CMIOs Look Beyond EHR Implementations
Despite the benefits associated with the use of EHRs, barriers to adoption still exist, mainly due to the changes in processes required by the caregivers. However, as EHR implementation becomes more commonplace—driven largely by the efficiency gains and financial incentives associated with meaningful use—the role of the CMIO changes from ensuring that the system meets the physicians' needs to a focus on system optimization.
The shift in informatics from implementation to workflow optimization is one that Brian Patty, MD, vice president and CMIO at St. Paul, Minn.-based HealthEast Care System, a 650-bed, four-hospital system, knows well. "One of the things we are looking at now is workflow optimization and how we can use the EHR to improve how physicians interact with the system more efficiently," he says. "People tend to want to utilize the EHR much like they do a paper medical record, so we've clearly defined those areas for physicians where they work differently, so they can be more efficient with the EHR."
Early in the book, the authors describe some causes for failed physician adoption: the early and persistent focus by clinical leaders and vendors on implementation as an indicator of success. "A singular effort... to ensure that the application is operational and has created an atmosphere where go-live becomes the endgame and all associated budget[s] and activities are directed toward that goal," the authors say. "This model will forever produce applications that are only partially utilized, with clinician resistance and shortfalls of expected financial returns. This thinking assumes there is a defined event whereby the application is adopted and used."
However, a number of CMIOs challenge this notion, pointing out that it is just one of many reasons their roles have evolved from system design and implementation to physician use and system optimization once the EHR has been implemented.
When Patty joined HealthEast as CMIO in 2007, he came into a failed EHR implementation. "We had to figure out why it had failed and how to approach it differently," he says. Patty organized a team of physician informaticists, described as, "the builders and implementers." Then, he estimated how much additional staff was needed to build and support an EHR.
His oversight and responsibilities have shifted from design and implementation to addressing system fixes and enhancements. "My team is now working on fixing what's not working, and improving physician workflow and outcomes," he says.
A group of five clinical informatics specialists are now dedicated solely to each hospital (two physician support staff, two nursing support staff and one clinical informatics specialist). Their responsibilities include identifying any pain points and bringing those issues back to clinical informatics.
Patty explained a recent interaction with one of his team members who was shadowing a physician. "The physician had ordered a blood transfusion, and in the paper environment, he would have ordered 'transfuse two units of packed cells,'" Patty says. "However, he now was given a choice: packed cells, Leuko-reduced packed cells, irradiated packed cell, Leuko-reduced irradiated packed cell and others.
"He had no idea if the patient needed just packed cells or one of the specially prepared packed cell options. While we do have the indications for each variation on our intranet, it took a while to find them," he says. "We worked with our pathologists to link the indications directly to the order set, giving physicians access to the information they needed to make a decision directly while in the ordering process. This is the type of decision support we can embed in the provider's workflow to help them make the right decisions more efficiently."
Patty also addresses system optimization and getting the most out of the systems now that physicians are using it. He and his colleagues are forcing people to aggressively look at what's not working, rather than waiting to hear about it.
"There are always going to be new functionality considerations, even when an organization, like ours, has reached HIMSS Analytics EMR Adoption Model [EMRAM] Stage 6," he says. "There are additional things buried in the nooks and crannies, or there may be vendor enhancements or new functionality that needs to be tacked onto the existing system."
Part of his evolving role has been to educate clinicians on things that aren't captured or where there may have been workarounds created to overcome system functionality issues. "If a nurse has a medication card in her pocket for the medications she commonly gives and isn't scanning them into the system, then we need to do some re-education," Babitch says, because handling an EHR process with workarounds defeats the purpose of having medication administration as part of the system.
A scanned report does not differentiate medications that were correctly scanned from a vial or patient's wristband versus one scanned from a card or a patient ID hanging on an IV pole. "Only by walking through the units and observing clinicians, can we catch those behaviors" where there needs to be re-education, he says.
