EHRs were designed predominantly for coding and billing, rather than clinical practice, and they often don’t connect seamlessly with the EHRs in surrounding doctors’ offices. So rather than making patient care easier, they end up slowing clinicians down.
Our experience inside TPMG has been different. While our physicians found entering data into the EHR cumbersome, they could also immediately see the advantages for their patients. Rather than having to wait for a patient’s records to arrive from their colleagues’ offices, they could access the information immediately. Instead of having to search for radiologic studies, they could access the studies as soon as they were complete. And instead of having to mail medical information to other physicians about next steps in the treatment process, they knew it would arrive immediately; as a result, they could be confident their patient would not fall through the cracks.
Like other doctors, our physicians worried about the added time required to learn the new system. So we reduced their schedules by half during the implementation phase. They had to learn how to use the computers most efficiently, with some having to first master basic skills like typing. But physician acceptance was relatively easy to achieve because all physicians saw the advantages right away. Unfortunately, for most doctors in small community offices, the fragmented nature of community practice and the lack of a single medical record make this harder to achieve.
Major operational change is always difficult, so unless physicians trust their leaders, they will resist it. As CEO of TPMG at the time, I knew that in order to earn physician trust, I had to personally lead the process. I drove to each of our 20 medical centers and met with thousands of physicians across Northern California. I explained how the EHR would improve clinical outcomes, how the additional time required for data entry would be offset by not having to wait for information and results, and how the system would help them avoid dangerous medication or medical errors.
Don’t Forget About Other Employees Using the System
We also heard concerns from other employees, especially the medical assistants. The EHR would require more work on their part — they’d need to do much more documentation — and they couldn’t foresee the clinical benefits as clearly.
In addition to providing extensive training on the new system, we launched a program called “I Saved a Life,” aimed to change how medical assistants interact with patients. When patients came to the office, rather than just asking them the reason for their visit and documenting vital signs, the medical assistants were expected to use the EHR to look for gaps in preventive care, and when appropriate for their level of training, address them. This often meant scheduling a mammogram in radiology if the person had not had one in two years, or giving the person a colon cancer identification kit when the computer indicated they needed it. Or, for example, when a woman was overdue for cervical cancer screening, they called OB/GYN and scheduled an appointment. The department threw a celebration when any of these interventions identified a cancer, as a way to recognize the contribution the medical assistant had made. Soon, rather than staff seeing the EHR as a burden, they wanted to use the new system to save a life.
Provide Ongoing Technical Support Throughout
When using a new technology, people want to know that they will be supported and protected should anything go wrong. To do that, we provided immediate, on-site technical support. We knew that it was one thing to use the system during preparatory training classes and another to use it in a live setting. In the initial weeks of going live in a particular department or medical center, physicians who had already implemented the application successfully in another location would act as consulting experts, making themselves available to their physician colleagues. Finally, we invested in additional IT staff to provide consultative support for months following implementation.
Implementation of an EHR needs to be thought of like any capital program: You invest heavily at the front and achieve the return on investment over time. A decade after implementation, the EHR allows our physicians to treat patients in offices, hospitals, and emergency departments more rapidly than in the past. It has helped Kaiser Permanente in Northern California become the only program in the country with a five-star ranking by the National Committee for Quality Assurance for both Medicare and commercial members. The comprehensiveness of the data continues to facilitate our data analytic work, our evolution of best practices, and our efforts to help patients avoid complications from chronic disease.
Practicing the best medical care in the 21st century is not possible without a comprehensive EHR. Advances in health care, including precision medicine, genomics, and artificial intelligence, will require universal access to these powerful computer systems. For many doctors in community practice today, the changes needed will be difficult. Investments will need to be made in hardware, software and training, and connecting the systems of different offices. Workflows will need to be modified and standardized. Hopefully, these lessons will facilitate the transition process for others and provide confidence that, over time, the advantages for patients will make the efforts worthwhile.