Monday, June 7, 2010

Preparing budgets for the jump to "going electronic"

I was a child of the 80s, really, so I don't remember what the hubbub was about Bob Dylan "going electric". Wikipedia has an article about the incident, including the public reaction. Apparently it caused enough of an uproar for there to be a whole article devoted to the incident.

Anyway, getting your hospital to "Go Electronic" is probably just as shocking. It's not just a "software update".

First, there are "hidden costs" to going electronic, that vendors can't really tell you about, including :
  1. IT/Software Maintenance costs
  2. Changing hospital managerial structure / governance
  3. Updating hospital policies
  4. Developing Informatics platform
  5. Developing robust training platform (for doctors, nurses, pharmacists, and all clinical staff)
  6. Policy / Protocol / Order set / documentation building and development
... among other things. The hard part : You should plan for these "hidden costs". (Vendors don't generally bring these up before a sale, I think because a) it might cause you to think twice, and b) they often sell consulting services to help fix this stuff later.)

Some more conspiracy-minded folks, when they figure this out, will accuse the vendors of "Not fair! You didn't mention those costs!" - But in all fairness to the vendors, these costs are a hard discussion to have.

Why? Not only are there conflicting financial interests, but vendors often can't gauge your hospital clinically. After all, they are software companies, not hospitals, and so they have trouble giving accurate opinions about your clinical operations.

What I mean is this : If you actually study those "hidden costs" in detail, you'll notice they all depend on how you run your clinical ship. Let's review some of these "hidden costs" again :
  1. IT/Software maintenance costs - Depends on your clinical staff, how they use the system, how often they want things fixed/updated - Every hospital is different. Software companies can't really gauge this for you.
  2. Changing hospital structure / governance - Depends on your hospital's culture, some hospitals have an easy time adjusting, others don't. Software companies can't really gauge this for you.
  3. Updating hospital policies - Depends on your hospital's clinical policies - Some hospitals require only minor updates, other hospitals require heavy changes. Software companies can't really gauge this for you.
  4. Developing an informatics platform - Depends on your hospital's budget and understanding of the term "informatics". Some hospitals will adapt quickly and assign these roles formally. Others will try to do this in small increments. Software companies can't really gauge this for you.
  5. Developing robust training platform for all clinical staff - Depends on your hospital's pre-existing training platform. Some hospitals will require significant changes, others will only need a little help. Software companies can't really gauge this for you.
  6. Policy / Protocol / Order set / documentation building and development - Depends on your hospital's already-existing policies, protocols, order sets, and documentation. Hospitals with good design will have an easier time converting them to electronic. Hospitals that mix their policies / protocols / order sets / documentation will have a harder time. Again - Software companies can't really gauge this for you.
I think one of the hardest things about preparing for the jump, is that to answer these budgeting questions accurately reqires getting an honest assessment of your clinical staff, so that you can plan a good budget.

A good CMIO can help guide these budgeting discussions and decisions before, during, and after your go-live. Most CMIOs continue to practice clinically, so they can learn your hospital and give you an honest assessment of your clinical workflows.

If you don't have this discussion before go-live, you may find yourself with unrealistic early budget decisions which eventually hamper your eventual growth electronically. It's always better to start this discussion and planning process early.

Next post, we'll talk about developing meaningful training mechanisms for both before and after your go-live.

Thursday, June 3, 2010

Denial, Anger, Bargaining, Depression, and Order Sets

More answers to questions about order sets.

Another common question I get asked, actually usually comes to me in one of three flavors :

1. "You mean we spent all of this money on an EMR, and they don't even give you decent order sets?"
2. "Can't we just copy order sets from ______ hospital? I have a friend there!"
3. "Can't we just scan the paper order sets and make them electronic?"

These are all variations on the same theme - What you purchased doesn't seem to fit, and there MUST be an easier way to do this.

I get this fairly commonly.

Many EMR vendors will sell you some sort of package of "Pre-made order sets". Beware! What vendors think of as "pre-made order sets" and what most administrators/clinicians think of as "pre-made order sets" are very different.

Pre-made order sets from a vendor are typically built around common clinical scenarios that most hospitals share in common - The CHF exacerbation, the pneumonia, the chest pain, the pre- and post-op patients.

The problem : A vendor has no way of knowing the exact idiosyncracies of your hospital or office. So they design something in a "one-size-fits-all" kind of way. (Think of it as a "one-size-fits-all" suit - Yes, it'll be too big for most people, but at least everyone can fit into it.)

So typically, these order sets tend to be VERY long, including EVERY evidence-based test and study and medication you can possibly think of.

When most doctors look at these lengthy, one-size-fits-all order sets, however, their first reaction is often : "What?!?! This is WAY too big!! We don't need all this stuff!!"

So the only way you end up trimming this order set to your particular hospital's culture is to go through the entire order set, line-by-line, and checking to see what you need and what you don't.

In the end : You usually end up doing the same amount of work you would as if you started from scratch.

Yes, this leaves many doctors and administrators frustrated. Some will complain to the vendor about this.

A vendor *could* try to help, and take a "best-guess" approach, and try to trim their "standard CHF admission" order set down - But this would leave 1/2 of their customers more happy, and 1/2 of their customers less happy. (Now, think of it as the vendor trying to make a smaller suit - It'll fit 1/2 of their customers better, but 1/2 won't be able to fit in the suit at all.)

Again - This is why the pre-built order sets often leave doctors and administrators frustrated.

After experiencing this phenomenon, clinicians and administrators will often go into "bargaining mode" - You may hear things like "I have a friend who can give us their order sets!" or "I found a web site with order sets!" or "Can't we just scan our paper order sets?"

The problem is - These order sets generally suffer from the same problem as the "best-guess" approach I described above - The suit may fit, if you're lucky, but it also may not. Often, getting order sets from a friend, or from a web site, or from your old paper version is a lesson in frustration, and again you have to tailor it to your hospital with your culture and your clinical circumstances.

In short : Thinking there is a "quick fix" to your order set problem is like thinking there's a "quick fix" to having a custom-made suit. Order sets, like a well-fitting suit, need to be tailored and adjusted and updated regularly.

Remember - It's the custom-fitted suits that look good - In the same way, custom-fitted order sets are the ones that doctors will *want* to use, will help increase your efficiency the most, and ultimately help cut your hospital's operating costs.

So ask yourself before you buy an EMR - Do I need a tailor to help build and adjust these order sets? Or can I get copies from other people, and hope they'll fit?

My advice : Make sure you have a tailor when you go electronic! :)