Improving EMR Satisfaction by Better Anticipating Clinical Needs

Hi fellow CMIOs, CNIOs, Clinical #Informatics professionals, and other #Healthcare leaders,

I'm writing today to share my thoughts about how to improve EMR user satisfaction through a better understanding of the user's clinical roles and responsibilities, and how they impact EMR configuration and training. 

Allow me to explain. Imagine you see a group of people with white coats and stethoscopes, eating lunch together. What are their needs? Are they all one kind of provider, or different providers? How could you tell them apart? And even if you could somehow tell them apart, how would you know exactly what their EMR configuration and training needs are?

Most clinical people think of these as small details. To them, clinical roles seem fairly intuitive, and credentialing seems like little more than a time-intensive requirement to 'do paperwork' before you can begin working clinically. Both of these are common misunderstandings. 

The truth is that clinical roles in modern healthcare are very nuanced, each with their own clinical functions and supervisions needs, and so your exact clinical role and responsibilities have an enormous impact on your EMR configuration and training needs. Without a clear understanding of your clinical role and responsibilities, it's very  challenging to provide the right EMR configuration and training, which can lead to frustrated end users.

So to help improve EMR configuration, training, and user satisfaction - I thought I'd offer this little blog post to help you understand how clinical role terminology, supervision requirements, and onboarding/credentialing questions can help improve EMR configuration and training, as well as end-user satisfaction. 

So in short, we'll discuss some basics about four topics : 

• A - What is a Doctor (Physician)? What are the different types of Doctors (Physicians), and when/how are they supervised?
• B - What is an Advanced Practice Provider (APP)? What are the different types, and when/how are they supervised?
• C - What is a Provider (Prescriber)?
• D - What kind of questions can you ask during on-boarding/credentialing to help make sure you fully understand the provider's role and responsibilities, so you can better anticipate their needs and provide great configuration and EMR training?

Let's get started!

A. WHAT IS A DOCTOR (PHYSICIAN)?          
For those of us who have been through medical training, this all seems fairly intuitive. You finish medical school, get through internship, complete your residency, and many docs continue through a fellowship (subspecialty) training, before becoming an Attending Physician. And along the way, you will work with lots of great Advanced Practice Providers (APPs) including Advanced Practice Registered Nurses (APRNs), Physician Assistants (PAs), and others. 

But imagine if you weren't clinical. Looking at a group of people with white coats and stethoscopes, how could an administrative or IT person tell them apart? It helps to have some good definitions to work with!

Let's start by looking at what exactly is a "Doctor" (Physician).

Note that the supervision model above requires a number of workflow configurations in an EMR - Most commonly, with orders and clinical documentation (notes) - 

• Which order(s) WILL require an attending countersignature?
• Which order(s) will NOT require an attending countersignature?
• Which note(s) WILL require an attending countersignature?
• Which note(s) will NOT require an attending countersignature?
• Knowing the EMR will function differently for Residents, Fellows, and Attendings - How will the EMR be configured for Fellows who sometimes moonlight as Attending providers?

In addition to a clear understanding of these roles, responsibilities, and configuration differences - It's also important that an organization have an easy way of knowing when doctors change their roles. (July 1st is not a guarantee that a doctor's clinical role will change!)

B. WHAT IS AN ADVANCED PRACTICE PROVIDER (APP)?       
With the expansion of medical technology and clinical specialties in the 1970s and 1980s, came a new set of providers who could help 'extend' the reach of the attending physician, including Advanced Practice Providers (APPs) such as : 

These roles also have unique EMR configuration and training needs, which are highly dependent on the supervision needs, which often depend on state regulations. Like Doctors/Physicians, having a clear understanding of these clinical roles and their supervision needs is key in providing the proper configuration, security, and training. 

C. SO WHAT EXACTLY IS A "PROVIDER" (PRESCRIBER)?      
So to put this all together, we can now represent the Doctors (Resident, Fellow, and Attending Physicians) and Advanced Practice Providers (APPs) as a common set of Providers (Prescribers), each with a DEA number and prescriptive authority, but with different supervision needs and expectations : 

Again, this catch-all term can be helpful, especially for pharmacies that want to provide services to all of these roles. It's not as helpful in legal/billing scenarios, where usually the Supervising Attending Provider (1c) (and sometimes the independent APRN!) are more commonly the focus of discussion.

D. CREDENTIALING AND EMR CONFIGURATION AND SUPPORT
So we've discussed how these clinical roles impact EMR security, configuration, and training. What other questions can you ask, to better anticipate a user's clinical needs, configuration needs, and training needs? While it may not be comprehensive, I recently drafted this list of questions you might ask a provider during on-boarding and credentialing, to better understand and anticipate their clinical, academic, research, and administrative needs:  

Again, this list of questions may not be comprehensive, but it helps show how good credentialing and provider on-boarding can help HealthIT people to better understand a user's clinical, administrative, research, and academic roles, and anticipate the specific needs for each role. 

