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.


ORQA said...

You may want to check out our Open Source (free) software for your Jedis. That role ties in very closely with Operational Risk Management, which is what we do.
Our app is true web 2.0 (no client) and integrates easily with EMR web & PACS clients for prepopulating specific forms.

-Document workflow
-submit technologist feedback
-physician peer review document
-manage policies
-link workflow to policy
-submit adverse event reports
-quantify cultural issues (good & bad)
-suggestion/comments forms
-incident reporting
-workorders (either internal Jedi workorders or for tracking IT)

rvaughnMD said...

Organizing your change management, when possible, around improved patient outcomes can help bring the various stakeholder groups together. We have found that nurses, physicians and pharmacists know only a fraction of the workflow of others and showing the entire workflow often helps them to agree to a change that makes things clearer for someone downstream. Pharmacists are key since they are the critical linkage between physicians and nurses - but if you aren't careful EHR can actually interfere with that relationship.

Dirk Stanley, MD, MPH said...

Yep - We have Pharmacy Jedis (two of them in fact) -
It's amazing at how involved people get when they actually understand the big workflow and their role in it.
Thanks for the comments! :)