Physician Engagement: Communicate, Align, Optimize

To truly reap the benefits of all that EHR systems promise, clinicians must effectively use the technology. That can be easier said than done. Alignment of expectations, education, physician champions, governance and a continual focus on optimization all play a role in driving physician engagement with the EHR.

Demonstrate the value of health IT to physicians, says Eric Herman, MD, medical director of population health management at MultiCare Health System in Tacoma, Wash., which earned the HIMSS Organizational Davies Award for outstanding achievement in the implementation and value of health IT in 2009.

“Present the value of an EHR in meaningful ways and they will become more engaged,” Herman says. That will allow you to engage in broader, deeper dialogue and ultimately develop the structure for governance and clinical content.”

Herman suggests a litmus test to demonstrate value to physicians. The current mainstay, he says, is the triple aim of better care and better outcomes at lower costs. “Explain how the system will improve the patient experience, the quality of care, the physicians’ experience and help the organization be more cost effective.” Another big draw is the time factor, he says. “This is the most important unit for physicians. Tell them how they can spend less time doing paperwork and more time with their patients.”

Evidence & education

The key to successful physician engagement is educating physicians about the importance of evidence-based medicine, says Sameer Badlani, MD, CMIO, University of Chicago. “For too long we have had education designed around best treatment rather than showing the consequences of not following best treatment.”

Even with a strong focus on costs, Badlani says providers “triviaIize daily decision making if it is not major surgery. People don’t really understand the magnitude of ordering a simple or cheap test.” For example, exposing patients to even cheap blood tests could lead to anemia and lowered hemoglobin which leads to more tests to determine the cause of the drop. All this can lead to expensive blood transfusions, longer hospital stays and perhaps severe site reactions. “Education becomes really important,” says Badlani.

Order sets are one way of delivering actionable data at the point of care, he says. Along with clinical champions, Badlani reviews order sets every year and looks at utilization. Underutilization can indicate lack of awareness of the order set or lack of need. A new associate medical officer for clinical quality will work with Badlani to analyze excessive clinical variation. “We are going to focus on areas we feel have real potential for improved patient safety. Focus your energy or the message becomes lost and part of the noise.”

Physicians need to be involved in developing order sets; otherwise “you get into a defensive discussion on whether that is an appropriate way to measure performance,” says Badlani. “It becomes a point of contention rather than a source of guidance and improvement.” Get physicians to agree on reasonable measures and then start showing them their data to drive performance improvement.

At the University of Chicago, Badlani says there is a system-wide effort to continually refine and optimize the EHR system. “Just having the ability to show data is only 10 percent of the battle.” The orthopedics department, for example, is a high-volume area that wants to deliver excellent service at a fast, efficient rate. “We’re looking to see how we can leverage the EHR to achieve that better by eliminating repetitive tasks that take up valuable time. It’s always going to be a work in progress.”

Set the tone

Clinician engagement is “first and foremost on most organizations’ minds,” says Charles Anastos, principal in consulting firm PwC’s health IT practice. With facilities spending millions on the implementation of information systems, clinical involvement is critical to get a decent return on investment.

“A lot depends on the organizational tone you set at the top and how the project will be managed,” Anastos says. A critical element is establishing these efforts as enterprise projects, not IT projects, in which physicians are integrated in the process.

Alignment from the top down is important, says Herman. “Your physician leadership will not engage in a process or project if there isn’t clear support from executive leadership. If executive leadership demonstrates clear and unwavering support and is responsive with resources, then physician leadership will be engaged and support your work in trying to embed best practices in the EHR and develop the necessary content for use in that EHR.”

Organizational alignment comes from the top but grass root efforts are critical as well, says Herman. Nurses, schedulers, analysts and other operational staff members “are going to put this thing in place.”

Recruiting effective physician champions also helped MultiCare successfully implement its EHR. “The best physician champions are cultural and clinical leaders that have engaged the EHR for the value it can offer,” Herman says. They often help recruit other physicians and change the culture of adoption. The organization identified the leaders in each specialty who “would help engagement, develop content, test content and ensure change management and best practices. The physician champions’ technological capacity is less than their value as leaders in their specialty. We targeted those individuals for a real transparent discussion about the risks and benefits.”

Communicate early and often

Clients hire PwC and other consulting firms for tasks such as project governance—who is involved, interactions between workgroups and the decision-making process. “Clinical expertise is very important” in that process, Anastos says. That upfront planning, including awareness, education and engagement, gets clinicians involved in the project and sets the stage for operational improvement.

Another hurdle organizations must address is misalignment of expectations. “Early on in the process you have to constantly bring everybody back to center about goals and objectives.” Make the expected outcomes clear, he says. “You can’t speak to it enough. Communicate early and often and repeat. A lot of organizations get into trouble because the expectations are not clearly set from day one.”

Communication strategy development is a big part of PwC’s offerings to healthcare organizations going through an EHR implementation. A good strategy is focused on internal communication to project teams, and external communication to stakeholders, end-users and the enterprise as a whole, as well as customers. “Weekly update meetings for team members have to happen,” he says. Anatos also recommends the use of technologies such as portals, electronic newsletters and an intranet page of the implementation to support communication efforts. The intranet “works very well because it becomes a living area where you can post updates and progress and people can feel part of it, write in with their comments and ask questions.”

Hunterdon Healthcare Services based in Flemington, N.J., has been using an ambulatory EHR among its practices for three years and is in the process of implementing its inpatient system, says Wayne Fellmeth, MD, CMIO.

The key to keeping the whole project moving is keeping the nurses happy, he says. “Nurses are in the records all the time and if they aren’t happy with the system that’s going to interfere with patient care which rubs off on the doctors,” he says. “But, if the nurses are raving about the system, doctors are much more accepting of the change.” Fellmeth makes sure he attends nursing meetings and addresses their concerns.

There is extensive input by physicians and nurses from each practice and specialty, even three years after ambulatory implementation. In preparing for the inpatient side, each department is very involved in what the screens look like and which pop-ups alerts to activate, Fellmeth says. Each department is “involved in the building of their specific instance of this general EMR we’re running.” Nurses are involved in decision making for various EHR processes and physicians are on the order set committee and medical executive committee determining policies for training, system use, use of verbal and phone orders and more. “We talk about it at every medical staff meeting and at individual department meetings.”

Addressing fears

Several Hunterdon physicians have been on paper for a long time so “it’s a little scary going electronic. I’m trying to put their minds at ease,” says Fellmeth. “I tell them, ‘My job is to make the computer work for you not the other way around.’ They will only change their workflow if the system makes it better.”

Herman also strongly believes in transparency. Be upfront with physicians about the benefits, the learning curve, the time involved in the transition and potential challenges, he says, and then be clear about what you’re offering to support the transition. “If you come from the culture that really brings forward transparency and the respect of the providers, then they will be far happier to engage in this as something of value of them.”

Take advantage of what resistance can reveal, Herman says. “Anytime there is change, resistance is a good thing because it tells you the concerns and fears. They’re often valid concerns. You need to validate and understand those concerns and determine whether they need to be further addressed. You have an opportunity to allay those fears.” 

Effectively handling a concern demonstrates your capacity to deal with that concern, or perhaps develop a partnership, Herman says. “You can’t please everybody, but in a transparent culture that demonstrates value, curmudgeons will be the exception not the rule.”