Secret Shoppers: EHR Style

Craig Joseph, MD
By: Craig Joseph, MD
Date: August 02, 2019

I recently read an article in the New York Times titled “Undercover in a Hospital Bed.” It describes how hospitals and medical centers are contracting with “secret shopper” consultants. Being a secret shopper at a fast-food restaurant or a retail clothing store is fairly straightforward: walk in, pretend you’re a customer, observe how you’re treated and if employees are complying with company standards, make a purchase, and walk out. When it comes to being a secret shopper in a hospital or emergency department (ED), the stakes are a bit higher.

When a hospital secret shopper (perhaps “secret patient” is a more appropriate term) shows up in the ED with vague complaints, it’s difficult to predict what’s going to happen. Maybe blood is drawn for some lab tests. It’s possible that an IV will be placed to give some fluids. A chest x-ray might be in order. But what happens when the physician wants to order a CT scan of the head which comes with a significant amount of radiation? What if the doctor decides that a gram of IV antibiotics will do the trick? That’s when the secret shopping experience becomes . . . tense. In all likelihood, this is when the patient decides she’s had enough and leaves, ready to report out her findings.

What can these consultants discover? Here are some findings discussed in the article: “The secret shopper . . . observed that caregivers were sometimes brusque and even dismissive of patients. They didn’t always interact well with each other, either. More than once, the secret shopper overheard emergency room workers bad-mouthing employees from other areas of the hospital.” What’s this? Employees from one part of a hospital talking smack about employees from another part of the hospital? Say it ain’t so! (It is so, and I wrote about this problem in a post because this attitude is omnipresent).

Secret Shoppers in EHRFaced with secret shopper findings, hospital and medical center leadership can, and hopefully will, react and make concrete changes: soft-skill training for staff, more emphasis on teamwork, and classes to help doctors and nurses realize how their language can affect patient trust and compliance. As I focus on healthcare information technology (HIT), I wondered if these sorts of lessons would translate to those of us who support electronic health records (EHRs) and other tech that clinicians use every day.

How would a hospital’s CIO/CMIO/CHIO implement a secret shopper program with respect to HIT? I think it best to consider the locations where technology work is done: in the classroom, in the clinic exam room, in the hospital room or nurses’ station, and where helpdesk technicians work.

One can imagine sending a secret shopper who knows what new physician training is supposed to entail to a class to see if the trainer is checking all the boxes. Are the necessary workflows being explained? Are specialists taught how to use the parts of the EHR that are unique to them? Are trainers using clinically-relevant examples to help make training seem real world and germane? Lastly, does the trainer seem to know what the important hospital or clinic goals and metrics are, and does he/she infuse those into the training? In other words, does the trainer make it obvious how achieving patient safety and quality goals are directly connected to how the EHR is used by clinicians?

A well-trained and prepped secret patient can walk into a clinic and quickly assess how staff are using the technology at hand. Is paper being used unnecessarily, and if so, how is personal health information (PHI) being safely disposed of? Is the patient being asked questions that have already been addressed by the nurse who roomed him? Does the doctor make eye contact with the patient and share the EHR screen when appropriate? Even better, is the layout of the exam room consistent with best practices so that patients don’t feel the doctor is ignoring them? (Want to answer that layout question of your own exam rooms? Read this and this.)

The EHR is used all over the hospital, and a secret patient can help ensure it’s being properly utilized. Remember that these folks are trained, so they will notice if a nurse is given a telephone order but the physician doesn’t stay on the line in case there are order-specific questions or clinical decision support tools that need to be addressed. Are doctors and nurses logging out of the EHR when they leave the workstation so that PHI isn’t exposed? If there are workstations in the patient rooms, are clinicians leveraging them to explain lab result trends and enter orders?

Patients don’t generally call the helpdesk (unless they’re having issues with the patient portal). That shouldn’t stop a secret shopper from acting like a clerk or doctor and calling the helpdesk with a technical question. Are the callers treated well? Did the helpdesk technician attempt to resolve the issue with the first call, or was it just easier to “take a ticket” and pawn off the problem on the next person? Did the person on the receiving end of the phone call practice active listening, or was the tech more like the Nick Burns character on SNL?

Have you implemented a secret shopper for your hospital’s IT shop? If so, tell me how it went.

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