You can order a pizza, groceries, school supplies and even make an airline or hotel reservation, just by using any connected device in your home, including smart speakers, your TV and beyond. You can track the progress of your pizza being prepared or your product being shipped down to a few minutes or a few meters. Security is handled painlessly with your choice of authentication method using your fingerprint, your voice pattern, a facial scan or a QR code. Need to modify a reservation or exchange an item? That’s equally easy for the end user.
But healthcare? Welcome to a world still heavily consisting of clipboards and paper forms, with many onerous and manual processes that still rely heavily on printing, scanning and faxing. This creates duplicative data entry, which is not only time-consuming but prone to errors as well. In a recent study, up to 20% of patients surveyed reported errors in their EHR records, with a substantial number of those errors deemed serious.1
Where technology does exist, the systems are cumbersome and siloed, requiring patients and staff to maintain disparate login information for dozens of different URLs and applications, which frequently work on one kind of platform (e.g., browser, operating system or smartphone) but not another. Every user interface is different, and for most users — especially healthcare providers — the technology experience frequently detracts from good patient care.
The COVID-19 pandemic severely strained all businesses, as they were forced to deal with drastically altered service delivery models, disrupted workflows and supply chains, along with mandatory social distancing. Most businesses quickly pivoted to modify processes and adapt technology to minimize contact and wait times and generally improve operations, such as implementing automated texts and just-in-time curbside delivery, direct messages and instant updates on wait times and product availability, and using web tools to provide more extensive and more timely information to their customers. In other words, the crisis forced businesses to streamline operations to gain much-needed efficiencies and improve the user experience. Whole new paradigms emerged in delivering better service, and most businesses have pivoted away from legacy processes that no longer fit the mold.
Healthcare, however, merely did what it has always done in the face of new compliance requirements or workflow changes: It added more layers of processes and forms. Even in cases in which the added processes were digital, it was usually not integrated into a seamless user experience and integrated data flow, and it certainly did not create any efficiencies. New ad hoc processes to quickly incorporate telehealth visits and support a remote, virtual workforce created additional pressure on what were essentially brittle and poorly designed systems and processes in healthcare.
This forced medical practices into a precarious middle ground, caught between virtual and physical worlds of healthcare delivery.
Now that things are returning (somewhat) to pre-pandemic routines, many practices unfortunately seem to be returning to the “old way,” bringing back processes that should have been eliminated long ago or keeping old legacy processes and the new pandemic-prompted processes in parallel, exacerbating the inefficiencies.
The pandemic is merely the latest example of compliance issues increasing the burden on systems and processes in healthcare. MIPS, MACRA, sexual orientation/identity, financial policies, HIPAA disclosures and permissions to treat are just a few additional recent examples where more layers were added instead of finding streamlined ways to comply with new requirements.
Healthcare has always lagged behind other industries in automating processes, despite tremendous spending under the American Recovery and Reinvestment Act (ARRA) and the HITECH Act, not to mention the spending by providers themselves. This spawned hundreds of EHRs.2 Sadly, providers soon discovered these EHRs were just glorified billing systems and electronic medical record repositories, lacking basic automation features they needed to run their clinics more efficiently, such as patient intake, patient payments, messaging, reminders and patient education. This, in turn, spawned hundreds more “add-on” products to fill the gap. This patchwork technology is one of the reasons CMS has mandated increased interoperability and data sharing,3 though with limited positive impact.
The back-office staff has jerry-rigged the use of technologies such as printing, scanning and faxing to replicate their highly manual workflows. In most cases, old processes have not been optimized or killed off to take advantage of truly game-changing technologies — sometimes new technologies were selected precisely because they replicated existing processes. The battle cry seemed to be, “Give us technology that requires the least change.”
Despite all this money and effort and new products, the healthcare technology landscape is a wasteland. This is indeed unfortunate, given that many measures show healthcare to be the most consequential part of the U.S. economy.4
Patient experience
Patients are asked to arrive 30 minutes early for appointments, only to find out (after they arrive) that their provider is running an hour late. Patients are usually still presented with a clipboard containing some paperwork, even if a kiosk, tablet or online forms platform is also involved. And now because of COVID-19, they still have to sit in a half-roped-off waiting room or in their cars.
