Collaboration Roundtable: Working to Get Past Analysis Paralysis

Healthcare organizations are feeling the push to implement and optimize health IT systems and tools, but how is that best achieved? If no one is willing to take responsibility for making the hard decisions, how does anything get done? Three CMIOs share their thoughts on getting past analysis paralysis and moving on to effective collaboration.

Roundtable Participants
Benjamin Alexander, MD, CMIO of WakeMed Health & Hospitals, Raleigh, N.C.	Howard Landa, MD, CMIO of Alameda County Medical Center, Alameda, Calif.	Richard Schreiber, MD, CMIO of Holy Spirit Hospital, Camp Hill, Penn.

What is your current governance structure surrounding EHRs and other health IT and the associated culture change?

Landa: Our project team is really IT focused. We had a governance committee, which consisted of the chief operating officer, the chief information officer, the chief nursing officer and the chief medical officer, but because of turnover in staff, became problematic. Right now, I am the CMIO and the CIO. We have an executive steering committee which consists of the CEO’s reports and they essentially are our EHR governance. If we can’t come to a decision, and that’s pretty rare, we take it to that committee.

Schreiber: Inpatient and outpatient aren’t integrated at all. That’s a long-term goal that will either be through actual interfacing or more likely a local and then more regional health information technology effort. My governance structure started years ago with the Physicians Information Technology Council and it went through a number of name changes and initially was attended with great enthusiasm and then rapid non-attendance. I kept it going, however, as a governance organization for quite some time and finally abandoned it.

One of my efforts is to ensure that the entire implementation and adoption is not an IT project but a medical staff project. I have been using the medical executive committee as that final imprimatur of implementation and adoption, but they are not really willing to say, “Yes, we own this.” I need to get the ownership not to be me or IT, but some kind of governance. Our governance is mainly done by me in concert with the chief medical officer, sometimes in private conversation and sometimes in public at the medical executive level.

Alexander: Our first EHR implementation a few years ago began with an executive steering committee, which was a great group with far too many priorities to provide the level of focus  needed for such a major initiative. We then tried setting up another governance committee with more front-line staff, but the challenge there was empowering members to make decisions for the masses.

With these lessons learned from our previous implementation, we are getting ready to replace our EHR over the next 18 to 24 months with a new governance strucutre that we think will be far more effective. An executive steering committee, charged with making strategic-level IT decisions, is made up of our CEO, the most senior vice presidents and medical staff leadership. Then we are putting together a clinical operations governance committee which is going to be made up of the operational VPs, physician champions, revenue cycle VP, and VP from our ambulatory practices. In the past, we have not kept tight control over IT governance. It seems to be easier early on in a project but then once you get into the later stages and the use of the product, that’s when things tend to degenerate. We have struggled with that and I hope that we can reset that to some extent with this new implementation.

Schreiber: You make a very important point which is finding the right administrative level at which to designate responsibility. I have had a governance structure that was representative of physicians whether they be department chiefs or just people that were interested, and they were willing to take some responsibility. The med exec committee is too high on the echelon to take responsibility because they are not supposed to work in the weeds, and yet you don’t just want to have eager beaver workers because they can’t take the responsibility for an entire department. Finding the right level is very difficult.

How does your medical executive committee function regarding health IT and how successful is it?

Schreiber: It works in the sense that the EHR is a medical staff project and not an IT project. My committee tells me to do what I need to do and keep them informed. But that’s not governance; that’s just consensus. Culture is part of this discussion as well. Our culture right from the get-go has been that decisions are reached by consensus. Everybody who is a stakeholder ought to be at the table to express their opinion. That process brings up new ideas and perspectives that others might not have so I favor that process but it's inherently slow, and it often stalls. We go by the old adage of “analysis paralysis.

In the non-interfaced, non-integrated world of 10-plus years ago, it didn’t matter that departments each did their own thing. Now that everything has to be hooked together, silos don’t work because that leads to fractured governance. Goals become dissociated so we have to work together. Silos are not great even though that gives you the advantage that you have somebody in charge of decisions. We need governance that will take that kind of responsibility.

Landa: We always struggle with governance. Going to med exec is great for consensus support but, as was said, it's almost impossible to get a decision out of that group. I think you need a specific group that gets blessed from above and below. A governance group that works has to be small enough to make decisions, large enough to represent everybody, acceptable to the C-suite and acceptable to those who report up or in those same departments so they can speak for the department, and medicine isn’t organized that way.

Alexander: I would agree with Dr. Landa, in that the medical executive committee needs to be aware of IT projects and has the responsibility to appoint members to be involved in decision making bodies, but they don’t necessarily have the time or inclination to get into the level of detail that is required. In addition, governance of health IT systems, more than perhaps anything else we do, is a shared responsibility of medical staff and hospital administration. The MEC, as a distinct organization from the hospital, cannot have sole decision-making authority on these matters.

