Sunday, November 29, 2009

Embedded Informaticist Culture = Wave of future?

I'm going to use this moment to play "Healthcare IT Futurist".

ARRA/HITECH are here, and the ink is almost dried. You may be asking yourself : How am I going to get my hospital up-and-running on a new EMR? How can I make our EMR project succeed?

I've already written a bunch about the little-known secret : Clinical Informatics.

If you're serious about success, then you may be asking yourself the follow-up question : If Clinical Informatics is the answer, how do I get this into my hospital?

Let me tell you about the inspiration I used to solve this problem.

Get ready - It's modern, hip (perhaps too much), and most healthcare people are sort of shocked when I tell them the answer : Star Wars.

The original 1977 movie, written by George Lucas, has clearly been influential on me and most Generation Xers. It is firmly woven into the popular American culture. It's been parodied endlessly on YouTube, and for good reason : Parody is the sincerest form of flattery. Words like "Jedi" and "Yoda" have worked their way into the general American lexicon, and for good reason : George Lucas managed to work the power of myth into a really good story about human themes like good and evil and redemption.

Obviously, it struck a chord : According to Wikipedia, a 2007 AOL UK Money article estimated the six movies have netted over $4.6 billion worldwide as of 2008. (I'm trying to find the actual source of this estimate, but it seems most internet links refer to the Wikipedia quote : Please don't shoot the piano player.) Anyway, the exact amount is irrelevant. It was still a worldwide hit.

Anyway, you're probably wondering, "So why is this CMIO writing about his Star Wars inspiration?"

Yes, I am a fan, but what I want to do is give some insight into how the movie helped me to successfully develop an embedded informatics program.

First, a reminder on the tribal nature of medicine : On starting down the road to implementing your EMR, you'll be quickly reminded of how tribal medicine is :
  1. Doctor tribe (includes the sub-tribes : ED, Hospitalist, OB/GYN, Pediatrics, Surgery, etc.)
  2. Nurse tribe (also includes the sub-tribes : ED, Hospitalist, OB/GYN, Pediatrics, Surgery, etc.)
  3. Pharmacist tribe
  4. Dietitian tribe
  5. Other ancillary service tribes
To take care of your patients, each of these tribes does a unique dance with eachother. Often patient care starts in your ED, where a member of the ED Nurse tribe - The triage nurse - Starts the dance. The Triage Nurse then communicates with other ED staff, to continue this elaborate dance. Eventually, your ED Doctor and Nurse start to communicate with inpatient staff, often a Hospitalist and inpatient (med/surg) nurse.

So... When you get an EMR, you'll quickly see these tribes come into conflict with eachother, as you try to re-arrange things to work in the "electronic world".

Again, you're probably wondering : "Dirk, where are you going with this?"

Well, here's how this tribal conflict affects your EMR implementation : To successfully implement your EMR, your CPOE, and your order sets : You will need to know VERY, VERY well about how your tribe members do their dance. And you will need to be able to negotiate their tribal cultures to adapt to a new world.

In clinical language, that means, "You will need to play nicely with other groups and be able to describe what you do very clearly for the IT people, or else your EMR implementation is going to be rocky."

In management language, that means "You will need to know, communicate, and negotiate their workflows VERY, VERY well, or else your EMR implementation is going to be rocky."

In political language, that means "You will need to figure out who's going to make these highly technical decisions, and how these decisions will be accepted, or else your EMR implementation is going to be rocky."

In financial language, that means, "You'll have to budget for people to help analyze your workflows, or else your EMR implementation is going to be rocky." (In a past post, I wrote about how this is the "hidden cost" of EMR implementation that most vendors don't fully explain, and even when they do, most of us don't understand the message.)

Now I can hear you asking, "So Dirk, how does a Hollywood movie (Star Wars) help me implement my EMR?"

Before I give you the answer : Remember, when you start to tackle the enormity of the workflow analysis needed to support your EMR transition, that you're generally faced with two options :
  1. Hire an outside consultant to help solve the problems.
  2. Use your own staff to help solve the problems.
Hiring an outside consultant is often a good answer, because outside consultants will often know the strategies needed to successfully implement your EMR. If your hospital is completely new to the term "Clinical Informatics", and/or you don't have a CMIO, an outside consultant may actually be your better option.

