Strategic EMR Adoption in Dallas: 5 Lessons Learned
A hundred years ago, the founding principle of Children’s Medical Center Dallas (CMCD), Texas, was the radical notion that children required specialized health care. Today, in a metropolitan area that is expected to experience a pediatric patient growth rate of more than double the national average, coordinating the various mechanisms that deliver it is a high-wire act.
Information technology figures prominently in meeting the strategic objectives of the 559-bed academic medical center spread across two campuses with 10 ambulatory care sites, says Christopher J. Durovich, FACHE, president and CEO, in a talk delivered on March 19, in Chicago, at the 2012 Congress of the American College of Healthcare Executives.
Emphasizing that strategic objectives must drive IT objectives (see figure), Durovich shared electronic medical record (EMR) lessons learned, and what lies ahead for the HIMSS Level 7 hospital, which delivers an estimated $1.7 billion of economic impact to the Dallas-Ft. Worth metro area.
Figure. CMCD’s strategic objectives drive IT strategies. Lesson No 1: Don’t cheat the decision process. CMCD began its EMR adoption process more than a year before it started to consider vendor options. It developed a series of white papers, clinical as well as business enterprise case statements, which Durovich described as hypotheses that were vetted across the organization. The information technology leadership team comprised people from top to bottom and left to right, Durovich says, with managers, clinicians, employees, and patient families included in every decision made at CMCD. “When a kid gets sick, everybody’s at the hospital. Moms, Dads, siblings, aunts, uncles, grandparents, so you do take care of the entire family,” he explains. Far from being an IT-owned project, EMR adoption had multiple levels of oversight, and multiple levels of checks and balances. Two independent multidisciplinary teams with a common set of questions visited four to five different sites, from which the salient issues were synthesized. Only then was a request for proposal issued. Two of the vendors were invited to the campus to present their proposal, including an hour-long CEO-to-CEO meeting, during which the two learned how the other’s organization operated. Durovich reports that CMCD began its EMR journey in 2007, has concluded attesting to stage 1, and will submit paperwork to undertake stage 2 attestation later this year. But the deliberative process provided greater stability, more engaged participants, and far less doubling back than other organizations committed to such an undertaking might encounter, Durovich said. Lesson No 2: If you don’t have IT expertise on your board, recruit it. Back in 2007, CMCD leadership knew it did not have IT expertise on the board, but it was aware that the city was home to almost 20 Fortune 500 organizations. What CMCD did have was an annually renewing position, an “associate” board member, enabling individuals to have a trial run on the board by sitting on a committee for a year. “We had people who wanted to do this and people we wanted in that context, so that we could add them to our technology database,” Durovich reports. CMCD was able to recruit a Fortune 500 CIO and the president of a technology services company, as well as bring high reliability organizational leadership onto the quality and finance committees. Durovich recommends quarterly updates for the board and conversations with individual board members to keep the process moving. Lesson No 3: As much pain as it entails, do not customize the EMR. Durovich’s guiding principle was that CMCD was not going to customize the EMR and, in the end, picked a vendor that would not let them customize. As a result, the organization had to go through and vet its own processes and procedures so that it could match processes to the software. “Having gone through this several times, that was the key thing I would always do, and I would do it again, as much consternation as it causes within the organization,” Durovich avows. “By virtue of that exercise, we were able to streamline some of our processes and procedures.” Presumably, other benefits accrue when spreading the software throughout a distributed enterprise. Lesson No 4: Choose KPIs from administrative as well as clinical and service domains. To measure the success of the implementation, CMCD chose a wide range of key performance indicators (KPIs) spanning the clinical, patient safety, and service domains, but also related to various administrative functions. KPIs in scheduling, billing, and registrations were identified, as well as inpatient, emergency, and outpatient indicators. “We had what we thought was a good heuristic going in, but obviously we have had to tweak that as we go along,” Durovich reports. CMCD has spent approximately $40 to $45 million on clinical information systems and realized about $19.5 million during the past two years as a result. By implementing a common patient information database for its children’s facilities, patients and families, physicians, and community hospitals, CMCD has fostered a good deal of cross campus collaboration in what it calls the Southwestern Medical District. An even tighter relationship exists between CMCD and its partners, UT–Southwestern Medical Center and Parkland Hospital, which, through a combination of design and serendipity, all use the same software. The CIOs get together regularly, and ADT information, problem lists, medical images and laboratory results, immunizations, and histories are all shared, a boon for the approximately 230 residents who move among the facilities. Physicians and other caregivers, patients, and their families have real-time online access to the Internet and patient information. That’s especially important when, as Durovich observes, you find that parents are tweeting, blogging, and updating social media sites around the clock with information about their experiences at your facility. Lesson No 5: Integrate social media data for process improvement. CMC IT has been able to generate a font of interactive patient information that has helped develop critical areas of care, including those for pediatric mental health, parent support groups, underserved populations, and non-native English speakers. Addressing and caring for the needs of adolescent patients in a world where social media is the most immediate source of information was a big challenge, Durovich says, especially when adolescents might want certain health information kept private from their parents. “We use crawlers and screeners, and we are constantly looking around in the digital world—a world where the patient owns the information, and not us,” Durovich says. Likewise, the investigation by CMC into its digital roots has provided valuable demographic information, “so we understand those patients better than they understand themselves” upon their arrival at the facility, he says. That includes leveraging data operations to uncover patient populations by disease state, socioeconomic status, zip code, ethnic origin—you name it. In trying to find out how patients access CMC services and what kind of feedback they are offered in return, the facility also came to learn about how it was perceived by its patients. “We’re continuing to marshal our information systems so we can understand patient populations,” Durovich says, “so when they present to us, we can offer a series of clinical pathways to help them get back to normal or find their new normal as soon as possible.”Matt Skoufalos is staff writer for HealthCXO.
