This document summarizes strategies for clinician adoption after an EHR go-live presented by Dr. Justin Graham. It recommends embedding HIT into organizational strategy, evolving governance from projects to operations, having realistic EHR expectations, setting virtuous workflow cycles, preparing for requests, learning informatics team management, and keeping vision and momentum. Culture change takes time and an engaged clinical leader, informatics team, and communication plan are important for adoption.

1. Life after Go-Live: The Next Phase of
Clinician Adoption
CMIO Summit
Boston MA, June 2011
Justin Graham, MD MS Chief Medical Information Officer
NorthBay Health System, Fairfield CA

2. Northbay

3. 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

4. Embed HIT into your organizational
strategy
 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

5. Culture eats strategy for breakfast

6. 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.

7. 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

8. 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 &
Infrastructure
Local Governance Issue Focus Advisory Clinical Decision Support
Groups Groups Workgroup

9. Have realistic expectations for your EHR
Standish Group, 2006. Successful projects were completed on time, on budget, and met user requirements.

10. 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. 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

12. Set a virtuous circle in motion
Improves Communication Ease of access
Decision
Support
Flexible data entry
Increases Knowledge Improves Documentation
Structure and
coding for quality
Workflow and outcome
automation measurements
Better Use of Time
Adapted from Blackford Middleton, MD

13. Avoid the vicious circle
Worsening Communication Difficult access
Distrust of
decision
support Rigid data entry
Increases 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

14. “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

15. Prepare for avalanches

17. Clinical Request Prioritization Scoring - 1
Quality and Effectiveness (3 pts possible)
•Decrease practice variation, promotes appropriate utilization of resources, promotes
evidence-based practice, or improves communication/documentation and care
coordination
•Intended to address deficiency in publically reported quality measure
•Aligns with approved NorthBay 5-year quality goal initiative
User Productivity & Satisfaction (3 pts possible)
•Reduces number of steps/time required or improves the experience
•Automates a manual process
•Mitigates significant adoption/retention risk
Compliance (required by law or external regulatory body) (3 pts possible)
•Enables capture, display, or clarification of required data, enables required privacy or
security 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

18. Clinical Request Prioritization Scoring - 2
Patient 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 event
Financial (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 initiative
Exception
Mitigates disruption to hospital operations (e.g. pandemic) -> moves to top
Adapted from Pravene Nath, MD, Stanford Hospital

19. NorthBay’s Agile EHR project tool

20. Learn the care and feeding of an
informatics 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

21. 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….

22. 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

23. Your questions

24. Thank you
Justin Graham, MD MS
jgraham@northbay.org
510-270-5141