Tuesday, September 22, 2009

EMRs and Governance - Brace yourselves!

So I think probably one of the things they don't warn you about when you "Go EMR" - It really does change the way you conduct business.

Doctors and nurses have to re-think the way they interact.
Nurses and Pharmacists have to re-think the way they interact.
Doctors and Pharmacists have to re-think the way they interact.

It also means Doctors have to be prepared for CPOE.

I've written a little about our "Jedi Informatics Pilot" that we're working on. The group has been super-useful in :
  1. Figuring out "What's an IT issue" and "What's a workflow issue" (So far, about 80% of the problems I've investigated have been workflow issues - The other 20% are "IT issues")
  2. Of the "Workflow issues", figuring out exactly *what the issue is*.
  3. Figuring out how to fix the workflow issue.
  4. Figuring out what education and/or policies are needed to support this new fix.
The problem is, that this is a special group that is new to most hospitals.
  1. Where do you put such a group?
  2. How do you control the "mission creep" of such a group?
  3. Who will lead such a group?
  4. Do they have adequate support from administration and department directors?
  5. How will your traditional committees and departments react to a new group of "Informaticists" dissecting your policy, dissecting your workflows, and reassembling things?
And lastly, one of the possible messy political issues becomes, "If there's a group that has to oversee the implementation of every systems change in our hospital, doesn't it in fact become the police for the hospital?"

And this is a challenge, I think, every CMIO faces as they grow their group - Navigating the political battles as they manage change in the hospital.

(Perhaps, another reason to be "Jedis" instead of "Police" - Has a more benevolent image, and, quite frankly, the "informal" nature feels less threatening to other interested parties.)

But then the difficulty comes - If your informatics group is an "informal" or "loosely-knit" group of clinicians, dissecting their workflows - How will their recommendations be received? Especially when their recommendations mean extra work for other clinicians?

I guess my only advice, to hospitals going through these changes is - Be prepared for the politics of "going electronic". Good IT follows good politics. Bad IT follows bad politics. If you want to be successful at EMR implementation, ask yourself these questions :
  1. Do our department directors have any experience with Informatics? (Do they understand what Informatics is?)
  2. Do our department directors "get along" in general?
  3. Do our front-line clinicians "get along" in general?
  4. Is there adequate administrative support for the political and cultural shift?
  5. Is there adequate clinician involvement? Do doctors generally show up for extra meetings?
  6. Who are the "thought leaders" in the various clinical tribes, and how can I get them to act as ambassadors in the new paradigm?
  7. Are our department directors and administrators aware of the culture shift associated with EMR use?
  8. Who will be responsible for overseeing this culture shift? (In general, "Leaving it to the vendor" is not the right answer.)
Thanks for all of the comments to my last few blog posts - Always interested to hear people's thoughts. Certainly interested to hear from other CIO/CMIO types to learn of how they handled the governance shift needed for successful EMR implementation.

Tuesday, September 15, 2009

Are Jedi Informaticists the solution to small IT staffs?

So I thought I'd write more about the "Jedi Informaticists" we're growing at our hospital.
(Yes, the "Jedi" title is informal, and makes everyone smile/cringe when you say it, but bear with me.) :)

I've recently come across CMIO types from larger hospitals who have robust informatics groups. Some have an entire informatics department. Others have large groups of physician champions, data analytics groups, report writers, workflow analysts, and multiple consultants helping to ensure the proper implementation of their EMR.

Smaller hospitals are often pressured to "do more with less", and don't have the budgets to support a large informatics staff.

Currently, we're piloting a group of "Jedi Informaticists" - Representatives from various clinical specialties who identify themselves as "Jedis". (Yes, we are looking for another name, but for some reason, people sort of enjoy the Jedi title - It keeps things informal, keeps it fun, keeps it light, and perhaps most importantly... They get to go home to their families at the end of the day and say "I'm now officially a Jedi." Oddly, this effect, so far, seems to inspire people to show up to meetings more regularly.)

So what is a Jedi, exactly?

A Jedi is a representative from a clinical specialty who :
  1. Is committed and passionate about good patient care.
  2. Is an excellent clinician (knows what it takes to be a good doctor, a good nurse, a good respiratory therapist, etc.)
  3. Knows and is passionate about understanding their *workflows* - Not only what it takes to be a good doctor/nurse/pharmacist/etc., but what information they need, what they do with that information, who they give that information to, and what order they interact with patients in a big-picture-type view.
  4. Is committed to "intellectual purity" - The same sort of purity that you get from having a curtain in a voting booth (so you can tell your family you're voting one way, but if you think it's really in the best interest of the country, you can vote the other way, as unpopular as it may be.)
  5. Is committed to political neutrality - Thinks mainly of "what is the best thing for the patient", and does not bring their political/emotional baggage to the negotiating table.
  6. Is committed to the art of negotiation - Nobody should walk away from a negotiating table unhappy, and *both* people have to be committed to making sure *the other* is happy before negotiations are done.
  7. Is IT-friendly, and knows the EMR software well.
  8. Is comfortable teaching their colleages (from their clinical tribe) about new workflows and software operations.
  9. Has basic "data-mining" capabilities - You provide them with raw data from your EMR, they can use Excel/Statistics packages, and a basic knowledge of descriptive statistics (e.g. gaussian distribution, mean, mode, median, etc.) to understand the functioning and efficiency of their clinical tribe.
Most often, these people are not the directors - But rather, front-line staff who work closely in conjunction with the clinical directors. (Jedis DO NOT replace directors - But they help the directors navigate the IT waters that sometimes can be time-consuming. Ultimately, all decisions are made by the clinical directors.)

