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CIO Unplugged 6/23/10

June 23, 2010 Ed Marx 9 Comments

The views and opinions expressed in this blog are mine personally, and are not necessarily representative of Texas Health Resources or its subsidiaries.

The Secret to Successful CPOE Adoption — Revealed

Before revealing the secret, let me establish credibility. I first implemented electronic health records in 1995. A few years later while CIO at University Hospitals, we achieved a 95% CPOE rate at our academic medical center.

Presently, with 12 of our 14 hospitals implemented at Texas Health, we are averaging over 85% CPOE. Remarkably, 65% of these are entered via standardized order sets. What makes the Texas situation particularly unusual is the lack of executive mandate. The all-voluntary medical staff made it happen.

We garner national attention because of this success. We were recently recognized as a CIO 100 for our EHR benefit realization. We host high-profile organizations from throughout the country (on site and virtual) who want a closer look. We tell our story through various media so we can share best practices.

Although I had little to do with the CPOE successes, I did learn the secret.

Organizations will spend millions on consultants, hoping to tap into some sort of magic sauce that they can liberally apply to ensure significant adoption. The majority of these consultants will have had no direct professional experience implementing or supporting the technology. The secret to successful CPOE adoption rides not on a specific firm or one silver bullet, but many.

You can do better than a consultant. Here’s how.

These 21 factors, when in synch, will bring your institution success with CPOE. You must excel at 18 or more of these to forge the secret.

  1. Senior Leadership Engagement. The CEO must actively promote and reinforce. They must receive regular reports. They should base enterprise incentives on CPOE adoption levels.
  2. Hospital Leadership Engagement. Presidents need to be visible and articulate. So do their direct reports.
  3. CMIO. This rare individual can bridge the gap between IT and medical staff. In IDNs, I recommend a multiple CMIO approach. It’s not an expensive tactic in the big scheme of things.
  4. Project Leadership. They must walk on water and they must be clinicians. They are the face and brains of the operation. Surround them with grace and all the resources they ask for.
  5. Project Team. The majority should be clinicians. The team must have 90% of its members actively engaged. The road is long with many winding curves. Build up staying power.
  6. Clinical Staff. You can’t be successful without engaged physicians and nurses. You must facilitate their engagement if they are initially resistant.
  7. Culture. Culture eats strategy every day. Set up literal shared incentives for success. In IDNs, the culture must acknowledge but transcend individual hospitals.
  8. Relationships. Relationships cover a multitude of sins. Develop relationships with everyone from clinicians to support staff to leadership.
  9. Visibility. Key leaders must be visible during and after go-live. Most of our leaders participate in go-live support, even if just to answer phones.
  10. Agility and Velocity. Have a pool of highly trained staff who can respond to crisis at a moment’s notice. This team should report to the CMIO.
  11. Build. Lay a solid foundation from the onset to withstand the continual storms. Design must include clinical staff for usability and acceptance.
  12. Standardized Order Sets. Present CPOE as the ultimate tool to drive transformation, clinical quality, and drive out costs.
  13. Governance. Set up an effective decision-making body on two levels: a senior executive team for strategy and a larger team for tactics and operations. Assign clinicians to key roles.
  14. Change Control Process. Control application evolution at a rate that introduces new features while maintaining an acceptable learning adaptation curve.
  15. Implementation. Keenly organized, with additional staffing at the physician’s elbow.
  16. Marketing and Communication. Have a multi-dimensional, targeted strategy that includes actual customers. Don’t limit yourself to traditional media. Be innovative and leverage social networks.
  17. Training. Use multiple venues — traditional methods blended with modern ones, such as our video vignettes. Make access to applications dependent upon completing training.
  18. Support. Post-implementation support must be impeccable and ubiquitous.
  19. Vendor Connections. The best relationships start at the top, with C-level execs exchanging strategy and vision. Establish escalation paths to solve issues quickly.
  20. Infrastructure. Monitor and tune to ensure optimal uptime and response speed.
  21. Software. Select a seasoned application. Test and retest enhancements and patches prior to releasing to clinicians.

