As a consulting CMIO, I often get asked to help organizations develop or refine their provider adoption strategies. Convincing people to do things that they don’t want to do can be tricky, especially if they’re not being incented to do so.
Creating incentives for employed physicians is fairly easy. Usually they are under contract and expectations regarding EHR use can be added to that framework. Creating incentives for independent members of the hospital medical staff can be challenging. Often we’re asking them to use new process that may add to efficiency for the hospital, but will lower their personal efficiency.
I’m working with a hospital that thought they could drive physician adoption strictly by saying use of the EHR was required. They had implemented various pieces of an EHR over the last decade, but use has always been optional. Physicians were allowed to continue writing paper notes that were scanned and they were allowed to continue writing paper orders that were entered by nursing staff or unit secretaries.
Because use of the systems (plural) was optional, the hospital never put the time and effort into ensuring that physicians had the training and support they needed to be successful. It was a vicious cycle of non-use costing them tens of thousands of dollars each year, so hospital administration simply decided that using it would be required.
You can imagine the revolt that immediately occurred with the medical staff. Physicians threatened to take their elective procedure business elsewhere, and did. High-dollar specialists left in droves. Now the hospital is trying to woo them back, having let some members of the administrative team go following the aftermath of their poor decisions.
I know the CMO from medical school, so he invited me in to work with them on a strategy to get things back on the rails. It was no surprise that simply “requiring” use of the systems drove providers away. Physicians weren’t presented with a compelling reason for the requirement; nor was it clear whether they were going to be retrained, supported, or left on their own to figure out how to document in the systems. Having been on the receiving end of bad policy decisions previously, they assumed the latter.
One of the first things I recommended was that we analyze their medical staff makeup, identifying what percentage of the physicians are using the systems as desired, and of non-users, how many were actually on staff when the various systems were originally deployed. Institutional memories can sometimes be short, and people were surprised to learn that the vast majority of medical staff members had joined long after implementation and training of the key systems was complete.
With that data, we were able to persuade the administration that we needed to essentially re-implement the systems. Rather than trying to target individual physicians, we’d do it over and do it right.
The VP of nursing was immediately on board since her staff had grown increasingly frustrated by having to support multiple workflows and data sources depending on the behavior of admitting physicians. The CIO was also on board, having had a sneaking suspicion that if physician adoption wasn’t achieved, leadership might decide that his systems were at fault and demand a replacement initiative. Another interesting result of the data analysis was that there was a small group of proficient users who could be leveraged to help move provider adoption in the right direction.
The CMO and I have been working together to use those power users as physician champions, helping their peers understand that fully using the electronic systems can actually make their rounding more efficient and reduce phone calls and interruptions for them. The excitement around re-implementing the system has allowed him to build a small clinical informatics team, so that the hospital has knowledgeable and trusted resources to not only help the physicians through the transition, but to carry them forward through all the changes that healthcare reform will surely throw in their direction.
Of those power users, we identified one with formal informatics training, who happened to be a community-based admitting physician. He had done a fellowship thinking he was going to go into academics, but personal circumstances put him in a small city where he didn’t think he’d get to use his expertise. He has been fun to work with, since he really gets it as far as what we’re trying to do and what else the hospital will need to accomplish over the next several years. He’s been a great help with the change management piece as we convince the physicians that this is the right thing to do for a variety of reasons, none of them being because someone said it was required. He’ll make an excellent CMIO if he’s ever willing to reduce his clinical commitments.
Rather than implementing the systems separately as has been done in the past, they’re treating it like a big-bang go-live, which I think is wise. That brings a lot more visibility to the project and allows us to have a greater number of support resources available for the providers – saturating them for the first few weeks rather than having fewer support liaisons for each of multiple system go-lives. The advantage for adoption this time around also includes the fact that the nursing staff has been live on the system for years, so they’ll be able to assist with some of the workflows that are common between nurses and providers.
Instead of only offering classroom training, we offered multiple methodologies including Web-based didactic, Web-based interactive, scenario-based training, classroom, and one-on-one. Over the last 10 years I’ve seen much more recognition of the different ways that people learn, and for those that have difficulty absorbing information, we scheduled the offerings so that providers could take advantage of multiple types of training if they found that what they selected didn’t work for them. Using this type of approach isn’t cheap, but when you look at how much they had been spending to run a fragmented, double-entry approach, it will pay for itself in short order.
I’m on site with them for the next few days, getting the command center ready for Monday and tidying up loose ends with provider preferences and favorites in the production system. We’re actually going live at midnight for in-house physicians and will be in full swing when the community physicians arrive for morning rounds. It’s been a while since I staffed a go-live like this and I had forgotten how exciting they can be. They can also be exhausting, and I’m sure by the end of next week I’ll be more than ready to head home.
Although it’s not a traditional go-live given the time the software has been in place, I’m sure having greater numbers of users doing many different workflows will still yield a number of bugs and issues that we’ll have to track down. Seeing this organization grow over the last several months gives me hope that they’ve arrived at a place where their technology and transformation efforts will be sustainable. It’s been a good recharge for me as well, since this type of work is where I got started. I’ll be on site next week and will let you know how it goes.
Email Dr. Jayne.