Don’t settle for traditional outcomes

Over the past 30 years, we’ve seen upsurges in requirements for organizations to measure quality and continuous improvement. While these methods for sustaining continuous improvement are maturing, unfortunately many organizations remain satisfied with traditional outcomes. They settle and stop moving forward.

Some lean on the proven traditional approaches to continuous improvement because they have to.  Their EHRs will not allow ad hoc accessibility to data, or development of locally interesting yet unique priorities and interests.

Continuous improvement should be just that – continuous and focused on locally crucial improvement needs. When it is, everybody wins – organization, clinicians and patients. When it is neither continuous nor capable of local improvement, everyone loses (even though it may feel like winning). Leadership often encourages and celebrates better outcomes, when they should be aiming even higher.

The quality of your outcomes depends on what type of EHR you have

To continuously improve, it’s important to have an electronic health record (EHR) that adapts to your specific needs. Continuous improvement should not be about the organization and clinicians adapting to the EHR, but about the EHR being continuously adaptable to local needs.

Following a meta-analysis approach, I studied the comparative impact of four continuous improvement approaches.  I gathered data from independent studies of 16 hospitals representing three different types of EHRs, on the condition we would not name the organization or data source.

The four approaches to continuous improvement included:

1) Traditional (no EHR) – include methods such as Lean and 6-Sigma.

2) Compliance-based EHR – Requires users to adopt and comply with vendor-specified standards and not allowing locally-developed improvement to be programmed into the EHR.

3) Clinical-based EHR – Enables some local adaptation, though limited options for users to program EHR for local needs.

4) Locally programmable EHR – Enables organizations and key users to fully adapt the EHR, whether to meet local processes, role definitions, governmental or community imperatives, or even unique patient population needs.

The first group of four hospitals represented the non-EHR approach, reflecting the traditional study-implement-monitor-restudy-repeat approaches.  The 32-month results were encouraging:

But contrast these results with outcomes from a group of organizations using EHRs, and the degree of improvement is quickly less inspiring.  Even though the EHR in this case represents a compliance-focused, non-programmable framework, the improvements are more impressive:


Note that impact was continuously better until the hospitals reached a new vendor-specified standard. Then improvement ceases.

Next I analyzed 32-month data from four hospitals using a different EHR, this one being more clinical-based and offering some limited programmability:


We see a longer train of improvement for greater end results.  Even limited programmability made better progress possible.

What these hospitals are missing

Unfortunately, in each of the previous examples the local leadership was oblivious to the second-rate outcomes they were achieving.  Next I looked at what happens when hospitals work with a fully adaptable, locally programmable EHR – I won’t name the other vendors, but these next graphs all represent Allscripts SunriseTM clients:

Every hospital on the locally programmable EHR achieved continuously better outcomes most quickly.

Each line represents a hospital that is able to adapt the EHR themselves to whatever else works best for the organization and community.  The orange and blue lines show more rapid improvements because they represent hospitals that used analytics, too.

Essentially an EHR is to an organization what personal technology is to any person – the more I can make it fit my needs, the more fruitfully I will use it and benefit from it.

With trust and the right EHR, better outcomes are possible

Whether this exact same pattern applies to all organizations, or to all clinically-related or financially-related outcomes has yet to be studied.

Things look good in the first charts, where adoption and compliance are the only measures of success. But look how much better an organization can do when they trust their clinicians and IT people to adapt the application to meet local patient and clinician needs.

I realize the easiest thing to do is use compliance-based options and demands.  Forced adaptation to what the EHR delivers as best care is easy to implement and easy to enforce from the top down.  But organizations that are truly committed to continuous improvements need to take the leap of faith, and use an EHR that enables far better outcomes.

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About the author

Steven H. Shaha, Ph.D., DBA, is a Professor at the Center for Policy & Public Administration, and the Principal Outcomes Consultant for Allscripts. Dr. Shaha received his first doctorate in Research Methods and Applied Statistics from UCLA and has taught and lectured at universities including Harvard, University of Utah, UCLA, Princeton, Cambridge and others. An internationally recognized thought leader, lecturer, consultant and outcomes researcher, Dr. Shaha has provided advisory and consulting work to healthcare organizations including the National Institutes for Health (NIH), and to over 50 non-healthcare corporations including RAND Corp, AT&T, Coca-Cola, Disney, IBM, Johnson & Johnson, Kodak, and Time Warner. Dr. Shaha has presented over 200 professional papers, has over 100 peer-reviewed publications in print, over 35 technical notes and two books. He served on the 15-member team that authored and piloted the Malcolm Baldrige National Quality Award for Health Care, and he contributed to the Baldrige for Education.


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