“I carry it with me in the office like I would a paper chart, except that I share it with the patient so they can see the work I’m doing,” he says. “Between patients I can either click or type my notes or use voice recognition software, and then I’m off to the next patient.”
Like many physicians, Zaroukian’s professional life is busy verging on frenzied. In addition to seeing patients, he is Chief Medical Information Officer (CMIO) and Professor of Medicine at Michigan State University (MSU), where electronic health records (EHR) have been in use for 10 years.
He also serves as the CMIO for Sparrow Health System, the Lansing region’s largest health system, with four hospitals and dozens of care centers. Sparrow is currently in the process of implementing an integrated inpatient EHR to complement its ambulatory EHR.
Though he is enthusiastic about the technology at his disposal, Zaroukian makes it clear he is not a tech-head.
“I am not interested in technology for its own sake,” he says. “I’m interested in technology only to the extent that it helps me achieve my goals. And my goals are patient care quality, safetyand efficiency, decreasing waste and waiting, and improving the overall care and satisfaction of our patients.”
The Single Biggest Benefit
The MSU Internal Medicine Clinic where Zaroukian sees patients is one of over 40 clinics comprising the MSU HealthTeam faculty group practice. With 18part-time faculty physicians and 36 internal medicine residents , as well as additional clinical and administrative staff, the clinic logs approximately 15,000 office visits per year. The EHR was phased in across the HealthTeam starting in 2001.
Zaroukian has no doubt that “this tool helps me perform better than I could otherwise, and in case after case, I see where it can help prevent inadvertent harm.”
“The single biggest benefit is immediate access to information that matters in the care of patients in the here and now,” he says. “I left medical school with the sober realization that I can’t know everything, and that my only chance of providing the highest quality of care was if I could manage information, not just remember it. As physicians, we need reminders more than we need new information.”
Zaroukian cites other EHRbenefits as well, such as easier collaborative relationships with other physicians.
“We found that the providers in our own group who were hesitant in a paper world to see each other’s patients—because it was difficult to provide effective and efficient care when so much important clinical information was buried in multiple volumes of a paper chart—weremore willingto see them after we implemented EHR because we could quickly find and review the information we needed.”
Now patients who need to be seen can get care more easily, even if their own physician is not in the clinic. “Open access appointments on the same day the patient callsbecame the natural consequence of the EHR and care redesign. We went from ‘How bad is it?’ to ‘Would you like to be seen by one of our doctors today?’ and patients were, of course, very grateful.”
Support staff who use EHR saw benefits almost immediately, says Zaroukian. “In our practice, staff spent 25 to 30 percent or more of their time simply trying to find paper charts so they could access information for patient care,” he says. “Within an hour of our clinic’s implementation, the staff was already saying what a vast improvement it was over the old workflow, and that they would never want to go back to paper.”
This doesn’t mean there aren’t stresses during implementation, he says, but the benefits of EHR are so clear that as long as the team plans for and addressesthe stresses along the way, this major change in how people work can go fairly smoothly for most users.
Three Signs of Readiness
Zaroukian understands that some physicians and practices may feel that implementing EHR is unnecessary or that it will be too hard, too time-consuming, or too expensive. While sympathetic, his message is clear: change is hard but look beyond those challenges to the benefits.
And, he adds, implementing EHR doesn’t have to be the burden that many fear it will be. Having led EHR implementation now in two health systems, Zaroukian’s advice on bringing in EHR is steeped in experience.
“Readiness to implement and use an EHR has three components,” he says
“First, the practice members knows they are personally ready if they work well together as a team and understand the important role that EHR will play in helping them meet their quality and performance goals. Second, leadership is ready if it is committed to being fully engaged and ready to ensure that everyone usesEHR in a meaningful way. And third, there must be a good IT track record, whether it is in-house or through a vendor, to assure that the system will work as intended, be reliably available and that there will be technical support for users when they need it.”
Training is Key
The importance of adequatetraining before the system goes live cannot be overstated, says Zaroukian. “Get as much training as possible. Set aside as much time as possible.”
“Make sure there are ‘super-users’ in the practice—both staff and physician— individuals who have been highly trained and are competent and able to help others develop and enhance their EHR skills.”
Zaroukian advises a dress rehearsal before taking the system live. “Close the office the day before ‘go-live’ and work through example cases of patients you’ll be seeing the next day. This gives you the opportunity to develop some muscle memory, to test everything in the actual practice setting and identify any challenges and get them resolved.”
Including Patients Is Powerful
Some physicians worry about how to balance high-tech and high-touch in the exam room. Zaroukian understands this concern, and says it is critical to include the patient in any activity involving the EHR in the exam room. “Early on I had a patient who said to mevery directlybefore we even started, ‘I need you to pay attention to me, not your computer.’ I said that’s fine, I’ll use the computer only when you think it’s appropriate.”
In the course of their discussion about the patient’s condition, a question came up about a previous test result. Says Zaroukian, “Frankly I couldn’t remember it. I asked if it would be okay to look it up in the EHR, and he said, ‘Of course.’ We looked at it together, and we also looked at a screen about his risk factors for coronary disease, and saw what would happen to his ten-year coronary risk if he changed certain risk factors. And he said, ‘Well, in that case, I’m willing to make some changes.’”
“It was really a perfectexample of how giving patients a choice and including them in the decision of when and how to use the EHR in their presencetransforms it from a perceived intrusion into a powerful therapeutic tool.”