Friday, August 14, 2009

Voyage inside the mind of a doctor looking at EMRs and CPOE

Next thought that came to mind - "Why don't the docs like the new system?".

(In CMIO terms, this is the currency we deal in : "Buy-in", as in, "I'm afraid I'm going to lose buy-in if we bring it alive before training is complete.")

So I thought I'd explain how a CMIO is a key role in EMR adoption... And to do this, we'll take a voyage inside the brain of a doctor faced with EMR adoption.

Let me explain...

Your AVERAGE doctor today faces certain challenges :

1. Generally, most docs feel (often rightfully so) that they've lost their autonomy - Regulatory agencies, insurance companies, and other governmental policies have more-or-less mandated certain daily practices that aren't intuitive. Some of those policies add value to patient care, but it is so far removed from the doctor's view, that docs often feel frustrated with these "outside interventions" into "what we're trying to do". (A TIP : If you're an administrator or IT person, be careful about using too many buzzwords - Too many buzzwords, to a doctor, means, "You're not part of my tribe.")

2. Generally, most docs talk to eachother. We have all heard rumors about EMR adoption : That the software is difficult, that it takes a while to learn, that offices and hospitals that adopt EMRs face a sudden slow-down. Lots of docs have "horror stories" that they share about a slowdown in patient care, increase in waiting times, and frustrated staff with initial EMR implementations.

3. A large number of practicing doctors are over the age of 50. Some can type, some still see typing as "something a secretary does for you". These docs are generally somewhat fearful of technology, since it could mean re-thinking their views on typing, or even worse, revealing that there's something they might have trouble learning, or even worse, something they might not be good at - A potential confidence-killer, for docs who need confidence to engage in their stressful practices. (In general, some docs carry a lot of emotional baggage into their EMR voyage.)

4. Very few docs have enough informatics experience or insight to understand the complexities of CPOE. (Not that CPOE is complex, but it requires a new understanding about medication delivery that most docs aren't used to.)

5. Docs practicing "in the paper world" have historically had many things automatically "adjusted" for them by ancillary staff, all along, without them realizing. Going to CPOE means : Nobody is there to adjust your order for you. If it's wrong, you'll get it sent back or get a call asking you for clarification. CPOE asks a doc to order it correctly the first time. Yes, in the end, CPOE can help you be a better doctor, but in the meantime, you'll have a learning curve and find out all of the things you didn't know because other people (nurses, pharmacists) were helping you all along. (This experience adds to the emotional baggage in #3).

6. Most docs are very skeptical about technology support mechanisms - Help desks that don't seem too helpful, training videos that take too long, books that don't "explain what I want in the 5 minutes I have between surgeries..."

So, why I'm glad to be a CMIO : I help smooth out these things.

In bringing a physician into CPOE and EMR use :

1. I try to talk to them and "feel out" their emotional state - Are they nervous? Fearful? Hopeful? What are their opinions about technology? Do they know the potential benefits? What is their "patience level"? These are all important to know, so I can adjust my teaching accordingly.

2. I try to put a personal name and face when I support a doc going to CPOE. I let my docs know, "You can call me anytime, 24-hours-a-day. If you have any problem, I want to know about it so we can fix it." (I'm glad to report that even though I have about 70 docs doing CPOE, the calls I get at night are very, very few.)

3. I remind them that "You will be a different doctor when you're done" - That doctors are going to look and act and think differently in the future, and that this is their way of keeping current and being part of today, rather than languishing in the past. (No doc wants to feel "old and outdated", so this can be fairly motivational.)

4. I remind them that even though there is a learning curve, EMR use actually does help patient care in the big picture - Even though most docs feel that it's "an IT thing", that this simply isn't true - Electronically sharing information with other doctors actually helps improve the overall care for their patients. If they are committed to the best care for their patients, they should be passionate about good information storage and retrieval. (e.g. When docs ask me about IT issues, I ask them where they keep their notes today, and then ask them, "How do your patients benefit from the way you chart today?")