Some people have asked me, "What's the difference between a 'Jedi' and a 'superuser'?"

I like to think of it as a Jedi has much more power than a superuser. (Yes, you can laugh. It's intended to be fun and informal.)

Most people think of superusers as clinical staff who know the software and can teach it to other people.

Clinical Jedis, I believe, fill some additional roles :
  1. Workflow experts and negotiators.
  2. Clinical Data Analytics / Data miners - They help perform CQI for the department.
  3. Information gatherers
  4. Workflow Trainers
  5. Translators : They speak IT for the clinical tribes, and speak their clinical tongue for the IT staff.
So far, our group has grown remarkably in size, and we are looking to "formalize" this position. Some challenges remaining include :
  1. Is there a more formal title we can call these people? How does that impact their HR positions?
  2. Is there a benefit to "not really being formal"?
  3. Where does this group fit in the traditional hospital hierarchy?
  4. Who will this group report to?
  5. How does one control the "mission creep" of such a group?
  6. How does such a group control the number of issues they are asked to tackle, from IT staff (e.g. looking to figure out what the immediate clinical needs are), Clinical staff (e.g. looking to develop IT systems to meet particular needs), Administrators (e.g. looking to increase efficiency in different departments), and Regulatory groups (e.g. looking to ensure that all compliance issues are being met.)
I'm currently helping to guide such a group, and proceeding cautiously and carefully as we start to navigate the twists and turns of meeting the rapidly-changing demands of a hospital going EMR in a modern healthcare environment.

Hopefully some of this will spur some ideas in other folks. Would love to hear from other hospitals about how they handled the governance issues involved in "going EMR".

Oh, and my advice : Don't use "Jedi" label - Not only does it potentially open up a can of worms, there's nothing harder than discussing a "Jedi Council" with a group of physician administrators. :)

Friday, September 4, 2009

EMR = Need for new hospital management tools

So I thought I'd write a little bit more about the cultural shifts that an EMR brings to a hospital. (I say this, after the remarkable success of our "Jedi Informatics" group that seems to be building as we move forward in navigating the culture shift.)

Have you read any blogs about EMR software? Recently I stumbled upon a group of ED physicians who were having a very public discussion trashing various EMR software vendors. I sat there, reading their testimonials, about "The ____ EMR was trash and we had to deinstall it!" and "Another EMR was awful and nobody is using it."

And then I thought... Are they serious?

Yes, I know (as a practicing physician) that EMR software, especially when you get into CPOE, can be a palpable culture shift. (To some, it's a speedbump - To others, it's an earthquake.)

Yes, I know there is some question about how long the efficiency-drag lasts, after implementing an EMR, and some physicians have questioned whether this drag makes the safety / organization worth it.

But then I wonder - How many of those implementations were improperly implemented?

As a former computer programmer, I can also tell you about programs which were well-designed, and well-constructed, but because there was no proper implementation plan, the software sat there, unused.

How many of you can testify about a particular program that "We spent a lot of money on, but nobody used"?

So again, reflecting on this group of ED physicians, who were relating similar stories - I wondered, "What kind of implementation plan did they have?!?!"

Ultimately, I guess, I seriously question : Was it their software, or was it their implementation plan?

As I continue to work in my CMIO role, I explore a lot of "computer complaints" which are perceived as "The computer isn't doing ____ right" - But after detailed exploration and analysis of these multiple complaints, more often than not it relates to :

1. An education / training issue
2. A workflow issue
3. A policy needs to be updated or modified.

... rather than an actual software issue. (Yes, the software appears to be malfunctioning, but when you do an analysis, the root cause of the problem often relates to 1, 2, or 3 above.)

(This is why, some people have asked me, "Why are you discussing so much management and policy? I thought you were supposed to be focused on the computers!?!")

So this brings up the problem : How is a hospital supposed to manage this sort of change? Are our traditional policy mechanisms (such as the Medical Executive Committee) nimble enough to adjust?

And this brings me to my points :
1. Hospitals that handle these changes nimbly will likely have successful EMR implementations.
2. Hospitals that are mired in their old policies/procedures, and fail to develop structures to adjust quickly, will likely have unsuccessful EMR implementations.

Or, more simply put : "Don't think of your EMR as 'an IT thing' - It's 'a hospital thing.'"

Having good leadership to help educate your department heads (like a CMIO) is a good way to ensure your managers understand the questions they'll be asked. Until then, I'll just continue to blog freely. :)

Will write more in my next post about what I'm doing to help adjust this part of the medical culture. :)