The majority of EHR functionality, he says, is through result reviews, hospital emergency departments, PACS, computerized physician order entry (CPOE), and decision support rules, with about one million rules on the inpatient side, including inpatient documentation.
Martich says his roles and responsibilities have shifted since the EHR implementation began.
"My job has changed from trying to decide on a platform and software on the inpatient side, and instead looking at different vendor products on the ambulatory side, including interoperability tools and how we may want to virtualize those environments," he says.
As part of the EHR implementation at UPMC's Presbyterian Hospital, clinicians document the same way they do at UPMC's Magee Hospital, Horizon Hospital and all other UPMC hospitals. "We have a unique process, led by Louis E. Leff, MD, whereby we put together practice guidelines," Martich says. "With orders and order sets, we had representatives from each of our hospitals—physicians, nurses, pharmacists and health system librarians [because of its association with the University of Pittsburgh and its library resources]—and examined the different order sets [e.g., Heparin, anticoagulants]." Each facility maintained its own protocols. UPMC decided to assess the medical literature, and use that evidence to develop standard order sets. The health system will revisit hundreds of order sets annually to make sure they are still current.
Martich says these guidelines take a principled approach to decreasing unnecessary variations in practice from hospital to hospital, service line to service line and doctor to doctor. "These are driven by evidence-based guidelines, and in cases where there is no evidence available, we use consensus among cohorts of physicians, nurses, pharmacists, informaticians and librarians," he says. For instance, UPMC has decreased the number of standing order sets for sliding scale insulin from over 50 to five. The medical literature expounds the need to decrease unnecessary variations in care, which leads to increased efficiencies, fewer errors, better quality of care and cost savings.
"My EHR adoption work includes trying to get physicians to use the system. The implementation involved getting programs designed and what will be the most optimal [functions] for the doctors and nurses who use the system," Schreiber says. A key aspect to the EHR implementation is to always communicate (and listen), Schreiber notes, adding that the staff often requests additional order sets or upgrades. Through periodic emails to providers, he provides tips and insights on making the users' experience better. "I include announcements on new order sets and other functionality, advice on how to view and process data and overall assistance with any changes to the EHR," he says.
When errors arise, or there are confusing orders or elements to the EHR, he quickly addresses them, "constantly ensuring that we communicate back to the person who noticed the problem, so that we send a clear message of responsiveness," he says. "The listening part is critical, and so is circling back to involve [physicians] in the changes and letting them know what I did to address their concern."
Schreiber has increased training to ensure proper use of the system in order that its filters provide the data to the users in the way they prefer, based on their feedback. Certain orders were altered to ensure that medications were properly processed, such as respiratory products, which follow dual transmission requirements: a message to respiratory therapy and verification by the pharmacy.
Once the tools were in place, the outpatient record, ancillary services, nursing documentation and CPOE were implemented. "You then start to do things with the data and have the users interact with the system," Hanson says. "We take information from these interactions and use that for retrospective and real-time reporting, dashboards and specific interventions with decision support. If the system knows that a patient should be on prophylaxis for deep venous thrombosis, it can recommend the appropriate medications for the provider to prescribe."
Penn Medicine is in early discussions with a predictive analytics company to take additional data from its EHR and use it for real-time evaluations of readmission risks, "so we can respond by putting the right resources in place when a patient is discharged."
As EHR implementation evolves, so does the CMIO's role, changing from system design to helping physicians' get the most out of the EHR.
The shift in informatics from implementation to workflow optimization is one that Brian Patty, MD, vice president and CMIO at St. Paul, Minn.-based HealthEast Care System, a 650-bed, four-hospital system, knows well. "One of the things we are looking at now is workflow optimization and how we can use the EHR to improve how physicians interact with the system more efficiently," he says. "People tend to want to utilize the EHR much like they do a paper medical record, so we've clearly defined those areas for physicians where they work differently, so they can be more efficient with the EHR."