5. I sit with them and personally work on teaching not only the software, but the behind-the-scenes workflows that result in their patient care - From their electronic order, to the pharmacy verification process, to the Pyxis functioning, to the delivery and charting on the eMAR. I feel that the workflows are important so that they can anticipate problems, and know how to adjust their orders when they occur.

6. Lastly, I take a ceremonial "graduation picture" (with my iPhone), and their completed "CPOE exam", for a few reasons :
a. I'd like to keep a historic record of our CPOE adoption, that maybe we can look at in 1-2 years at a holiday party and reminisce.
b. I think it's important to have some sort of ceremony after graduating into CPOE - A doc should walk away with the feeling, "I'm a little different now."

So why a CMIO? Because of the tribal nature of medicine - (See my previous post) - These messages are much more palatable when it comes from another doc, especially, a doc who also worked with you on that really sick patient in the ICU last week.

Again, some of you might not have the resources for a CMIO - A good consultant can also help you improve your training and support, and if not, I'll just keep blogging. :)

Tuesday, August 11, 2009

Tribal nature of medicine and EMR implementation

This is in response to a request, "Please write more about the tribal nature of medicine"... [And how it impacts EMR adoption]...

Some people are surprised to learn how tribal medicine is, especially those who don't work in healthcare. This was once parodied in the TV show "Scrubs", where the Internal Medicine residents were "Jets" and the surgeons were "Sharks", and they reinacted a medically-themed version of the "West Side Story" dance...

One of the reasons "Scrubs" is so popular with medical people, however, is because it really rings true. The show is actually written by a bunch of doctors who have been successful by making a TV show that parodies the culture of medicine.

So, back to the tribal nature of medicine.

Medicine is full of tribes : The "Doctor" tribe, the "RN" tribe, the "LPN" tribe, the "Pharmacist" tribe, the "Respiratory therapist" tribe...

Doctors even further separate into "Inpatient doc tribe" and "Outpatient doc tribe"... and even among "Inpatient doc tribe", they further separate into "Medicine tribe", "Surgeon tribe", "Cardiologist tribe"...

Nurses have similar tribal divisions, between "Floor nurse tribe", "ICU nurse tribe", "OR nurse tribe"...

The point I'm making is that virtually everyone who works in medicine feels a part of some tribe. Their membership depends partly on their clinical training, and partly on their physical location. It sometimes approaches a quasi-military structure, with various ranks, a semi-formal hierarchy, and a specific method-of-interaction between people of different ranks.

Why bring this up? Because as you start to navigate the culture changes needed to successfully deploy and implement and EMR, you will examine your clinical workflows and be forced to deal with some hard tribal questions : "If the doctor tribe used to do step A, and the nurse tribe used to do step B, and NOW the nurses can't do step B anymore, will the doctor tribe accept doing step A AND B?"...

And when you announce to the doctors that they will need to do step A and B, you will quickly learn about the tribal nature of medicine. Often, discussions about workflow changes and negotiation will dissolve into "MD versus RN", "ED RN versus inpatient RN", "MD versus Clerk", "Clerk versus Respiratory therapist", and so on, and so on, and so on...

This is often the hardest part of managing cultural change in medicine - How do you balance the needs of one tribe versus another?

My feelings about this : A good leader teaches other clinical leaders about two things :

1. The art of teambuilding (breaking down tribal barriers)
2. The art of negotiation (nobody walks away from the negotiating table unhappy.)

To help with teambuilding, the first step is to gather some people from a wide swath of clinical departments : Doctors, nurses, pharmacists, clerks, lab workers, respiratory therapists, and anyone else you can get who is passionate about doing something different. Appeal to them to participate in this new tribe : "By being a part of this new tribe, you can help improve patient care through technology."

Take that group, and to help break down tribal barriers, create a new tribe for those clinical leaders. In our hospital, we've worked hard to create a culture for those clinical leaders, and we look at them as a new tribe.

Once you can get the members of this new tribe to commit to the art of negotiation (in the name of good patient care), it becomes much easier to negotiate workflow changes that satisfy both of their representative tribes.

