Improving an EHR-based Cancer Screen Reporting Process

“Let’s Try This!”

Quality problems are endemic in all health care organizations. They are an inevitable consequence of process complexity and the need to mix-and-match processes to meet individual patient needs.

Personnel working in such organizations have been trying to eradicate quality problems forever, yet they persist. In part, this is because their preferred quality improvement strategy is, “Let’s Try This!”

Not getting drugs to the bedside on time? “Let’s Try This!”

Too many patients missing their scheduled appointments for CT scans? “Let’s Try This!”

“Let’s Try This!” often fails because it doesn’t address the root cause of the quality problem in question. Root cause problems can be subtle and easy to overlook, even by people who work in the process every day. Nurses on the floors of hospitals for example, have no idea what goes on in the Pharmacy department downstairs, and vice versa.

Remarkably, the premise underlying several recently published studies of quality in hospital settings has been “Let’s Try EHRs!” The results of these studies have been mixed, which should surprise no one.

An EHR that automates an error-prone process will, at best, produce errors at a faster rate. At worst, efforts to incorporate EHRs introduce more errors because they haven't properly configured the EHR to accomodate existing workflows.

A recent study by Hardeep Singh and colleagues at the Michael DeBakey VA Medical Center illustrates this point rather well.

The FOBT Reporting Process
Singh’s group had determined in an earlier study that an EHR-generated alert system designed to notify physicians about positive Fecal Occult Blood Test (FOBT) results failed to generate any sort of caregiver response 40% of the time. Positive FOBT results may be caused by colon cancer, so they require some kind of response.

To determine the root cause of these communication errors, the scientists interviewed physicians, laboratory and IT personnel, and audited communication flows when positive FOBT tests were generated.

They found that since many patients who are given FOBT cards never return them to the lab for processing, laboratory personnel were instructed to place an order for the FOBT test only after a card was received in the lab. The EHR was configured to accept orders from laboratory personnel.

But lab personnel had no way to link their orders to appropriate caregivers, unless the patient had written the provider’s name on the card. Thus, although the EHR generated alerts as it was supposed to, the alerts never reached the caregiver. Poor communication between caregivers and lab personnel meant the latter were unaware that caregivers were not getting the alert.

After identifying the root cause of the quality problem, the scientists worked with appropriate personnel to reconfigure the EHR and redesign the FOBT ordering process so that the responsible caregiver could be notified.

As soon as the process changes were made, positive FOBT alerts were responded to in some way by caregivers 95% of the time. These gains were maintained 4 months later.

The scientists concluded that EHRs have great potential to improve fragmented and discontinuous care processes that characterize care in hospitals and outpatient settings. But their potential can only be realized if staff understands that electronic communication by itself doesn’t improve care, and it may well make care worse if the system isn’t properly designed to accommodate existing work flows.

They added that “robust quality assurance and oversight systems are needed” to assure that maximal benefits from EHR-generated alert systems can be maintained.

This parable of EHRs and quality speaks for itself, with one important caveat. Hospitals have thousands of error-prone processes, so it is cost-prohibitive to rely on teams of scientists to fix them all. Ultimately, the responsibility for improving the quality of care in hospitals—whether they have EHRs or not—falls to the people who work there: from top execs to the front line.

Glenn Laffel MD, PhD
Sr. Vice President, Clinical Affairs, Practice Fusion