Beyond implementation
In the book, "Beyond Implementation: A Prescription for Lasting EMR Adoption," authors Heather A. Haugen, PhD, and Jeffrey R. Woodside, MD, from Denver-based The Breakaway Group, describe barriers to EMR adoption, the primary reasons for failed adoption, as well as methodologies for achieving higher quality care and improved financial outcomes.Early in the book, the authors describe some causes for failed physician adoption: the early and persistent focus by clinical leaders and vendors on implementation as an indicator of success. "A singular effort... to ensure that the application is operational and has created an atmosphere where go-live becomes the endgame and all associated budget[s] and activities are directed toward that goal," the authors say. "This model will forever produce applications that are only partially utilized, with clinician resistance and shortfalls of expected financial returns. This thinking assumes there is a defined event whereby the application is adopted and used."
However, a number of CMIOs challenge this notion, pointing out that it is just one of many reasons their roles have evolved from system design and implementation to physician use and system optimization once the EHR has been implemented.
When Patty joined HealthEast as CMIO in 2007, he came into a failed EHR implementation. "We had to figure out why it had failed and how to approach it differently," he says. Patty organized a team of physician informaticists, described as, "the builders and implementers." Then, he estimated how much additional staff was needed to build and support an EHR.
His oversight and responsibilities have shifted from design and implementation to addressing system fixes and enhancements. "My team is now working on fixing what's not working, and improving physician workflow and outcomes," he says.
A group of five clinical informatics specialists are now dedicated solely to each hospital (two physician support staff, two nursing support staff and one clinical informatics specialist). Their responsibilities include identifying any pain points and bringing those issues back to clinical informatics.
Patty explained a recent interaction with one of his team members who was shadowing a physician. "The physician had ordered a blood transfusion, and in the paper environment, he would have ordered 'transfuse two units of packed cells,'" Patty says. "However, he now was given a choice: packed cells, Leuko-reduced packed cells, irradiated packed cell, Leuko-reduced irradiated packed cell and others.
"He had no idea if the patient needed just packed cells or one of the specially prepared packed cell options. While we do have the indications for each variation on our intranet, it took a while to find them," he says. "We worked with our pathologists to link the indications directly to the order set, giving physicians access to the information they needed to make a decision directly while in the ordering process. This is the type of decision support we can embed in the provider's workflow to help them make the right decisions more efficiently."
Patty also addresses system optimization and getting the most out of the systems now that physicians are using it. He and his colleagues are forcing people to aggressively look at what's not working, rather than waiting to hear about it.
Growing with the EHR
At Detroit Medical Center, CMIO Leland A. Babitch, MD, says the EHR implementation has evolved much like his CMIO role. "In the beginning, there is an effort that goes into an implementation; however, this never really ends," Babitch says."There are always going to be new functionality considerations, even when an organization, like ours, has reached HIMSS Analytics EMR Adoption Model [EMRAM] Stage 6," he says. "There are additional things buried in the nooks and crannies, or there may be vendor enhancements or new functionality that needs to be tacked onto the existing system."
Part of his evolving role has been to educate clinicians on things that aren't captured or where there may have been workarounds created to overcome system functionality issues. "If a nurse has a medication card in her pocket for the medications she commonly gives and isn't scanning them into the system, then we need to do some re-education," Babitch says, because handling an EHR process with workarounds defeats the purpose of having medication administration as part of the system.
A scanned report does not differentiate medications that were correctly scanned from a vial or patient's wristband versus one scanned from a card or a patient ID hanging on an IV pole. "Only by walking through the units and observing clinicians, can we catch those behaviors" where there needs to be re-education, he says.
Ordering up order sets
G. Daniel Martich, MD, CMIO at the University of Pittsburgh Medical Center (UPMC), sees EHR activity from 20 academic, community and regional hospitals with more than 4,200 licensed beds and more than 400 outpatient locations. The health system is nearly 90 percent complete with its EHR rollout, Martich says.The majority of EHR functionality, he says, is through result reviews, hospital emergency departments, PACS, computerized physician order entry (CPOE), and decision support rules, with about one million rules on the inpatient side, including inpatient documentation.
| EHR Implementation Findings |
In their book, “Beyond Implementation: A Prescription for Lasting EMR Adoption,” Haugen and Woodside identify several things that can lead to a successful implementation.