So far I've remarkable success with this approach, and I'm continuing to pursue this as a model to help with the multiple governance issues which arise from EMR implementation.

This again is something a good CMIO can help you with, but until then, I'll just keep writing. :)

As always, feel free to ask questions! :) Keep 'em coming! :)

Sunday, August 9, 2009

Is medical culture ready for EMR and healthcare change?

I've written about the "tribal culture" of medicine a few times on Twitter, and it seems to resonate with people who work clinically, so I thought I'd write a few thoughts about the cultural shift needed for successful EMR implementation.

When people first try to understand the challenges involved with EMR implementation, they commonly reach for common life experiences which they imagine might be similar : Like, for example, installing software on your computer at home or at work.

The problem is that if you use this as your conceptual model for EMR implementation, you will make one of the most common mistakes : Thinking, "'s like installing software on your computer."

Problems that arise from this conceptual model :

Mistake 1 : The belief that "training" is an instruction book or training class that teaches you to "use the software"
Mistake 2 : The belief that "support" is a help line to answer questions.
Mistake 3 : The focus on "the software" as being an experience at the computer.

Okay, so I'm not being fair in saying that these are really mistakes, since they are certainly useful in starting to understand the enormity of the issue. But if that's where your understanding ends, then you make the bigger mistake of not seeing the bigger picture at work.

"It's not just the software, folks..."

The point I wanted to convey tonight is that "going electronic" is a major cultural shift in healthcare.

1. It means you need to take a hard look at some well-held beliefs, and prepare to readjust them.
2. It means you need to examine your workflows and prepare to resort them.
3. It means you need to build new managerial structures to deal with the culture shift and navigate the tremendous amount of information you will uncover along the way.

So now, the challenge becomes : In addition to buying the software and arranging for starting training and continued support, how do we manage change in a culture that is so fiercely tribal?

So here are my thoughts of useful cultural features to help prepare your office / hospital for this shift :

1. When discussing management or IT : Lose the formal titles of "Doctor" or "Nurse" or "Administrator" or "Pharmacist". (I personally cringe if people use my formal "Dr." title, since I really believe that use of the title reinforces the "us-vs-them" mindset. It's much easier to build a team when everyone feels they're in the same tribe.

2. Take a hard look at the culture your front-line employees live in. Are they nervous to try new things? How do your front-line managers handle their mistakes? If the environment feels too punitive, you will suffer from people not trying the software, and from people not sharing the problems-everyone-should-learn-from.

3. Invest in your employee's skills. There are front-line employees who understand the operations of their department very well, and are interested in being more involved in managerial decision-making. Rather than a the older top-down approach of decisions coming from the top, consider bringing some front-line staff to the top, and let them be responsible for the outcomes.

4. Prepare for new sources of data on clinical functioning. One of the benefits of going to an EMR is that you will suddenly be able to sort through large amounts of data quickly. Things that took hours of chart review in the past now become a quick Excel spreadsheet. Make sure you plan for staff who can help you tap that information and sort through it in a meaningful way. Then develop plans for how to deal with the information you'll obtain.

5. Realize that good teaching is much harder than it looks. It's helpful to talk to anyone who has worked in the educational field about how complicated good education is. (Ask a teacher what the difference between "education" and "good education" is.) You will need to commit to the training and support of a large amount of employees - Are you prepared for that challenge? What resources do you have for this, and when are they available? People will eventually be able to blossom on their own, but generally training will get your employees to a 100-level understanding of your EMR - Eventually, you'll want to bring them up to a 400-level understanding, and that takes resources.

6. Set realistic expectations. It's a simple fact : Some people are impatient. If you have too many of these people, you will have a hard time meeting their expectations early on, and you risk losing confidence and buy-in of your clinical thought leaders. If you focus on setting realistic expectations early on, you'll help avoid the problems that can result from these people.

Sorry it's not a nice list of five things... So it's six. I'm sure I'll think of more in the future.

