Cultural context and the implementation of a new EHR: Lessons for the VA from Denmark

July 3rd, 2019 / By Travis Bias, DO, MPH, FAAFP

A recent Politico piece on the implementation of Epic in Denmark highlighted some key areas where the American-grown electronic health record (EHR) was simply “lost in translation” in the Scandinavian country. The C-section was confused for the C-suite. The right leg became the “correct” leg.

Were it not an EHR platform with such history, built over the past four decades, the resultant confusion likely would have been worse. Regrettably, the Danish breast surgeon quoted in the Politico article, Dr. Henrik Flyger, said the experience had “exported burnout” to Denmark.

U.S. EHRs are built to efficiently bill private insurance companies, yet Denmark’s system is largely publicly financed (84.2 percent of health expenditures versus 49 percent in the United States). A reliance on social solidarity underpins the delivery of health care throughout Denmark, quite different from the American approach to healthcare access. According to the article, most U.S. EHRs are so hard-coded in U.S. medical culture that they can’t be disentangled.

Cultural context ought to be a central consideration before implementing any initiative into a new “foreign” environment.

When I taught for the U.S. Peace Corps a few years ago, my first six weeks were spent in orientation. This time included basic language training and the inculcation of critical customs. What is the expected level of eye contact? How do you greet a colleague? Longitudinal reinforcements of this training continued throughout my time of service. Learning these customs, plus the value of an in-person meeting over tea, helped me integrate a bit more seamlessly into a new institution, in a different health system, as an expatriate in Uganda.

Similar preparation and appreciation of local context is necessary prior to implementing new technologies in healthcare settings. What would this look like in a hospital or clinic? It could involve advance interviews with nurses, physical therapy assistants, environmental services, physicians and administrators to understand their pain points. Weeks of observation on-site may allow the implementer or vendor to better understand the recipient facility. These efforts could open up relationships and mutual understanding, while breaking down barriers to necessary teamwork. Instead of viewing the Epic representative as a combatant, the Emergency Department nurse may come to see them as more of a supportive partner in patient care.

The field of usability, sometimes known as user experience or “UX,” calls this contextual inquiry. The methodical approach involves semi-structured interviews and observations while the users work in the environment in which the new system will be employed. This technique focuses on the user’s purpose and their workplace, while partnering with them to understand the critical pieces of their daily work.

The technical goals of expanding technological capacity within health care are typically set with good intentions: improve health outcomes, strengthen efficiency, expand meaningful data collection and make health records systems interoperable. These will, in theory, lower costs and positively impact the patient experience. But the introduction of new tools or platforms commonly misses the mark with health workers. Whether it is a failure to understand the current state, adequately train users, formally communicate the rollout plan or support the early days of implementation, clinicians are commonly left wanting much more.

The Department of Veterans Affairs (VA) has plans to rollout Cerner’s Millennium EHR across their system over the next decade to catch up and, ideally, be interoperable with the new Cerner system currently being deployed throughout the Department of Defense. Each of these organizations, despite both being federal agencies serving our military, have their own cultures according to Representative Jim Banks of the House Veterans’ Affairs Subcommittee on Technology Modernization. These entities, making up the largest health system in the United States would be wise to ensure they remain focused on the human impact of this new platform. This will ensure their cultures, values and priorities are respected and effective adoption is widespread, while avoiding struggles similar to Denmark.

Any technological implementation requires human interpretation, translation and an appreciation of local context. That translating between languages, systems and norms can present challenges to patient care. The costs of missing the mark on such a rollout can be great: turnover, burnout, missed diagnoses and exposure to liability. Holdouts married to the status quo, or resistant to new technology in health care, may feel justified after stories such as Denmark’s. But we must keep our sights set on the goals of making patient care easier on clinicians, bolstering collaboration, decreasing duplicative services and helping patients navigate a complex system. We simply need to do better at taking the human component into account when these platforms are built and before they are implemented.

Travis Bias, DO, MPH, FAAFP, is a Family Medicine physician and Clinical Transformation Consultant within the Performance Matrix team at 3M Health Information Systems.