These inefficiencies are frustrating to all concerned and make it harder to practice social distancing, which increases the risk of infection. This isn’t just a recent COVID-19 issue — there has always been a problem with potentially infected people sitting in waiting rooms.
Patients are barraged with different technology systems and different processes, even within a single practice, with disparate interfaces, logins and security protocols. Most practices have multiple different systems for the patient to deal with, including appointment reminders, patient portals, insurance verification, check-in, medications, X-rays, labs, compliance matters, satisfaction surveys and many others.
And when you think of a patient’s experience going from one practice to another, one can easily see how frustrations mount exponentially.
John Hughes, chief financial officer of Ventura Orthopedic Medical Group, recently reflected on his experiencing getting a new driver’s license after moving to a new state. “Even the DMV now has better technology than healthcare,” Hughes said. “I can sign in on my smartphone and see what the wait times are, schedule an appointment, and I can magically see how I move up in the queue before I even leave my house.”
Staff experience
Patient-facing staff are already buried in a jumbled mix of legacy paperwork and different electronic devices and systems, and then they have to deal with frustrated patients and family members, repeatedly explaining (and apologizing for) the delays and lack of clarity and the sheer difficulty in just getting an appointment.
Now because of COVID-19, the staff must juggle additional manual phone calls to shepherd patients from waiting in their cars to entering the clinic. It’s no wonder staff burnout and turnover are high.
Despite automation, nearly every patient encounter still involves some physical paperwork. It is safe to say that, not only has healthcare not gone paperless — there’s more paper than ever. Massive and expensive multifunction printers, along with a huge proliferation of desktop printers and scanners, are the norm in healthcare; whereas in most businesses the use of these technologies have vastly diminished.
Provider experience
Providers have an ever-increasing burden to document everything, and the automation tools that were supposed to reduce or even eliminate this drudgery has instead forced them to contend with cumbersome and often quirky technologies and systems, requiring them to click through dozens of screens and drop-down lists. Physician burnout and dissatisfaction are at an all-time high, and “technology fatigue” and dissatisfaction with EHRs are at the top of most surveys in the literature.5
Fee-for-service payment models have forced doctors to maintain large waiting rooms and fill them with patients stacked like raw materials in a factory setting. Hoping patients won’t notice this too much, there is virtually a waiting room “arms race” for more creature comforts. The ubiquitous lobby fish tank and worn copies of Highlights magazine have been replaced with coffee bars, aromatherapy units and giant flat panel monitors with hundreds of channels. In fact, grand opening announcements of a new medical office typically feature pictures of the fabulously attractive new waiting room.
Amid COVID-19, the waiting room density must be sharply reduced, leading to the prospect of having to devote even more nonclinical space to waiting rooms in the future.
Solution
So how can we dig out of this mess? How can we get rid of or sharply reduce duplicative paper forms, fax machines, scanners, waiting rooms, check-in front desks and clipboards?
Stop buying more products and systems, especially add-on systems that create more interfaces to your EHR. This is costly and inefficient, as maintaining all the separate systems and interfaces impact the clinic. If you have 12 add-on systems (we typically see twice that amount and more), and each system has an update once a year, then you will be continuously upgrading every month of the year.
Look closely at your workflows and operations and stop looking for products and systems that merely automate what are in essence inferior processes in the first place. Processes should be reengineered before they are automated.6
What if Amazon merely decided to design tech to speed the flow of shopping carts up and down the aisles of megamalls? What if Uber had merely created a massive, centralized call center with thousands of agents and a single, easy-to-remember 1-800 number so you could get a cab anywhere in the country with shorter phone wait times? What if Google just stopped at making a web search engine for all the books in the Library of Congress? Think of all the innovations that occurred because smart people worked together to think beyond merely making existing processes faster and/or digital?
As Jeremy Ealand, chief operations and technology officer, Sierra Pacific Orthopedics, notes, healthcare delivery largely has gone unchanged in the past 100 years, from the days of house calls to the traditional patient visits in a clinic.
“We can no longer continue to grow by increasing patient volumes and relying on existing processes, putting even more stress on providers, staff and patients. We have to find efficiencies in all areas — staffing, real estate, patient flows, etc.,” Ealand said. “We need new ways of thinking to figure out how to incorporate technology beyond just supporting billing and compliance. We have to have a better patient/provider experience.”