Thanks for the feedback on the last posts! I look forward to sharing some more insider CMIO tips in the future! :)

Tuesday, August 4, 2009

Workflow Analysis and Clinical Jedis

Okay, time for Entry #2 -

It's all about the workflow analysis.

This concept is *very* hard to grasp, unless you practice clinically - Either as a nurse, a pharmacist, a doctor, or some other clinician.

"Workflow analysis - It's not just the software and training you have to worry about!"

This is the hidden part that nobody really tells you much about. And if they *do* try to tell you, you probably won't understand it until you're staring it in the face.

Here's the summary : When you go-live with an EMR, you have to re-think your workflows. Basically, if you've never had an IT strategy, you'll be inventing one, whether you like it or not.

It means you have to re-think :

1. What information do I need as a clinician? (Nurse? MD? Respiratory therapist? Dietitian? Pharmacist?)

2. What do I do with that information?

3. Where do I send that information?

4. What order do we do this in, as patients flow through our practice?

5. Who needs access to this information, and when?

The things you used to do on paper often don't translate to the electronic paradigm. And quite frankly, "making the computer do what you did on paper" is a lost opportunity to re-think your IT strategy.

So how do you do this? Who should do it? What governance do you need to do this?

Either, you can look for a CMIO to guide you, or a good consultant who understands this issue very well. Or, you can look to grow your own group of clinical workflow experts and IT training experts.

There's no good term for people who do this new role - Some of us have jokingly called them "Jedis", but they are the clinical operations experts that are hidden in your front-line staff. They are the people in your institution who understand this problem, and can help you understand and maintain the order of your universe.

The first step to taking control of this situation is to identify these allies. In each of your clinical areas you're looking to integrate, look for the person who is :

1. Politically neutral
2. Intellectually open
3. Embraces technology
4. Believes the phrase : "there is no substitute for hard work"
5. Is a respected leader in their clinical specialty
6. Is patient when teaching others.
7. Is *PASSIONATE* about their workflows - Not just "what does it take to be good?", but "What does it take to be good and what information do I need and what order do I need it in?"
8. Is creative
9. Understands the basics of interpretive statistics (Mean, mode, median, SD) and is amenable to some degree of database querying / Excel spreadsheet analysis.
10. Believes *strongly* in the art of negotiation - Nobody walks away from a negotiation unless everyone is happy.

Once you've found that person, hold onto them. They are your greatest asset.

Then start the discussion about "If we went electronic, what information would you need to do your job? What would you expect a doctor to do in a particular clinical scenario? What would you expect a nurse to do in a particular clinical scenario? What should a pharmacist do? etc..."

Start this discussion with the Clinical "Jedis" in one particular department. You will learn a lot about how your unit functions.

You can then work with your IT team to create an IT infrastructure that meets the needs of this new workflow. IT teams have a much better time understanding the clinical demands when the clinical demands are clearly defined.

Then after you agree upon the new paradigm, your "Jedi" can help bring the new workflow and education back to their clinical specialty. And when you "go-live", they can help reinforce good behaviors that fit the new paradigm.

And if your "Jedi" can understand the basics of data analysis (datamining, using Excel or another statistics package), make sure you share your raw EMR data with your Jedis - It will only help them understand your workflows better.

Again - A good CMIO or consultant can help you develop this sort of culture, but I hope I've communicated some of the work that's necessary to give adequate support to your EMR implementation. Please remember that "Jedi" is just an informal term - To avoid problems, you might call them "Clinical Samurai" or "ClinOps expert" or a term of your choice - In fact, I'd be curious if anyone has another term for someone who would fit this position.

Looking forward to hearing feedback. :)

Saturday, August 1, 2009

Formal entry into CMIO blogging


I realized, after I posted a bunch of stuff on Twitter this week, that people actually read what I posted.

As in, they asked me to make some sense of the chaos that I posted, because people were curious if I had any tips about good EMR implementation.

