HIStalk Advisory Panel: Increasing Physician Involvement

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news developments and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a hospital or practice, you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This month’s question: What successful actions have you taken to improve the involvement and satisfaction of physicians with IT projects and services?

• We ask physicians what kind of IT solutions they believe would be beneficial to our service, quality, and affordability objectives. Physicians help us evaluate proposed solutions. Project teams are partly staffed by physicians, and in some roles, we pay them for their subject matter expertise. CIO meets directly with CMIO to ensure alignment on priorities and clarity regarding improvement opportunities.
• We strive to find ways to use HIT to make it easy for our physicians to do the right thing. We obsess over how many clicks each action takes, and whether someone else on the team should be doing it instead of the doctor. We are not perfect, but we’ve stumbled into a few things based on these principles which are unique ways to use our EMR, but which result in improved efficiency and quality.
• We formed a physician group called the PIT (Physician Information Technology) group that meets every other week. We do this so frequently because we are in the middle of a large EMR project. We run all decisions impacting docs through this group, from order sets to clinical notes design. Another thing we have done is launched a physician portal that has a blog manned by our CMIO and CIO, but I will have to tell you it does not get much traffic.
• The single most important tool for physician engagement has been shoe leather (OK, shoe rubber?) Getting out and making face-to-face contact with them in the hospital and in the clinics. Asking what works and what we can do better. Optimizing the EMR is an ongoing task and the first step is to convince them that we’re committed to it. Also, recognizing that one size does not fit all, whether it is the interface or the device or the software tools, has been critically important. Be flexible wherever possible about the tools we provide.
• I think this follows the classical thought process today: First, have a physician in a key leadership area seen as the owner of the project. I like to have a VPMA or Medical Director leading the charge depending on the scope of the project. (IMO, depending on this roles relationships with physicians and the physician model of the organization, this may or may not have any impact on the project.) Another key is having the right type of person in a Physician/IT role (CMIO, Med Dir of Informatics, etc.) Someone that can earn the trust and respect of the other Docs, translate clinical needs between IT and business workflow, and "prep the battlefield" for major decisions by meeting with groups or individuals off-line. Having key physician champions attend discussions with other clinical areas is a must. This is where workflows overlapping various areas (physicians and nursing, for example) come to a head. For ongoing support, maintenance, and optimization, having IT topics on MEC, division meetings, physician steering/champion groups, etc is a key strategy. And as a last resort, free meals are always appreciated. 
• We’ve taken a new approach to engaging physicians with our EMR via an online collaboration / community. Our "MyEMR" secure intranet site is unique and now has almost 500 physician members. Physician IT champions moderate discussion forums, answer questions for their peers. Education ‘tips and tricks’ videos. Design drafts are posted for review on new content and development items. New information (e.g., Stage 2 Meaningful Use information) also posted for review and education. Project status documents posted so that all can see progress on important efforts. This site was conceived by our physicians and now co-managed with them.
• Defining specific roles for physicians and using physicians to recruit other physicians has been a successful approach that I have used. Whether it is software implementation work or ICD-10 implementation or anything in between, physicians need to have clarify on the expectations and time commitments that they will be signing up for.
• We created a steering committee for them that reports to the medical staff executive committee. The only person from the hospital who is there routinely is the IT director (no CIO here). It is their chance to blow off steam about issues, and they do. If they gripe to the hospital administration about IT, they’re told that they have a channel for those complaints, and they are asked to use it. Once they recognized that we do listen and that within the strictures of the software and legalities, we’ll accommodate them if we know there are problems, they started using the committee. Now, it is more about moving forward than about fighting the battles of the last 20 years.
• With any change, you need executive leadership support (administration and physician), evidence-based metrics, peer-to-peer pressure, and a system’s level continuous process improvement culture that is combined with a comprehensive, multi-pronged communication plan that reaches all levels of your organization. You have to include physicians (champions and high-volume user representatives) at the table from the very beginning and recognize that they are key stakeholders, and not just barriers to IT implementation. Physicians, like us all, are slow to adopt new, disruptive technologies. Active involvement and an active communication plan are critical to getting them involved.  If they feel like they are part of the solution, then it will work. The solutions themselves also have to be designed for the user (the physician). They need to here "what is in it for them." Perhaps it is a reduction in time, errors, callbacks, etc. The more specific the better.
• We created a CITAC (Clinical Informatics Technology Advisory Council) made up of physicians representing most of the sections of the hospital(s) and we take them all of the new things we look at, get their input, get advice as to how to communicate with the entire medical staff, or to introduce new systems or technologies, etc. They also bring us suggestions from their respective sections on order sets, CPOE screens, prompts, core measure attributes to build in, etc. It’s really been helpful. In addition to the docs, we also include some nursing staff, my IT clinical informatics staff, and our vendor representative. We air some dirty laundry, and deal with some turf issues, some of which can be awkward but the end result is pretty positive. In addition to this, we have made trips to each of the major provider clinics to meet with those physicians to discuss issues and desires related to CPOE screens, prompts, processes, etc. But, one of the biggest things that I feel contributes to better adoption of new technologies, is that we use a lot of hospitalists in our organization, and once we get them to use technology and make some changes based on their feedback, we’re finding the other physicians are more prone to try it (since they see the hospitalists using it).
