Thomas R. Yackel, MD, MPH, MS is chief health information officer at Oregon Health & Science University in Portland, OR.
Tell me about your background and what you do.
I’m a general internist by training. I continue to practice outpatient and inpatient medicine about 30% of my time, but 70% is in a relatively new position here at OHSU called chief health information officer.
I started out at informatics. I actually came out to Oregon to do a fellowship with Bill Hersh in medical informatics, one of the National Library of Medicine fellowships. Did that for two years, got a master’s degree, and then was lucky enough to stay on at OHSU.
At the time, we really weren’t doing too much in health IT. We had Siemens Lifetime Clinical Record, we had a scanning system, and so we had a pretty good repository, but we weren’t doing any CPOE or anything really challenging or interactive.
After I was here for about two years, the medical group got interested in EMRs when they were building a new building and realized that record rooms would cost too much per square foot. That really kicked off our adventure into enterprise electronic health records.
I guess six years or so later, here we are and we have an almost fully-deployed enterprise electronic health record and the full suite of Epic applications; including e-prescribing and MyChart, and rolling this out to affiliates and all the billing and scheduling and good stuff that goes with it. Reporting, too. It’s just been kind of a neat and fun ride.
How important do you think it is for your credibility that you continue to practice medicine?
I think it’s important for a lot of reasons. Credibility, I think, is one thing, just in terms of making contacts with people outside of the context of the EHR is super helpful to me. Having some people actually come to me as their patients, who I also work with, is kind of an honor and something neat.
I don’t know how other people do this if they don’t actually use the system that they work with, but I would have to spend a lot of time learning a lot of details that you just kind of learn as a user. So I find it immensely helpful and fun to continue practicing.
What are the most important lessons you learned from the Epic rollout?
You pretty much have to do everything right. Health IT is not fault-tolerant, in terms of big projects. You really have to get all the ducks in a row in order to be successful. There are some exceptions to that you make and do better at some things versus others, but I think you really have to cover all your bases to keep the thing moving forward. It’s an uphill battle to do it.
Truthfully, a lot of it is attention to detail. Details are critically important in this. Keeping an eye on those details, making sure all the ducks line up, and trying to acquire the best talent that you can. People that appreciate those details that have a passion for doing informatics-type work. Pairing up with a vendor that shares that same attention to detail and understanding that you have, to get everything right in order to be successful, that has smart people.
Having leadership/ownership buy-in to everything that you do is crucial. We don’t implement health IT for health IT’s sake, we implement it for health systems’ sake. Getting executives behind that and understanding they need to understand a lot of the details too, because sometimes you look under the hood in health IT and it’s a little bit frightening what you see under there. They’ve got to be comfortable with that and be there to back you up when things get tough.
How is your project structured, in terms of ownership, and how did IT fit in the mix?
In terms of the rollout, IT was the project. I don’t want to say ‘owner’, but maybe we’ll say ‘steward’. We organized everything around IT. Once the project was done, we delivered things back to operations. In places where we didn’t have an operational owner, we created one.
The interesting part of this whole project was that initial kickoff. It was our medical group that actually wanted to do this and put up the money to do it. It was the physicians actually paying more than half of the cost. That was instant ownership for them.
Then we organized around IT for the project and for getting it rolled out. When we were done, really wanted to, again, turn the keys back over to the owners and say, “This is your tool, and now it’s yours to use and IT is here to help you.” In the places where we didn’t have an owner, we created one.
As chief health information officer, what I oversee now is a new department called the Department of Clinical Informatics. That group was created because as we sat around the table figuring out OK, now that we’re done, what goes where, we realized there was no owner for all the workflows that we had created in the EHR. There was no group that fronted the customer to IT, or owned the institutional organizational issues that basically came to light as a result of the EHR. So, we created a new department for that.
We also created the Department of Learning and Change Management too, because we didn’t have an operational institutional owner for projects of this magnitude and the ongoing training and change management that would be required for it. That was kind of neat because all of that bleeds out beyond just the EHR and you realize, “Wow, having an informatics department is helpful not just for EHR, but for things that you want to accomplish with electronic systems, or when you need to organize people together around an electronic system to make something happen.”
Likewise, in the learning and change management department, there’s operational changes that may be somewhat enabled by IT. But really, now you’re teaching people how to do their job differently. Not just the new tool, but really do what they’re doing differently, and then how to use the tool to do that. To achieve quality objectives, for example. That’s been kind of neat to watch.
The Department of Clinical Informatics, does that cover just the practice side or the whole facility? Also, what’s the structure and composition of that group?