If you can’t deliver on the majority of the above factors, stop your project. Take the hit early where impact is limited rather than when you are too far down the tracks where a collision will occur.

We took a three-month hiatus because our standardized order sets were suboptimal. We retooled. We’re hitting the 85% CPOE and 65% order set numbers I gave above.

A final point to remember. None of these factors is a one-time event. Each requires continual care and feeding. Indefinitely. Implementation is just the forerunner of optimization.

Want more? Follow our CMIO and Medical Director on Twitter; ftvelasco; Isaldanamd

Update 6/28/10

Thanks for all your responses. When you have great success, it becomes easy to take some fundamental things for granted. This includes a stable technical infrastructure and all the non-clinical analysts who make things hum. So if I ever rewrite this, I will add that point.

I will take issue, however with Ex-CMIO. While computers are a commodity, successful EHR implementations are not. A gap exists because of the relative immaturity of the EHR experience. This will change over time and that gap will close in the next couple of years. We are all learning and the lines between the silos are blurring.

Ed Marx is senior vice president and CIO at Texas Health Resources in Dallas-Fort Worth, TX. Ed encourages your interaction through this blog. Add a comment by clicking the link at the bottom of this post. You can also connect with him directly through his profile pages on social networking sites LinkedIn and Facebook, and you can follow him via Twitter – User Name “marxists.”

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Currently there are "9 comments" on this Article:

  1. Another excellent post – each of the 21 points has a moderate to long checklist of items in support of the summary-level comments. If you ever run low on ideas (I doubt that), I would be interested in seeing those types of details. Thank you for the thoughtful post

  2. Agreed; there is no secret formula, incantation, or sauce that can make innovation happen. These points are good strategies to consider, especially since so many of them depend on everyone being engaged in the process and supporting it. Bottom up usually works better than top down.

  3. Great article. These are concepts that we promote with every project, but it helps to have someone spell them out for us once in a while. Gotta sharpen the axe!

  4. Ed, having been directly involved with the implementation of an Emergency Department EMR and CPOE in nearly 200 hospitals, I can confidently say “you have eloquently nailed it”. I could only wish that a fraction of those hospitals had the leadership and wisdom that I see in this message.

    My favorite quote of yours is “Culture eats strategy every day”. Nicely done and congratulations on your CPOE successes.

  5. Is it just me, or is the 21 points missing something like, oh i don’t know… Non-Clinician IT staff… analysts, build staff, and the folks who will suppor the app are also important, if not because they make the gears turn, but because they also need help bridging the gap of IT & Care.

    Maybe Ed’s org. doesn’t have that general analyst sort of role, but many do.

  6. Great Summary of our journey. Agree especially with the “continued care and feeding” … from an OB Nurse point of view, implementation is like birth…..it’s just the end of labor…and the beginning of a whole new life….

  7. Re – CMIO. This rare individual can bridge the gap between IT and medical staff. In IDNs, I recommend a multiple CMIO approach. It’s not an expensive tactic in the big scheme of things.

    If CMIO’s were truly C-level officers geting C-level pay and benefits, rather than figureheads “bridging the gap”, that would not be the case.

    One should also ask why the “gap” exists, and it’s not because physicians do not understand computers which are now commodity.

  8. Very nicely stated! The 21 points (give or take a few) all fit within a basic project management methodology. This is one of those projects that you cannot shortcut and these 21 points are a great guide for someone just starting on the cpoe journey. Our experience has been that workflow is king. If you don’t get that right, you will have a disaster on your hands. Support of the entire leadership team is required to make the necessary changes in workflow. The typical hospital silos have to come down. It is a fun project! We couldn’t do it without a CMIO and our physician champions working with nursing leadership.

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