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"My job has changed from trying to decide on a platform and software on the inpatient side, and instead looking at different vendor products on the ambulatory side, including interoperability tools and how we may want to virtualize those environments," he says.
As part of the EHR implementation at UPMC's Presbyterian Hospital, clinicians document the same way they do at UPMC's Magee Hospital, Horizon Hospital and all other UPMC hospitals. "We have a unique process, led by Louis E. Leff, MD, whereby we put together practice guidelines," Martich says. "With orders and order sets, we had representatives from each of our hospitals—physicians, nurses, pharmacists and health system librarians [because of its association with the University of Pittsburgh and its library resources]—and examined the different order sets [e.g., Heparin, anticoagulants]." Each facility maintained its own protocols. UPMC decided to assess the medical literature, and use that evidence to develop standard order sets. The health system will revisit hundreds of order sets annually to make sure they are still current.
Martich says these guidelines take a principled approach to decreasing unnecessary variations in practice from hospital to hospital, service line to service line and doctor to doctor. "These are driven by evidence-based guidelines, and in cases where there is no evidence available, we use consensus among cohorts of physicians, nurses, pharmacists, informaticians and librarians," he says. For instance, UPMC has decreased the number of standing order sets for sliding scale insulin from over 50 to five. The medical literature expounds the need to decrease unnecessary variations in care, which leads to increased efficiencies, fewer errors, better quality of care and cost savings.
Community care
At Holy Spirit Hospital in Camp Hill, Pa., CMIO Richard Schreiber, MD, was actively involved in EHR design from 2006 to 2007, and throughout the EHR implementation in 2007. Last year, he worked closely with community physicians to adopt the EHR and achieve meaningful use requirements."My EHR adoption work includes trying to get physicians to use the system. The implementation involved getting programs designed and what will be the most optimal [functions] for the doctors and nurses who use the system," Schreiber says. A key aspect to the EHR implementation is to always communicate (and listen), Schreiber notes, adding that the staff often requests additional order sets or upgrades. Through periodic emails to providers, he provides tips and insights on making the users' experience better. "I include announcements on new order sets and other functionality, advice on how to view and process data and overall assistance with any changes to the EHR," he says.
When errors arise, or there are confusing orders or elements to the EHR, he quickly addresses them, "constantly ensuring that we communicate back to the person who noticed the problem, so that we send a clear message of responsiveness," he says. "The listening part is critical, and so is circling back to involve [physicians] in the changes and letting them know what I did to address their concern."
Schreiber has increased training to ensure proper use of the system in order that its filters provide the data to the users in the way they prefer, based on their feedback. Certain orders were altered to ensure that medications were properly processed, such as respiratory products, which follow dual transmission requirements: a message to respiratory therapy and verification by the pharmacy.
Furthering implementation
For C. William Hanson III, MD, CMIO at Penn Medicine in Philadelphia, the initial phase in rolling out an EHR was physician engagement. Hanson explained what the processes meant, what workflows would look like and any hardware or software issues.Once the tools were in place, the outpatient record, ancillary services, nursing documentation and CPOE were implemented. "You then start to do things with the data and have the users interact with the system," Hanson says. "We take information from these interactions and use that for retrospective and real-time reporting, dashboards and specific interventions with decision support. If the system knows that a patient should be on prophylaxis for deep venous thrombosis, it can recommend the appropriate medications for the provider to prescribe."
Penn Medicine is in early discussions with a predictive analytics company to take additional data from its EHR and use it for real-time evaluations of readmission risks, "so we can respond by putting the right resources in place when a patient is discharged."
As EHR implementation evolves, so does the CMIO's role, changing from system design to helping physicians' get the most out of the EHR.
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