Example 2: Conflicting Priorities: Regulatory Compliance vs. Clinical Workflow

Issues Encountered

A large community hospital recently implemented a comprehensive EHR system. The hospital's nurses are some of the most vocal critics of the new system. In addition to generally slow response times, the nurses felt that the EHR's admission assessment form was too cumbersome and as a result took too long to fill out completely. The poor design of this form has resulted in many incomplete patient records.

Finding a Solution

Hospital administrators were reluctant to change the admission assessment form because in their view all of the items in the form were necessary in order to document the hospital's compliance with regulatory rules. After pressure from the clinical staff mounted, hospital administration made some efforts to streamline the electronic admission assessment form. However, the nurses still find the admission assessment form to be too long and too difficult to fill out.

The hospital's continuing problems with their EHR are a symptom of conflicting priorities among key stakeholders. In this example, the hospital administrators' priority appears to be the ability to document regulatory compliance, while ease of use is most important to the clinicians. Under the current arrangement, the needs of neither administrators nor clinicians are being met: the administrators are not getting the documentation they need because the clinicians are not filling out the form completely, and the clinicians are having difficulties using the EHR. However, the priorities of administrators and clinicians are not necessarily mutually exclusive. Trade-offs and compromise will be necessary; successful EHR implementations must incorporate and balance the preferences of all the relevant stakeholders.

Lesson Learned: 
  • To enhance agreement about goals, involve all relevant stakeholders in the design, implementation, and governance of the EHR.
  • Cooperation and compromise are necessary for successful EHR implementation and use.
  • Some conflicts over priorities cannot be readily resolved. In these cases, management needs to inform all stakeholders why it favors one priority over another and actively solicit stakeholder support of the preferred course of action.

This material was derived from responses to a membership survey about unintended consequences that the American Health Informatics Management Association (AHIMA) conducted in 2009. For further information, contact Spencer Jones at the RAND Corporation at sjones1@rand.org.

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