What an EHR troubleshooter knows
March 31, 2020
By Ann Crow
When you’re tasked with managing a hospital’s EHR, you have an insider view into how much is impacted by these systems. One misaligned workflow can put patient care at risk or leave millions of dollars on the table. You also learn that hospitals live with certain deficiencies in their EHRs that could easily be remedied if they had the IT capacity and knowledge. But more commonly, internal teams have too many competing priorities--and after a while, the organization becomes immune to issues perceived as “low level.”
In the interest of illustrating how these seemingly minor issues can turn into big ones downstream, here are some of my most candid observations taken from years of managing outsourced application support teams.
Manual workarounds are more costly than they appear. With so many trouble tickets to address, an internal skeleton crew tends to prioritize those without an existing workaround in place. In my experience, many of these workarounds exact a heavy toll on the hospital the longer they remain.
I once worked with a hospital whose labor and delivery department had issues with scanning barcodes into their EHR for many commonly administered meds. It became standard operating procedure for nurses to manually enter the order, call the pharmacy to alert of the order, who then sent a runner with the meds. Obviously, this delayed administration of medications to the patient. It also disabled the use of automatic dispensing units and the automatic posting of the charges. This resulted in the omission of these meds from countless claims.
Given these clinical and financial impacts, it’s clear the root issue—problematic barcoding—wasn’t such a low level matter after all.
One faulty routing rule can cost millions. And there’s probably more than one faulty rule in a complex claims criteria. Let’s look at a common example: a rule that flags whether or not Medicaid, Medicare or a commercial insurer will pay for a certain test or procedure. Orders that meet the payer’s criteria drop charges to claims; those that don’t drop to an error queue.
However, as we all know, patient insurance coverage regularly changes in this country. These changes can occur at the next annual enrollment period, after a job switch, or because of other events. What doesn’t change, at least not automatically: the original pay/don’t pay routing rules in the EHR that were based on the patient’s previous coverage. At this point, the system deciphers a conflict between an order and a routing rule—and drops the order into an error queue.
This is no exaggeration: my teams have discovered and cleared queues with over $1.2 million in charges waiting to be processed. Sometimes there’s a system issue that prevents faster discovery of these errors. But an even more common reason is no IT or business unit was assigned ownership of monitoring certain queues. Bridging these costly gaps between process and technology begins with clear, open communication. Another requirement: solid testing when changes are made; whether to a system, to a business process, or with the introduction of a new or revised regulatory requirement.
With every EHR upgrade, something gets broken. Let’s take a closer look at testing in the wake of EHR changes and upgrades. The reality is most hospitals and provider organizations customize their systems according to their unique patient mix, service lines and clinician workflow preferences. They also apply custom interfaces with other systems, such as those used in the pharmacy and lab.
For a while, these custom features work as intended—until the next vendor upgrade. Suddenly, a custom alert that nurses relied on has stopped alerting, or custom orders aren’t being processed by the lab information system. The longer it takes to discover and fix the root causes, the more frustrated system users will become.
Vendors do test their upgrades, but they’re testing their standard features. It’s simply not possible for a vendor to test the impact of an upgrade on all the countless customized features in thousands of hospitals’ EHRs. The solution resides in frequent, thorough testing on the user end. However, in my experience this is another area where hospitals strain to find the time and resources, including mastering use of automated tools that perform enterprise-scale testing.
Certification does not mean experience. I recognize that training and certification on an EHR are not easy feats. Nothing, however, can replace the experience gained from working with EHRs in multiple healthcare environments. That’s why an analyst who has supported an EHR for years at one hospital may know the system build and history very well, yet not have the knowledge required to introduce new functionality requested by users.
One example that comes to mind is a hospital that manually verified seasonal vaccine history for patients by reviewing previous visits. This process wasn’t just time-consuming; it had a high probability of error. My teams were able to replace it with a vaccination history panel accessible with a simple mouse click, based on knowledge gleaned from other projects.
At another hospital, dressing changes for catheters were sometimes missed, which is obviously out of compliance with evidence-based guidelines around preventing sepsis and other complications. Nurses had long voiced their dissatisfaction that the EHR could not provide a reminder for wound care. When my own teams discovered this issue, we created a status board for wound care patients, and incorporated a reminder for dressing changes.
The overarching point: these are the kinds of tweaks users will commonly ask for and will improve safety and quality. But they aren’t part of the standard EHR certification and training curriculum.
Ultimately, the more usable applications are—especially EHRs—the less stress users experience. This is certainly reflected in studies that have identified a direct link between EHR usability and burnout, which is yet another compelling reason for hospitals to commit to rigorous application management, either internally or externally. Again, hospitals don’t have to live with a problematic EHR. And after discovering the experience of an EHR that works as intended, they’ll never go back to the old, frustrating way again.
About the author: Ann Crow is a senior client support executive with IT solutions consultancy CTG. Ann specializes in large-scale, enterprise application support that enable business continuity for health systems during mergers & acquisitions, the shift to value-based care, technology deployments and other major initiatives.