The downside? They won't know your hospital culture. If you're lucky, they'll have some clinical experience, but ultimately they're not a member of any of your clinical tribes, so they will take time to learn the workflows. And that's going to cost you money as they learn.

So suppose you want to use your own staff...

The good parts of using your own staff (embedded informaticists):
  1. You can potentially find your own clinical tribe members who know your workflows.
  2. You can potentially harness them to help train your other clinical tribemembers (e.g. An ED doc making sure all ED docs know your ED doctor workflows, an ED nurse making sure all ED nurses know your ED Nursing workflows, etc.)
  3. You can potentially harness them to help your IT department develop systems which integrate well into your hospital.
  4. You can potentially harness them to develop decision support to increase your revenues.
  5. You can potentially harness them to perform CQI/Datamining for their clinical tribe.
  6. You can potentially harness them to help negotiate new workflows (e.g. If we have to re-do things to work in the new electronic world, how are we going to do it?)
The hard parts of using your own staff (embedded informaticists):
  1. Budgeting for their time to do this.
  2. Identifying "Who's the best person in each tribe to do this?"
  3. Training them to do this.
  4. Figuring out, "Once these embedded informaticists start to organize, how are we going to fit their highly technical opinions into the hospital hierarchy?"
So finally : Here's where George Lucas and Star Wars have provided me with enormous inspiration to solve this problem. (I highly recommend going out, buying the entire series, and watching it to review!) :)

When you watch the series, pay serious attention to the Jedi Knights that exist throughout all six Star Wars movies.

Loosely paraphrased from the Wikipedia page on Jedis, I bring to you the mythical Jedi code (for those of you who may not be big fans of the movies) :
  1. Jedi are the guardians of peace in the galaxy.
  2. Jedi use their powers to defend and protect, never to attack others.
  3. Jedi respect all life, in any form.
  4. Jedi serve others rather than rule over them, for the good of the galaxy.
  5. Jedi seek to improve themselves through knowledge and training.
In the interest of avoiding legal problems, I am certainly *not* advocating creating a new position in healthcare called "Clinical Jedi". At least, not unless you get George Lucas' blessing. And even then, prepare for your HR department to raise some ugly questions, like, "What is the going rate for a Jedi?" :)

But what you will find by watching the series : To adopt an embedded informatics culture in your hospital, you will essentially need to find the people in your hospital who follow this mythical Jedi code.

What I did, to develop our embedded informatics group, is make some modifications to the mythical Jedi code, to give it some real-world clinical practicality :

An embedded clinical informaticist :
  1. ... is a solid clinician who lives in the clinical world (generally at least 80% of the time)
  2. ... ultimately serves the patient, then their clinical tribe, then IT/hospital administration (in that order).
  3. ... is passionate about knowing their workflows.
  4. ... is politically neutral, like Switzerland.
  5. ... is intellectually pure, like behind the curtain of a voting booth.
  6. ... believes in the power of negotiation and education, rather than "brute-force" solutions.
  7. ... is "IT-friendly".
  8. ... can perform basic data-mining on your electronic clinical data, to help them understand the functioning of their clinical tribe, and thus become a better informaticist.
  9. ... works with administration to identify goals for improvement and help support those goals from an informatics perspective.
  10. ... works with their clinical tribe members on training, education, and workflow analysis.
Traditionally, informatics has been seen as something that's run in an office, or a small group. What's unique about an embedded clinical informaticist : This brings informatics right to the front line of your clinical care.

Culturally, this is like Gutenberg developing the printing press to spread the power of communication to everyone. Having an embedded informaticist in a clinical tribe will only help the functioning of that tribe.

I can only report that we have had tremendous success with following this model, and while I admit I am still struggling with budgeting and organizational issues (like most hospitals do, when they implement an EMR), I have quickly been able to identify about 25 clinical people who are willing to follow that code and fill this role, and we now have a mechanism to help bring clinical informatics to the front-line of clinical care.

This not only helps the stability of our EMR implementation, but it also helps improve communication and coordination between departments. Ultimately, this all helps to improve patient care.

So finally, before I end for tonight, I would like to thank George Lucas for using the power of myth to inspire a generation of leaders. Even those working in healthcare. :)

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