How Palmetto Health Doctors Defied the Health Information Technology (HIT) Productivity Paradox: Part 1

10 September 2013 | Dr. Dennis Schmuland, Chief health strategy officer, U.S. Health and Life Sciences, Microsoft
In this post-EHR implementation age, clinicians are spending more time than ever documenting in electronic health records, logging on and off of exam room workstations, and working late to finish their documentation because, too often, workstation work restricts their eye contact with patients which intrudes on patient-physician relationship.  As a result, they're spending less time with patients, communicating and collaborating with colleagues, and at home with their families because they're staying late to finish documentation.
Palmetto Health, based in Columbia, SC, the largest Cerner ambulatory EHR deployment in the US, covering 60 practices, experienced this post-EHR productivity decline and initially turned to the iPadtm to reclaim the productivity and eye contact they had enjoyed back in the days of paper charts.  Unfortunately, the results didn’t match the expectations. But when they put Microsoft Surface Pro tablets in the hands of mobile physicians, they realized that they no longer needed to log in and out of the workstations, and they were able to regain eye contact with patients and they were able to more than reclaim lost productivity. 
After spending an entire day with Palmetto Health care teams, it became clear to me that the boost in physician productivity they realized above pre-EHR baseline was the result of doing five things right: The right objective, the right form factor, all five data input modes, the right pen, and the right apps.  As a result, these physicians report that they're seeing at least 2-3 more patients per day, spending more time with patients, going home on time, and have even improved their CGCAHPS scores (Clinician and Group Consumer Assessment of Healthcare Providers and Systems). 
Part 1: The HIT Productivity Paradox Curse
When I ask physicians and nurses what's top of mind for them, the answer typically sounds something like this:  "Our revenue and reimbursements are falling or stalling.  As a result, I feel like I'm in a pressure cooker to see more patients in the same or less time, improve the care experience for my patients, and somehow reduce the total cost of care.  Further, I seem to be spending more time with the EHR we just installed, which leaves me with less time for patient care.  No surprise that over one third of physicians are planning to retire or leave their medical practices within the next 10 years, according to a survey conducted by Jackson Healthcare, a healthcare staffing company.
Being more productive is a battle that physicians and nurses fight every day and, despite massive investments in IT, a recent comparative analysis (see Chart below) reviewed in the October 13, 2011 New England Journal of Medicine (“NEJM”) confirms that healthcare industry is actually losing the productivity battle.  Yes, that’s right, productivity is falling despite a record 72% adoption rate of EHRs by US office-based physicians as recently reported by the CDC. The NEJM cited that, in contrast to virtually every other sector in the US economy where productivity has consistently improved year over year, productivity in the health industry hasn't just lagged other sectors, but has actually experienced a 0.6 percent decline in productivity every year for the last 20 years.  This embarrassing correlation between a rapid increase in IT use within the health industry and arrested productivity has become known as the "Health IT Productivity Paradox," and reviewed in the June 14, 2012 NEJM article entitled, Unraveling the IT Productivity Paradox — Lessons for Health Care.

You'd think that by now we'd have more to show in the way of productivity gains for the $30 billion in ARRA EHR incentive payments for health care providers adopting and meaningfully using EHRs.  But, true to the HIT productivity paradox, a recent UC Davis study estimated initial EHR-related productivity losses to range from 25-33% for most clinics.  Several months after EHR implementation, the results were disappointingly mixed.  Internal medicine physicians eked out slight productivity gains above their pre-implementation baseline, but the productivity of pediatricians and family physicians remained below their pre-implement baseline.
Most of the physicians and nurses I talk to tell me that the explanation for this paradox is simple:  They're spending more time documenting in electronic health records, logging on and off of fixed or mobile multi-user workstations, and staying after hours to complete their documentation because they refuse to turn their backs to their patients in order to enter data into the workstation when they're in the room with the patient.  As a result, they're spending less time with patients, less time communicating and collaborating with colleagues, and less time with their families because they're staying late to finish their documentation work.
How are you defying the HIT Productivity Paradox Curse?  Do you have a success story that others might benefit from hearing about? Stay tuned for Part 2 next week with an example from Palmetto Health.
Dr. Dennis Schmuland
Chief health strategy officer, U.S. Health and Life Sciences, Microsoft