Survival strategies after go-live Embed HIT into your organizational strategy Culture still eats strategy for breakfast Evolve governance from projects to operations Have realistic expectations for your EHR Virtuous circles not vicious cycles Prepare for avalanches Learn the care and feeding of an informatics team Keep the vision alive
Embed HIT into your organizationalstrategy Do you have a strategic plan that guides decision- making? Is HIT a line item or an enabler? Compare “2011: turn on one decision support rule” versus “2011: prevent 30 cases of severe sepsis, leveraging workflow redesign and automated alerting” No one can achieve their clinical goals without touching the EHR Don’t let IT become the bottleneck for everyone’s projects
Don’t expect quick changes 1497: 100/160 sailors on Vasco de Gama’s voyage die of scurvy. 1601: Capt. James Lancaster conducts the first randomized controlled trial. On 1 ship all sailors get lemon juice and none die of scurvy. On 3 ships, no lemon juice and 110/278 die halfway through the voyage. 1747: James Lind publishes similar evidence. 1795: British Navy adopts citrus policy. 1865: British Merchant Marine adopts same policy. Will your cultural shift take 264 years? Rogers, Diffusion of Innovations, 2003.
Evolve governance from projects to operations Enterprise HIT governance, not just one project (“CPOE”) IT is too important to be left just to the IT Department The EHR exists to serve the needs of operational leaders, not the other way around. The enterprise needs to prioritize the use of limited resources in an open and accountable way
Information Technology Executive Steering Committee Financial/HR/Admin Revenue Cycle IT IT Steering Clinical IT Steering Committee Committee Steering Committee Informatics EHR Operations Leadership Workgroup Team EHR CLC EHR Architecture & InfrastructureLocal Governance Issue Focus Advisory Clinical Decision Support Groups Groups Workgroup
Have realistic expectations for your EHR Standish Group, 2006. Successful projects were completed on time, on budget, and met user requirements.
A cautionary tale from a different roll-out Ignaz Semmelweis introduced handwashing to the Vienna Obstetrical Clinic in 1847 In four months, the maternal death rate dropped from 18% to almost zero. Over the next 18 years he is criticized, harassed, and ridiculed by the medical establishment In 1865 he is lured into a mental institution by a fellow physician, where he is severely beaten and confined to a cell. He dies of sepsis 2 weeks later. Nearly 170 years later, clinician adoption of handwashing remains stalled at about 45%.
11 reasons for HIT project failure Lack of alignment with No definition or business strategy measures for progress or Weak executive-level success sponsorship No organized Underestimating impact mechanism for on organization communication and feedback No readiness assessment for change Lack of formal training plan Unrealistic expectations Lack of effective Lack of an effective, physician leadership cross-functional implementation team HIT does not meet core provider needs
Set a virtuous circle in motion Improves Communication Ease of access Decision Support Flexible data entryIncreases Knowledge Improves Documentation Structure and coding for quality Workflow and outcome automation measurements Better Use of Time Adapted from Blackford Middleton, MD
Avoid the vicious circle Worsening Communication Difficult access Distrust of decision support Rigid data entryIncreases Errors Spurious Documentation Garbage data and documentation Workflow unsuitable for breakdown and quality metrics or dysfunctional patient care workarounds Time Wasted Adapted from Blackford Middleton, MD
“It’s the workflow, stupid” Prescription Renewal The process begins when a medication request is received from a pharmacy. The end point is that a medication is renewed. Front Office Staff Attach Rx Obtain Rx Obtain Patient Schedule patient Visit Test/ Result Start Rx Request request/Place in Received A Information Chart for Test/Visit Review Queue A Follow-up with End patient Rx Confirm patient, Ensure Additional Forward Rx Order in Yes medication, Information is Request/Chart to Chart? dose, route, Obtained MD MA/LVN Generate No Patient Education Sheet Document Order Information Transmit Authorized Rx to Update Chart* pharmacy Check for drug/ Test/Visit drug, age, allergy Yes Write order interactions required? Physician No Authorization/ Signature? Yes Sign Rx No Further Practice End *Consider Tracking for Drug Utilization Review, patient registry entry, and insurance coverage Action
Clinical Request Prioritization Scoring - 1Quality and Effectiveness (3 pts possible)•Decrease practice variation, promotes appropriate utilization of resources, promotesevidence-based practice, or improves communication/documentation and carecoordination•Intended to address deficiency in publically reported quality measure•Aligns with approved NorthBay 5-year quality goal initiativeUser Productivity & Satisfaction (3 pts possible)•Reduces number of steps/time required or improves the experience•Automates a manual process•Mitigates significant adoption/retention riskCompliance (required by law or external regulatory body) (3 pts possible)•Enables capture, display, or clarification of required data, enables required privacy orsecurity control, or enables required workflow process control or audit control•Responds to preparation for upcoming site visit or audit<3 months•Responds to specific citation, site visit, or survey finding Adapted from Pravene Nath, MD, Stanford Hospital
Clinical Request Prioritization Scoring - 2Patient Safety (3 pts possible)•Reduces likelihood of potential near-miss or adverse event scenario•Responds to UOR filed, no adverse event•Responds to UOR filed, adverse eventFinancial (3 pts possible)•Favorably impacts revenue or expenses•Favorably impacts revenue or expenses by > $25K•Favorably impacts revenue or expenses by > $50K (including HITECH)Scope/Urgency (3 pts possible)•Affects < 50 transactions per week•Affects > 50 transactions per week•Aligns with Senior Management approved priority initiativeExceptionMitigates disruption to hospital operations (e.g. pandemic) -> moves to top Adapted from Pravene Nath, MD, Stanford Hospital
Learn the care and feeding of aninformatics team Visible clinical leader Preferably practicing physician (CMIO) Leadership skills Understanding of project management, IT governance and operations Informatics training a plus Informatics team resources Nurse lead Analyst staff Ancillaries including pharmacy, rad, and lab Budget Training
Keep the vision alive Read “Heart of Change” by John Kotter Use emotional appeals and anecdotes to create a sense of urgency Enlist opinion leaders early in the process Strong messaging and communication plan Learn from the masters: Big Pharma Detailing Freebies One-on-one training and education Leverage the MAs, PAs, RNs, office staff, etc….
Keep up the momentum Become a pro at workaround whack-a-mole Influence behavior rather than force compliance Make it very easy to do the right thing and very hard to commit errors of omission Compliance should be the path of least resistance PDSA cycles and small tests of change The antithesis of the IT “big project” mindset There is no EHR roll-out that couldn’t have been improved upon There’s always one more thing to do