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. :)


Ahier said...

Excellent post Dirk! Thank you very much for sharing your insights.

Ahier said...

Excellent post Dirk! Thank you very much for sharing your insights.

rvaughnMD said...

Great stuff but one suggestion - don't feed into the age bias. Some of our under 50 doctors don't type or use the internet (which I think is really surprising) and some of greatest champions are those docs over 50 that have jumped in with both feet.

Dirk Stanley, MD, MPH said...

Oh my god, you're absolutely right - Some of our higest-scoring CPOE physicians are over 50 - There are plenty of people who "break the barriers". It's all about openess and willingness to try new things. Thanks for the suggestion. :)