It’s the whole, what we would call ‘OHSU Healthcare’. It’s both ambulatory and inpatient. It’s multidisciplinary. My title, chief health information officer, was chosen … we didn’t want to make it a chief medical information officer. We didn’t want to create separate silos of medical informatics, nursing informatics, etc. Put it all under one umbrella.
I have two roles. One is this operational person who has this department that I oversee; but then also, I chair one of the four subcommittees of our professional board, our governing structure. We’ve got four subcommittees: safety, quality, operations, and the new one, informatics. People really recognized how important informatics was, and that it really stood up against all those other things that we needed to work on.
In the informatics department we’ve got a director. Then underneath that we’ve got three main groups. One is our clinical champions: physicians, nurses, pharmacists, etc. that work on the project. Our entire HIM department, including coding, was brought in as well.
Then we’ve got a group that came from IT. The systems experts — people that were involved with workflow, design, clinical content creation, and reporting — all came in as well. We created this team to try to make sure we had people covering the entire lifecycle of project changes and implementation, delivering stuff to users, and reviewing the contents of the quality of the record, which is obviously an important task for HIM.
That’s probably a bigger scope than the average CMIO, or even IT department, to have all of HIM plus the functional IT people. Was that difficult to sell, clinically?
I should point out that we also have about a dozen people that came from IT, and yet we’ve still got our whole IT department which is separate from us. We’ve divided up the responsibilities where we’re more content-oriented, we’re more workflow-oriented and we front the customer. So, we’re the ones that run all the subcommittees of the professional informatics board to figure out OK, well, what are the requirements that people need? How do we prioritize projects?
Then the idea is that we hand off to IT well-spec’d out details of, “Here’s what we need the system to do”, or “here’s what we need built”, or “here’s what we need you to work on with the vendor so they can do their IT role and not get too bogged down in trying to figure out what does the customer really mean when they say, we want this.”
But I think you’re right, in terms of the HIM part of it and really seeing HIM as now part of informatics. I don’t know that everybody’s doing that, but we thought it was crucial. I think HIM is the glue that holds your record together. They’re the ones who are charged with doing quality reviews of the record.
People complain all the time, “I don’t like the record. I don’t like the notes. People cut and paste too much.” HIM oversees that. They have a huge role in scanning, and scanning’s another piece of glue that keeps an electronic system together because we’re still in a paper world and we interface a lot with paper systems.
Then coding, too — we create clinical content in informatics. The doctors use it, and then the coders read every single thing that they create. It would be a missed opportunity if we didn’t have the coders able to talk to the people that created the content in the first place and say, “Hey, I’m noticing people are using this well” or “They’re not using it well.” Or, “We could do a better job in our templating to accomplish our documentation requirements.” That’s how we thought about it when we put it together.
When you started the project, I’m sure you had some metrics in mind to measure before and after. What kind of measurements have you done, and have you seen the results that you had hoped to?
Looking back, I always feel like we could have done a better job with metrics; and also recognize that a lot of the things that you’d love to know when you do this, you never measured before. We looked at some of the standard things, and a lot of times, the data that we had.
I think one of the most easily available metrics that we had was our dictation. We were dictating pretty much 100% for all outpatient visits, all H&Ps on inpatient, all discharge summaries, all operative notes.
We watched each clinic as we went live and saw what happened to their transcription. It was so interesting. In primary care, it went from 100% to about 2% within a calendar month. In specialty care, it dropped down to more like 10% of what it was previous and then just kind of hung out there. It was an interesting marker of use of the system for me. To think, “Wow, people went from 100% dictation to 2% dictation. They must really be using the system.”
Although I learned that wasn’t really a statistic I should really share with my physician colleagues, because when they looked at that, they said, “Yeah, now we’re typing all our notes. We’re doing all this work. See that? We’re busting our chops to get this done. We don’t like that number.” So, I stopped showing them that. But to look at it as a measure of adoption, I thought it was pretty dramatic.
We saw that happen on inpatient, too. The same thing. We left transcription on. We didn’t take it away. Providers don’t suffer a penalty for using it, other than a workflow penalty of “now I’ve got to read this and authenticate it later”. But they were naturally drawn to it in just about every case, except the one area where it’s only fallen about 50% has been procedure documentation. Surgeons are still dictating a fair number of their procedures, but everything else fell pretty quickly.
Obviously, the financial people watched all those metrics very carefully. I’m probably not as versed in them as maybe I should be, but my gestalt of that is they’re all extremely pleased and happy with what happened. Then a lot of the other things that folks look at, I think, are more subjective and we’re still trying to actually figure out how to measure.
One of my major projects this year has been developing what we’re calling the Informatics Dashboard. There was this great article a couple of years ago that looked at how you measure the success of an informatics project. They looked to the management information systems literature and came up with these six dimensions.