• We’ve worked very hard to partner with and develop Physician Champions. Physicians in this role are more in tune with current projects and services, and enjoy being involved in the decision making process. For many of our physician champions, we have regularly scheduled meetings with them and their Practice Administrators to prioritize projects and discuss options, which is beneficial for all of us. We are expecting to roll out a full Physician Governance program this next year.
• Physician IT committee, physician champion for certain projects, specific physician IT ‘helpline’ to facilitate quick resolution of their issues.
• The key to physician satisfaction and engagement in health IT efforts is definitely having them involved. It is not enough for them to just be invited to receive information about the project. They need a seat at the decision making table and a voice that is heard and listened to. The level of their involvement in decision making and governance can vary depending on the project/program at hand, but having as many thought and action leaders from the medical staff in active roles in the project/program as feasible pays dividends with the entire medical staff. The opposite situation (zero physician involvement) yields highly negative results in terms of medical staff satisfaction, engagement, and adoption. However, it is also absolutely vital to choose wisely those physicians that are selected for involvement. We naturally want to involve those who have "connectedness" with their peers and thus high influence, but we also must select for traits such as "collaborativeness", ability to understand and explain the "vision" and rationale of what we are doing to peers, and flexibility (as plans necessarily change while in progress more often than not).
• Most success has been to not just involve the docs, but have them lead initiatives. For example, we have three MDs that have had tasks and expanding roles in our Epic project. In addition, when you can have the docs be decision makers in projects, and those docs have the respect of most of the medical staff, per se, then things seem to go better. Having docs sit on a committee and updating them or asking for opinion is clearly not enough. They have to be like the pig at a breakfast of bacon, sausage, and eggs. Not like the chicken. 
• When we went through the process of choosing an EMR we intentionally set up a steering committee made up largely of our physicians. We had representatives from all of our clinic types and almost one from each clinic. These docs were an integral part of the process. Once our selection process was down to three, we did demonstrations of several days with each vendor and asked all of our clinicians docs and staff to sit in. We required a survey upon exiting even if it was just a check mark on a few basic questions. After demos, site visits, and analysis was completed, the only folks who voted were the physicians. We have tweaked the system we purchased to make it as useful to the docs as we can. When we have a live date planned, we make sure the physician has someone within hearing distance to answer all questions and concerns. It is all about the support.
• This is a long story, but something for which we are proud.  Many years ago (1993, in fact) we created a Clinical Systems Advisory Committee. It came to be because there was significant dissatisfaction among members of the user agreement. It started as a very small group of physicians who would meet with us weekly, then ultimately bi-weekly, to discuss our work. We provided dinner and (cheap) wine. We would always meeting in the evening; we would always make it a comfortable, and somewhat informal meeting. Over the years, it grew, and grew, and grew. And now, we meet monthly. The room is full with doctors, nurses and IT professionals. There are often more than 50 people in the room. Sometimes there are 75 or 80 people in the room. It is open to anyone who wishes to attend, although there is a membership list. Lots of great folks participate, and we all genuinely look forward to the meeting. It’s a social event as well as a work event. Lots of time to network and catch up. The meeting typically lasts for about two hours, but many folks stick around late into the evening. We serve great dessert. We have learned so much, made important decisions, and used the output as a way to advise our executive team. It has been a real joy. Additionally, now that we have embraced Epic as our enterprise-wide solution, we have added a Physician Council and a Nursing Council. In this case, we have ensured that we have a representative from every department or division. It is equally effective, equally active, much more focused and a bit more formal.
• Use of "Tech Rounds" at one of our hospitals, conducted by the local CMIO; done monthly and showing latest technology applications, use of system, etc.
• We have a mature CPOE implementation and a lot of community docs and contracted hospitalists (in many disciplines). It has been challenging to maintain physician involvement and enthusiasm for continuous improvement of order sets, decision support, etc. On the satisfaction front, hiring a CMIO (me) has been very helpful, and having a crew of dedicated physician educators / support specialists has been essential. Most of our physicians don’t bother with the IT Help Desk any more.
• Lots of one on one discussion; open conversations with physicians in various meeting formats, informal lunches, working  to provide prebuilt documentation screens by specialty, demonstrating the improvements in outcomes using computer associated protocols agreed to by provider groups.
• As part of our Epic implementation, we formed a Physician Advisory Group chaired by our CMIO consisting of physicians representing every discipline across our health system. This group has been key to driving significantly increased engagement by physicians in the requirements, design, implementation, testing, training, go-live, and ongoing improvement of our new EMR. The core advisory group has been meeting weekly for a year and has been very successful. We also invite other physicians, outside the core group, to participate in requirements and design sessions when needed, which extends our reach further into the community. These, and other supporting, actions have been effective in improving involvement and satisfaction of our physicians with IT projects and services.