Work with technology vendors to demand change. Refuse to accept the infrequent once- or twice-yearly software updates. Don’t continue to pay for bug fixes that should never have been there in the first place. Get much more involved with EHR and other user groups and make them more than just a booster section for their corporate leadership. This isn’t about being adversarial; it’s about collaborating with your technology partners and demanding consolidation of systems, breaking down silos and creating more user-friendly interfaces. Drop vendors who only want to sell you some new product or system; instead, seek out and work with technology partners who want to help you solve operational problems, regardless of whether it helps them sell a product or consulting service.
Many practices and providers seem to hate their current EHR and want to change, and the depth and breadth of this dissatisfaction is borne out in numerous industry surveys.7 What these surveys clearly show is that there is no good EHR, because if there was a good EHR, everyone would be on it. In the end, almost every “top-ranked” EHR is top ranked in some highly selective category. Why change from something that is terrible to something that, at best, is merely less terrible?
The time, expense and impact of selecting and implementing a new EHR is extremely significant. Consider spending that time and money working with your current EHR provider to make it better. An old version might need upgrading, and your team likely could benefit from more training and optimization. It will require work and spending, but it will likely be a fraction of what would be involved in a rip-and-replace action. Unless your EHR is at risk of being sunsetted or decertified, or your EHR vendor has lost a significant part of its core brain trust of critical engineering and/or customer-facing talent (which frequently happens after an acquisition), there is little rational justification for changing EHRs.
Stop designing and building new medical offices with elaborate and wasteful waiting rooms. Instead, spend the time and money on creating ways to change your processes and utilize technology to sharply reduce the waiting process. Then partner with the right design team — one focused on making the physical space support better processes, rather than making your waiting room look like the Ritz.
Bruce Cohen, MD, practicing surgeon and chief executive officer of OrthoCarolina, echoes the need to avoid adding more real estate for clinics.
“I don’t want more and bigger and fancier waiting rooms. I may not even need a front desk,” Cohen said. “We need to figure out how to design new processes and new technologies to reduce or even eliminate those constructs. We need to use our resources more efficiently, whether it’s people or space. It will require a completely different way of thinking, because what has worked in the past won’t work in the future.”
One of those people working to make those types of design changes is David Baker, director of Health Facility Advisors. “We are doing everything possible on the facility design side to work with practices to maximize useful clinic space and support more efficient workflows that take advantage of newer technologies,” Baker said.
“Much less space is needed for large waiting areas, check in/check out desks, space for printers, copiers and fax machines, plus associated supply storage,” Baker added. “Clinics can be more open and more productive, resulting in a better experience for patients, providers and staff, with lower overhead and better profitability.”
It is well past time for physician practices to stop complaining about poor technology and operations, and instead do something about them. Look to where you can optimize workflows and streamline operations, and partner with the right type of healthcare technology firms and space planners to improve the process.
By working together, we can bring real and lasting change — including lower costs and a better experience — to patients, providers and staff.
Notes:
- Bell SK, Delbanco T, Elmore JG, et al. “Frequency and Types of Patient-Reported Errors in Electronic Health Record Ambulatory Care Notes.” JAMA Network Open. 2020;3(6):e205867. doi:10.1001/jamanetworkopen.2020.5867
- ONC. “Certified Health IT Product List.” Available from: bit.ly/2Z2FAgA.
- Gans DN, Jenkins M. “21st Century Cures Act: After 10 years of broken promises, is EHR interoperability finally at hand?” MGMA Connection, September 2019. Available from: mgma.com/21stcenturycures.
- Nunn R, Parsons J, Shambaugh J. “A dozen facts about the economics of the US healthcare system.” Brookings Institute. March 10, 2020. Available from: brook.gs/3zGC36A.
- O’Reilly KB. “New research links hard-to-use EHRs and physician burnout.” AMA. Nov. 14, 2019. Available from: bit.ly/3DH8h48.
- Enginess. “Why You Should Improve Business Processes Before Automating Them.” Oct. 10, 2018. Available from: bit.ly/3BBqRIZ.
- Sukel K. “Switching EHRs.” Medical Economics. Jan. 5, 2020. Available from: bit.ly/2WHzAe0.
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