What’s your best advice for achieving solid decision-making?

Landa: You need a department head or a high-ranking, roll-up-your-sleeves person, who can do real work but also manage the department. I have got a few department heads who want to get into the details enough to understand it and give me a firm commitment and then take it back to their department. If you've got those people, I think that’s huge in getting governance working.

Alexander: We need to provide some level of accountability for voiding a decision. In terms of an implementation project, we can say that every week a decision isn’t made, this is the impact on the timeline, which is attached to real dollars. How you do that in other settings is more difficult. There ought to be consequences to not making decisions because that would push us to do better. My colleague says, “Everybody can say no, but nobody can say yes,” and that just hamstrings you and prevents you from getting things done. There’s got to be a push to get people to struggle, get through a decision, make it, support it and move on.

How do you see health IT implementation and optimization changing in the near future?

Landa: The new wave is not whether to go electronic, but which vendor. The change from one vendor to another is enormous—it’s horrendously expensive and data conversions are extraordinarily complex. One of my managers who has done data conversion before said, “I don’t care what project you are talking about, implementation, adding new modules, the worse thing possible from a technological point of view is data conversion.”  

Alexander: Our decision to switch EHR vendors stemmed out of a medical staff board retreat a couple of years ago when this wasn’t even one of the agenda items. One of the discussions that came up was the lack of integration of all our systems and the frustration that caused. The CIO and I got handed all of this and our response was, yes, you are right, but now let’s talk about what it really means to be integrated. We brought a lot of medical staff together with administration and did a couple of offsite retreats and really educated people. If you want a truly integrated system, here is what it means. You guys in the ED who are very happy with your niche ED system, don’t get to keep that anymore. You folks in the rehab hospital who have a niche system that works extremely well for you, you don’t get to keep that anymore either—but here’s the benefits of doing that.

We have benefitted from educating a lot of people about those decisions. When we went through the EHR evaluation process, and people said we are at risk of losing this amount and it’s going to cause this drop in productivity, the medical staff who had been involved with this all along said, “we don’t care, it’s the right thing to do for the patient and for the organization.” So we are starting to take very small steps towards doing things in a better fashion. Our ability to get broad involvement and make sure people take the patient-centric and the organization-wide view has really helped us get where we are today--ready to embark on a two-year, major systemwide EHR implementation..

Schreiber: I need to be in very good, close communication with even the chief operating officer and the financial officer, even though I do not have an official administrative connection with them. I don’t often need to speak to the CFO, but I need to know that I have good access to his office. Likewise, I need to have good contacts and communication with my nursing informatics people, my pharmacy informatics people and so on, and they need to know that they can find me and contact me. I also need to have good contacts with all the department heads. Since I predominantly represent the medical side of things, I have got to know every department chief and as many of the staff as I possibly can to have good relationships with them. The hardest part about all that is good communication. We mostly use email but it’s not the best tool.

Who I report to is irrelevant because I really report to everybody in every direction and they need to have access to me. I know that’s been said in many ways about what the right role of the CMIO is but until I was really in the middle of this, I didn’t realize how much in the middle I was.

Alexander: Similarly, I see my role as a communications referee among all parties involved--making sure we are all on the same page, working toward a common goal. While the parties may have different ideas about how to get to where we’re going, we truly all want to get to the same place: having a safe, effective EHR system that will really allow us to be smarter, safer and more efficient in a changing healthcare environment. My role is to make sure we don’t forget that.

What are the best ways to communicate change?

Landa: When we started the [EHR] implementation, I sent out an email to every physician. I can't tell you how hard it was to get an e-mail address for every doctor. I make sure my emails fit on a single screen. It’s called News-You-Can-Use and I committed to making them infrequent, but important.  I said these will be things I need you to read because they are going to tell you how to do things, and I won't overwhelm you.

Every time we had an issue, I attached a one- or two-page document with screenshots to explain the problem. It would be a quick hit that people would look at, and I was absolutely amazed at how many people actually read them. I occasionally got emails asking to be added to the list.

Schreiber: I put out something named Schreiber’s Snippets, with the same concept; screenshots, do this, not that and this is what's new. Refining it to once a week is what I have been doing, but I need to get more granular.
Plus, I am on the agenda for every med executive committee meeting for an informatics update. I am on every agenda for quarterly and annual staff meetings. 

Alexander: I have found that my best success has been very short, very direct communication. Don’t lose your credibility. When somebody sees something from me they know there probably is some real information in there.

Schreiber: To add credibility, I promised them I will not sell this or give this list to anybody else. Nobody else has access to it; it is literally password protected on my computer.  The only name they see is my own. I send it to myself and blind copy the other 623 names because I include nursing supervisors, nursing leadership and office managers.