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Curbside Consult with Dr. Jayne 4/23/18

April 23, 2018 Dr. Jayne 2 Comments

I met up with a colleague this weekend who is knee-deep in an enterprise-wide EHR installation. They’re rolling it across several hospitals and are dealing with the challenges of trying to unite community-based physicians, hospital-employed physicians, and a couple of residency programs on the same platform.

My friend is one of the hospital-employed physicians. He splits his time between clinical and administrative duties. Originally hired to streamline implementation of the hospitals’ soon-to-be-legacy EHR nearly a decade ago, he has a great deal of experience in change leadership and trying to unite people around a common goal. He was looking forward to the new project, thinking it they could use some of the same strategies and techniques that had been used with success in the past.

The first thing that set him back was the way that the project was legally structured. Since it is a joint venture between the hospital and the residencies (which have ties to both the hospital and a medical school in the region), the software purchase was handled by a new entity with representation and funding from the constituent entities. Although technically they’re supposed to be partners, it sounds like there is constant tension between the parties as each struggles to be in control of various decisions. The hospital is definitely larger with its employed medical group and large number of community physicians who are on staff, but the residencies try to bring the weight of the medical school to bear and play the prestige card when they feel they’re not being allowed to be in charge.

From my time at Big Medical Center, I know that often the employed physicians are easiest to deal with. Although they will hem and haw and posture about various decisions, they ultimately understand where their paychecks come from and will eventually get on board with the project. There will be tensions among the specialties and between the hospital-based physicians and the ambulatory-based medical staff, but usually there is enough common identity to get everyone to pull together.

Then there are the community physicians, those who have admitting privileges at the hospital but who might also see patients at various other facilities. They tend to be a little more challenging to work with since they frequently will threaten to pick up their patients and go elsewhere if decisions aren’t to their liking. Depending on the specialties involved (think orthopedic surgery and interventional cardiology), the financial impact to the hospital can be significant, so project teams are often instructed to “play nice” with them.

The reality of the threat to “go elsewhere” is that it tends to be a hollow one. If you’re in a city with multiple hospitals or health systems, everyone has an EHR and everyone has similar challenges and mandates, so it’s unlikely that they can move their cases across the street and have 100 percent of their demands met. They’re going to run into employed physicians and hospital administrators over there, too.

Although some community physicians still attend at multiple hospitals, the stresses of that type of practice are great. We’re seeing more and more community-based physicians who have put their proverbial eggs in one basket with a single hospital and the pain of change is worse than the pain of same when it comes to moving to another facility. They already know how their current hospital schedules, what schedule they can be guaranteed in the operating room, if the hospital carries their preferred joint implants and medical devices, etc. Still, the EHR project teams have to deal with these threats and pressure from administrators to ensure physician happiness, so it’s something that has to be considered.

Residency programs are another situation entirely. In some of the smaller programs that aren’t based at an academic medical center, there may be a mix of attending physician types. Some might be from a local medical school, but rotate through the residency program a couple of weeks or one month a year to provide that academic pedigree. That can mean accommodating a dozen or more physicians and their opinions, although they don’t have a lot of dedication to the program since it’s not their primary focus. There may be full-time hospital-employed or community-based physicians that form the core of the faculty, and then part-time physicians who provide additional coverage or who keep working in the program as they move towards retirement or who just want to keep their toe in the residency world.

Then there are the resident physicians. Some may be dedicated to the program and will be part of the care team for three or more years. Others may just rotate through a month or two across a three-year span, such as family medicine residents who rotate through OB/GYN programs. These various structures lead to the need for a lot of users who are in the system but not on the system with great regularity, as well as a breadth of opinions about how the system should work that you won’t see anywhere else.

As we caught up over coffee, my friend lamented the fact that the organization seems to have underestimated how diverse the opinions would be when they began working with these different constituencies. He thought they would be able to apply some of the governance principles that they had used successfully on the hospital side in the past as they united with the other two hospitals, but the reality was very different. He’s been pulled into nearly a year of infighting, posturing, threatening to leave the legal entity, and backstabbing behavior. The lack of governance is a real challenge and he doesn’t have a lot of hope that it will be resolved anytime soon.

They’re also faced with cost overruns as they discover that certain parts of the project were under-scoped or not scoped at all. For example, the pathology lab interfaces were forgotten – the scoping team assumed they were part of the main hospital laboratory system. There were plenty of similar misses across the facilities, each of which adds a little bit more to the price tag. In the realm of under-scoping, they forgot to account for the needs of community physicians and part-time physicians in the training budget, failing to appreciate that these providers would want to train after hours or through different modalities than the hospital classroom. They’ve been working with consultants, but recently decided to add several other consulting groups to handle various subprojects, which will likely add more challenges to the situation.

It was good to commiserate and I think my friend felt validated in the fact that I see similar situations across the country. It doesn’t seem like there are a lot of good answers unless you have strong leadership that is willing to find the right mix of persuasion, financial incentives, and maybe even a “take no prisoners” approach to get the job done.

As our catch-up time wound down, my friend asked whether I knew of any good opportunities in the area or whether I had any recommendations on working with physician search firms. It seems he may be reaching the end of his tolerance for the process and I certainly sympathize with him. We scheduled another coffee date for the end of summer. I’ll just have to see how he is hanging in there.

How has your EHR project team handled governance? Did you survive a situation like this one? Leave a comment or email me.

Email Dr. Jayne.

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Currently there are "2 comments" on this Article:

  1. I’m not struck by the infighting or backstabbing; that’s par for the course at a complicated organization as you describe. I am struck — shocked even — that you’ve got physicians who want to be involved in decision making during the implementation. Maybe we all have finally learned that if you’re at the table, you get to make decisions. All too often, docs who were begged to come to meetings but are “too busy” are upset at the final result they see at go-live!

  2. I have seen a mixed bag of tricks for these situations. There is no specific singular “path” for for every organization or hospital/medical center to follow. “Buy in” starts with ownership and who has control of the purse strings- for instance, one hospital contracted their anesthesiologist and the anesthesia group contracted their nurse anesthetist who did not want to use the electronic surgical record. “ Buy In” came when we worked with the anesthesia group to give them the “WIIFM” (What’s In It Form Me) benefits of using the EHR. Once we had anesthesia on board. We worked with the nurse anesthetist groups “key influencers” to gain their willingness. ultimately, the organization made the EHR trading mandatory and they agreed to pay for RNA’s time spent learning to use the EHR which turned out to be the biggest “buy in”.
    We worked out the residency problems by coming to the conclusion the organization would hire scribes in emergency areas.
    These methods may not have worked in another organization or another part of the country. It also depends on whether they have unions and the budget.

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