I hope this was helpful in shedding some light on these important topics! Remember : It's the little details that matter. If you have any feedback or comments, please leave them in the comments section below.

Remember this blog post is for academic and educational discussion only - Your mileage may vary, and always check with your local Legal, Compliance, and Clinical Informatics experts for guidance in your own organization. Have any feedback or thoughts? Feel free to share below!

Why You Should Always Map the Current State

Hi fellow CMIOs, CNIOs, #Informatics, and other #HealthIT leaders,

Today I'm writing to discuss a fairly common question in clinical change management, related to the practice of 'mapping the current state': Is it really necessary?

When planning a clinical improvement project, it may be one of the most common newbie mistakes: Thinking you can't, or don't need to analyze the current state : 

It has been said that Clinical #Informatics and #workflow engineering is a bit like 'rebuilding the plane while it is still in the air' - Healthcare is in business 24x7, and can't really shut down, even for a few minutes, without a potential impact on patient care. (This is one of the things that separates #HealthIT from #BusinessIT, #AcademicIT, and #ResearchIT.)

So in today's fast-paced healthcare environment, it's more important than ever to make sure that projects are executed well, on-time, on-budget, and according to plan. And this is where our discussion starts : How to make sure you're really planning well. 

First - Without mapping the current state, it looks something like this : 

... and then it becomes impossible to tell if your project is going to look like this : 

... or this...

... and so without a current-state assessment, it's easier to either under- or over-estimate the work it will require to get to Point B. 

Remember, smooth workflow change is not just about the configuration you need to do inside the EMR - It's the work you need to do outside of the EMR too, including development of staff education needed to get your clinical teams from Point A to Point B - See #7 in the grey box on the left-handed side below : 

Taken from my 11-18-2015 blog post, 

"The Informatics Domain and Workflow Management"

Again, in today's healthcare environment, having smooth, well-executed workflows and projects is more important than ever. As an example, Dr. Danielle Ofri recently wrote this very relevant opinion piece in the New York Times which really introduces the importance of well-designed, well-planned workflows :

"The Business of Health Care Depends on Exploiting Doctors and Nurses"

(June 8th, 2019)

... in which she writes, "With mergers and streamlining, [corporate medicine] has pushed the productivity numbers about as far as they can go." After she describes some real problems with the efficiency of some EMR documentation, she shares this insight, "But in health care there is a wondrous elasticity - you can keep adding work and magically it all somehow gets done."

While Dr. Ofri is quite right that this is a commonly-held belief, there's still a basic problem: Math is math. Healthcare should not plan to do 25 minutes of work in a 15 minute timeframe. So in the national discussion about physician burnout (#physicianburnout, or as ZDoggMD describes it, 'moral injury'), it's more important than ever to make sure workflows serve the needs of the patients, providers, nurses, pharmacists, and other clinical and administrative people working in #healthcare. To make sure we're not overloading our clinical teams, every data element needs to be well-analyzed, well-studied, well-planned, and serve a legitimate patient care or business function.

And this is why the current state is important. Without studying the current state, it becomes very challenging to answer questions like: 

• Which stakeholders need to be involved in this project?
• How much time will this project take?
• What training and support will we need to go-live with the planned future state?

Still, some people express concern about the work it takes to map the current state, or question the real benefits. Allow me to share some common arguments, along with my counter-arguments : 

ARGUMENT : "We don't have time or resources to map the current state." 

COUNTER-ARGUMENT : "Will we have time or resources to fix things that we didn't account for? How will we know the scope of the effort, who to invite to meetings, or how much educational effort we will need to plan for?" 

ARGUMENT : "It's not worth mapping the current state, last time it took us hours and we still couldn't figure it out." 

COUNTER-ARGUMENT : "Not being able to map the current state, despite best efforts, is still a really important factor to consider when scoping and planning a project." 

ARGUMENT : "We don't want to map the current state because we don't want to bring old habits into our new workflow." 

COUNTER-ARGUMENT : "Even though there may be parts of your current-state workflow worth keeping, it's not to bring old habits into your new workflow - It's to make sure we're covering all of our bases, and doing the best job planning, designing, and executing that we can."

ARGUMENT : "It takes too much work to map the current state." 

COUNTER-ARGUMENT : "It doesn't need to take a lot of work, and you don't always need Visio swimlane diagrams. For many workflows, a simple well-written procedure with each line written as [WHO] will/may [WHAT] will do the trick. Even if it's not documented - it's still important that whoever plans the project has ample access to someone with a good understanding of the current-state workflow(s)."

Fortunately, most experienced Clinical #Informatics and #HealthIT professionals know the importance of mapping the current state in planning clinical improvement projects, and how to map it quickly. So if you ever need help mapping the current state, ask your local Clinical #Informatics or #HealthIT experts for assistance!

Remember, this blog is for academic discussions only - Your mileage may vary. Seek expert advice from your leadership, legal counsel, clinical informatics, or project management teams before changing strategies. Do you have any questions, comments, or feedback? Leave them in the comments section below!