Managers, the Link Between EHRs & Effectiveness

IT is a just a tool. It takes people to make IT effective. In complex organizations such as hospitals and healthcare systems, good or bad management may make or break adoption of EHRs. That was the hypothesis that researchers tested in a recent study.

Julia Adler-Milstein, PhD, a health policy and management researcher at the University of Michigan in Ann Arbor and the study’s lead author, discussed their findings with Cardiovascular Business.

How did you get involved in this research area?

JA-M: I became interested in health IT and the potential impact it could have on the healthcare system over a decade ago when I was working at the Center for IT Leadership at Partners HealthCare in Boston. It was a small think tank group that was trying to quantify the value that could be realized from nationwide adoption of healthcare records and CPOE [computerized physician order entry].

It was at a point in time when these systems were not widely adopted. It was a formative experience because I started to recognize the power of these systems to transform and improve care but also how hard it was going to be to actually do that. The technologies in and of themselves weren’t going to cure diseases or improve care. They had an important role to play but a lot of other things had to fall into place.

What made you think about looking at management?

It came from the growing number of studies with a consistent relationship between EHR adoption and improvement in performance. It sets up the natural question of under what conditions would we expect EHRs to improve performance.

EHR adoption is an incredibly complex change management undertaking. There is the technology side of it but that is only a part. You need to be skilled at helping people change their behaviors, their workflows and everything else. That would take good management.

It was a combination of talking with a lot of people on the front lines of EHR implementations and evidence from other industries that had shown strong relationships between good management and effective IT. If this matters in other industries, then it is likely to matter in healthcare.

It often is said that healthcare differs from other business models. Would you agree?

There certainly are differences. When I think around this domain of effective use of IT, it is harder for me to argue that the things that make information and information technology valuable in other industries will not be true in healthcare.

Some of the market pressures are different in healthcare. But when we talk about infrastructure and tools, I don’t think that argument holds as much water. Having good data is valuable no matter what industry you are in.

Does hospital management differ from management in other industries?

There is a common set of good management practices that are true of all settings but there are particular challenges in healthcare settings. Your frontline staff are extremely skilled experts who have received a lot of training. You don’t usually see that in many other industries.

There also may be schisms between the two sides if they don’t interact that much.

That is one of the theories in our paper. In those well-managed organizations, those administrators have figured out how to build a strong bridge to frontline clinicians. In organizations where that is not happening, probably EHR adoption is perceived as much more of top-down. ‘We are being forced to use the system and we don’t want to.’  It shouldn’t be surprising that there aren’t gains from that scenario.

Did the interviewers ask specifically how the EHRs were being used?

When they collected the data they weren’t even thinking about connecting it to the EHR piece. One of the things that is fascinating to go back and do now is to take well-managed and poorly managed organizations and ask exactly that question. Try to figure out if we can more precisely point to what is happening differently in organizations that are well managed vs. not, specifically with respect to EHR use.

In the paper you talk about four different areas: operations, performance, target setting and talent management. Are all of these equally important in this context or is there one that stands out?

I think they are all important. Some of the process pieces may lend themselves a little bit more to EHRs because you could imagine that one of the things that EHRs are good at is instituting some type of process control. That might seem a little more relevant than talent management.

Even there, [talent management] has an important role to play in terms of being able to select for people who have skill sets around being able to work well with computers and data. You can imagine that in this day and age, part of being a good doctor is someone who can look at data and performance measures and understand them. Having the ability to perform well in that domain could have an impact on the extent that you could get value from an EHR.

Is it important to have a physician champion?

Absolutely. In well-managed organizations, they probably not only identified a champion but figured out how to leverage that champion in the most effective way: Trying to get people to not only use it but learn about all the different functionalities.

What do better managed organizations do differently with their EHRs compared with poorly managed ones?

We had a couple of potential hypotheses. One had to do with engaging frontline clinicians and helping them make the change and use the EHR well. Another could be that well-managed organizations are able to do more with advanced functionality in EHRs; not just that they are capturing more basic data, but they have more clinical decision support turned on. Maybe in better managed organizations they have learned how to use their system in more advanced ways.

Really what electronic health records are is an incredible repository of data that can for the first time help you understand how well your organization performs in a variety of areas. Maybe in better managed organizations they actually look at the data and try to figure out what it tells them and use it to boost performance improvement.

Is cardiology representative of physicians as a whole?

It is an area where there are cultural norms around performance and measuring performance as well as reasonable measures to do so. If we are going to see the biggest benefit from EHRs with care standardization, it would probably be in cardiology. It was a great setting to choose [for the study] and it may be why we found something.

What have you done since this?

I am on a hunt for what explains when an EHR improves performance and when it doesn’t. This paper is emblematic of one particular factor that I am interested in, which is the link to quality and management. I am interested in trying to capture the context around the organization and does that shape the magnitude of impact the EHR can have.

We are making such a huge investment in these systems and we are just beginning to understand how to make them pay off. These tools have so much potential impact but it is not just flipping a switch. It will take a lot of work and investment and people and processes and things far beyond the technology.

Better Management Quality, Better Outcomes

Julia Adler-Milstein, PhD, of the University of Michigan in Ann Arbor, and colleagues designed a retrospective study to assess the relationship between hospital management and EHR adoption and outcome s (Am J Manag Care 2014;20:SP511-SP519). The study used several data sources, including the World Management Survey, to determine management quality. The final sample totaled 191 acute care hospitals in the U.S.

They focused on acute MI-related outcomes because most of the managers interviewed as part of the survey came from cardiology departments. For outcomes, they looked at risk-adjusted 30-day mortality, average length of stay and average payment.

The researchers found no association between EHR adoption and improved performance, but adding management quality to the equation affected outcomes. Hospitals with EHRs and higher scoring management were more efficient, with shorter length of stay and lower costs, compared with hospitals with no EHR. Thirty-day mortality dropped as quality increased at both hospitals with or without EHRs.