So we looked at them and said, “It would be great to have a couple of metrics that we could describe, relating to each of these dimensions of system success.” Things like system quality — how good is it? Does it turn on when you turn it on? How’s the up time? How’s the response time? Information quality — sure it turns on, but is there information in there that you want and is accessible and you can use? The third one is usability, and how much usage does the system actually get? If it’s a really great system, people use it a lot, right?
Then there’s metrics for organizational impact and individual impact. Organizational impact like quality and how are you impacting that? And then individual impact, which is the thing I think physicians get very concerned about with an EHR, and it’s also the hardest one to measure. How much time am I spending documenting? Is this taking away from teaching or research? What about all this time doing notes at night when I go home?
We’re still struggling a little bit to figure out how do we measure that type of stuff and make it objective. When people complain about it, can we say, “Yeah, we really have a problem.” Or is this a problem of one instead of a problem of many, and how do we prioritize all those?
When you look at that, in context of the proposed Meaningful Use criteria, do you feel good about where you are?
Oh, yeah. I’m thrilled with where we are for Meaningful Use. In some ways, we got lucky. In some ways, it was vision. But for us, I think achieving Meaningful Use is going to be about crossing some Ts and dotting some Is. It’s very, very attainable for us, and so for that part, I’m really happy.
What are you doing with form factor stuff like mobile computing, or anything creative with nurses?
I don’t know how creative we are. We’ve got our devices on wheels. Pretty standard, like other folks have. We committed to having fixed devices in every patient care room, both inpatient and outpatient.
Being an academic center, we shied away from devices that could walk. Anything that wasn’t tethered. When you’ve got students and residents and people rotating through, our experience is if it’s not tied to the wall, it won’t be in the room for too much longer. It’s the same reason we have ophthalmoscopes tethered to the wall. Because after a year, if we handed out a bunch, they’d all be gone and nobody would know where they are; they wouldn’t be charged. So we focused a lot on fixed devices and trying to have them ergonomic so you can move around and stuff, but you couldn’t walk with them.
I think that’s been pretty successful. We’ve had some good luck with that, although there is always a lot of interest in the latest hand-held stuff. We had a lot of people who were interested in tablets when we started out. Of course that died because tablets weren’t really usable. Now it’s the iPhone and the iPad. I don’t know, maybe Apple will crack that nut a little bit better than some of the early PC tablet people did. We’ll have to see.
The industry is struggling a little bit to digest a couple of recent studies that tried to prove that the clinical information systems don’t improve outcomes or save money. Do you believe that those conclusions are accurate?
Yes, but I think we’re asking the wrong question. When we ask a question like, “Do EHRs work?” It’s kind of like asking, “Does surgery work?” What surgery? For what problem? In who’s hands? With what training? All those details are the things that determine whether or not surgery works, you know?
It’s the same thing with EHRs. Do they work? Well, they can work if you do the right things. The other problem with it is we wrap everything up and call it the EHR, but it’s really not. It’s not the software; it’s a process that we’ve developed. It’s a way of taking care of patients that we’ve codified, to some extent, in an electronic system. But when we look at all the studies that show effectiveness — or lack of effectiveness — what I try to look at is, OK, but why? What was it that made this one place really effective at doing this and not another?
I think informatics, as a science, is still pretty much learning those things. What are the necessary and sufficient conditions for success? It’s obviously not just about having a piece of software that does a certain thing. Otherwise, everybody’s experience would be the same with it. I’m not sure we fully understand … I know we don’t fully understand all the things that make it successful or make it not successful; such that we could develop a checklist and say, “Okay, as long as you do these 50 things, or maybe it’s these 500 things, you’ll be 100% successful.” I don’t think we have that yet.
What would you say your goals are for the next five years?
Oh boy, five years? I seem so focused on today. I think for us, it’s to build out the house that we’re ready to create. We’ve laid a great foundation here to do some really amazing things in medicine with the technology that we have. Over the next five years, I’m really excited to see how we will build that. What will it look like? Who will need to be involved? How will we fully engage caregivers? Operational departments like quality and safety to really see this as a tool that is their tool to use and operate and manipulate to achieve the ends that they want to see. I think that’s the most exciting part.
The other is to continue to refine the system, such that my colleagues who are nose to the grindstone, incredibly busy, by and large see this as a positive thing that enhances their ability to do a good job. Right now we see a lot of variability in people’s opinions along that line and we still don’t fully understand what the factors are that result in that variety of opinion.
I tend to think it’s that we still have a somewhat coarse tool that needs to be refined before people say, “Aha, this just works the way I expect it to. It works like Google, or it works like my iPhone.” I don’t know if we’ll get there in five years, but I’m sure we’ll be a lot closer than we are today.