It was then that I decided I needed to actually start to write something a little better organized. So I'll try writing more on this blog - Mainly, for those of you who want/need a CMIO, but don't have one yet - I'll try to give you the little tips and tricks that I think can help a hospital have a good EMR implementation.

My little pithy blog is no substitute for an actual CMIO in your hospital, but until then, you'll have to read on.

Now, without further delay, my EDITED list of tips for good EMR implementation :

#CMIO tip #1 for DOCS wanting to fit into the new #EMR paradigm WELL: Learn to type, even a little, or learn to use Dragon well. Your thoughts are too important to be lost to handwriting.
#CMIO tip #2 for DOCS wanting to fit into the new #EMR paradigm WELL: prepare to redesign yourself. You won't be Dr. Kildare or Dr. Welby or Dr. Auslander or Dr. Dorian or Dr. McDreamy when you're done -
You'll be a whole new doctor. Same look, same skills, same caring, same name, new doctor.
#CMIO tip #3 for successful #EMR implementation : the EMR isn't "an IT thing", or an "MD thing", or a "RN thing" - it's everybody's thing.
#CMIO tip #4 for successful #EMR adoption : Patience, part II: Like humans, no product is perfect. You will always question if you made the right choice. The truth : it probably was.
#CMIO tip #5 for successful #EMR adoption : Patience. Realize that government, vendors, docs, administrators, and patients are "still trying to figure it all out"
#CMIO Tip #6 for a successful #EMR implementation : Persistence. Never stop pruning, weeding, and gardening. Have a good gardening team.
#CMIO Tip #7 for successful #EMR implementation : Learn that no doc, nurse, pharmacist, administrator, IT person, or consultant knows the whole story. You need them all to work together before you'll understand.
#CMIO tip #8 for a successful #EMR implementation : plan your budget well. Then increase your budget for training and support.
#CMIO tip #9 for a successful #EMR implementation : Plan your data needs for go-live. Then prepare for them to increase exponentially after go-live.
#CMIO tip #10 for a successful EMR implementation : Break down the wall between IT and clinical worlds. Promote both sides together.
#CMIO tip #11 for a successful EMR implementation : Prepare to cringe every time you hear "Why can't we just _____?" Generally this is NEVER the answer.
#CMIO tip #12 for a successful EMR implementation : Plan for docs in the middle ground. Aim for happy mediums. Walk before you run.
#CMIO tip #13 for a successful EMR implementation : don't just plan for your inpatient docs, plan for your outpatient docs EARLY. Doing this well can be strategic as long as you stay within Stark laws.
#CMIO tip #14 for a successful EMR implementation : Leave your emotions and personal baggage at the door when redesigning clinical workflows. Focus on good patient care.
#CMIO tip #15 for a successful EMR implementation : Recognize the tribal culture of medicine, but don't be limited by it.
#CMIO Tip #16 for a successful EMR implementation : try to avoid the four-letter word : "INTERFACE". Use only when absolutely needed.
#CMIO tip #17 for a successful EMR implementation : Plan staffing for an initial reduction in efficiency. Develop measurable metrics.
#CMIO tip #18 for a successful EMR implementation : be prepared for more training AFTER go-live.
#CMIO tip #19 for a successful EMR implementation : Have a politically neutral, teambuilding, personable, persuasive, and creative CMIO.
#CMIO tip #20 for successful EMR implementation : Dont be discouraged. Even a flat #CPOE rate will respond to nurturing and TLC.
#CMIO tip #21 for a successful EMR implementation : make sure you work on building allies early, before purchasing software.
#CMIO tip #22 for a successful EMR implementation : The secret to physician involvement - give them a chance. A good CMIO will help.
#CMIO Tip #23 for a successful EMR implementation : Grow a crop of clinical "Jedis" who KNOW your clinical workflows,can help bargain and teach them, and help reinforce good IT behaviors. (Clinical "Jedis" : they're not just superusers. They investigate workflows and datamine. They're your best management consultants.)
#CMIO: Tip #24 for a successful EMR implementation : work hard to make a comfortable environment for change. Bad blood slows progress.