“We literally have cross-walked everything we’ve done in the IT space to make sure that what we do in our strategic initiatives is benefited by and informed by—and by extension, informs—our IT time, dollars, people, and facilities.”
—Christopher J. Durovich, FACHE, president and CEOChildren’s Medical Center Dallas
Figure. CMCD’s strategic objectives drive IT strategies. Lesson No 1: Don’t cheat the decision process. CMCD began its EMR adoption process more than a year before it started to consider vendor options. It developed a series of white papers, clinical as well as business enterprise case statements, which Durovich described as hypotheses that were vetted across the organization. The information technology leadership team comprised people from top to bottom and left to right, Durovich says, with managers, clinicians, employees, and patient families included in every decision made at CMCD. “When a kid gets sick, everybody’s at the hospital. Moms, Dads, siblings, aunts, uncles, grandparents, so you do take care of the entire family,” he explains. Far from being an IT-owned project, EMR adoption had multiple levels of oversight, and multiple levels of checks and balances. Two independent multidisciplinary teams with a common set of questions visited four to five different sites, from which the salient issues were synthesized. Only then was a request for proposal issued. Two of the vendors were invited to the campus to present their proposal, including an hour-long CEO-to-CEO meeting, during which the two learned how the other’s organization operated. Durovich reports that CMCD began its EMR journey in 2007, has concluded attesting to stage 1, and will submit paperwork to undertake stage 2 attestation later this year. But the deliberative process provided greater stability, more engaged participants, and far less doubling back than other organizations committed to such an undertaking might encounter, Durovich said. Lesson No 2: If you don’t have IT expertise on your board, recruit it. Back in 2007, CMCD leadership knew it did not have IT expertise on the board, but it was aware that the city was home to almost 20 Fortune 500 organizations. What CMCD did have was an annually renewing position, an “associate” board member, enabling individuals to have a trial run on the board by sitting on a committee for a year. “We had people who wanted to do this and people we wanted in that context, so that we could add them to our technology database,” Durovich reports. CMCD was able to recruit a Fortune 500 CIO and the president of a technology services company, as well as bring high reliability organizational leadership onto the quality and finance committees. Durovich recommends quarterly updates for the board and conversations with individual board members to keep the process moving. Lesson No 3: As much pain as it entails, do not customize the EMR. Durovich’s guiding principle was that CMCD was not going to customize the EMR and, in the end, picked a vendor that would not let them customize. As a result, the organization had to go through and vet its own processes and procedures so that it could match processes to the software. “Having gone through this several times, that was the key thing I would always do, and I would do it again, as much consternation as it causes within the organization,” Durovich avows. “By virtue of that exercise, we were able to streamline some of our processes and procedures.” Presumably, other benefits accrue when spreading the software throughout a distributed enterprise. Lesson No 4: Choose KPIs from administrative as well as clinical and service domains. To measure the success of the implementation, CMCD chose a wide range of key performance indicators (KPIs) spanning the clinical, patient safety, and service domains, but also related to various administrative functions. KPIs in scheduling, billing, and registrations were identified, as well as inpatient, emergency, and outpatient indicators. “We had what we thought was a good heuristic going in, but obviously we have had to tweak that as we go along,” Durovich reports. CMCD has spent approximately $40 to $45 million on clinical information systems and realized about $19.5 million during the past two years as a result. By implementing a common patient information database for its children’s facilities, patients and families, physicians, and community hospitals, CMCD has fostered a good deal of cross campus collaboration in what it calls the Southwestern Medical District. An even tighter relationship exists between CMCD and its partners, UT–Southwestern Medical Center and Parkland Hospital, which, through a combination of design and serendipity, all use the same software. The CIOs get together regularly, and ADT information, problem lists, medical images and laboratory results, immunizations, and histories are all shared, a boon for the approximately 230 residents who move among the facilities. Physicians and other caregivers, patients, and their families have real-time online access to the Internet and patient information. That’s especially important when, as Durovich observes, you find that parents are tweeting, blogging, and updating social media sites around the clock with information about their experiences at your facility. Lesson No 5: Integrate social media data for process improvement. CMC IT has been able to generate a font of interactive patient information that has helped develop critical areas of care, including those for pediatric mental health, parent support groups, underserved populations, and non-native English speakers. Addressing and caring for the needs of adolescent patients in a world where social media is the most immediate source of information was a big challenge, Durovich says, especially when adolescents might want certain health information kept private from their parents. “We use crawlers and screeners, and we are constantly looking around in the digital world—a world where the patient owns the information, and not us,” Durovich says. Likewise, the investigation by CMC into its digital roots has provided valuable demographic information, “so we understand those patients better than they understand themselves” upon their arrival at the facility, he says. That includes leveraging data operations to uncover patient populations by disease state, socioeconomic status, zip code, ethnic origin—you name it. In trying to find out how patients access CMC services and what kind of feedback they are offered in return, the facility also came to learn about how it was perceived by its patients. “We’re continuing to marshal our information systems so we can understand patient populations,” Durovich says, “so when they present to us, we can offer a series of clinical pathways to help them get back to normal or find their new normal as soon as possible.”Matt Skoufalos is staff writer for HealthCXO.