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On the vanguard of thought. The future of healthcare requires nothing less.
While the EHR and other clinical IT resources present tremendous value potential, health systems struggle with wringing value from these tools. Success in achieving the intended transformation required by advanced care models has been elusive.
Many healthcare leaders expected meaningful benefits to quickly follow once the EHR was installed. Yet, successful installation of the EHR does not equate with effective integration of the tools into the workflow and culture of a healthcare organization.
TO GET REAL VALUE FROM THE EHR, ORGANIZATIONAL COMMITMENT AND CLINICIAN INVOLVEMENT ARE CRITICAL, AND AN ORGANIZED CLINICAL INFORMATICS PROGRAM PLAYS A PIVOTAL ROLE.
Looking for More Value from Your EHR? An Informatics Program Can Play a Pivotal RoleAuthor: Dr. Mark Van Kooy
Looking for More Value from Your EHR? An Informatics Program Can Play a Pivotal Role
Page 1
Most health systems employ a traditional approach to Clinical Informatics (CI), focusing informaticists on unit-specific workflow efficiencies, increasing individual clinician adoption levels and responding to often-disconnected requests for system enhancements. While this approach has resulted in steady progress in improving usability and access to patient information, more advanced system potential remains untapped.
Instead, a new approach is required that deliberately drives measurable progress in achieving an organization’s strategic and operational priorities—one that operates in support of clinical excellence, quality and safety, clinician experience and engagement, and the organization’s operational and financial success.
True progress arises from a coordinated focus on achieving system-wide consistency in care delivery and documentation, care quality and efficiency improvements, reductions in cost of care delivery, higher patient engagement and effective population health, as well as reduced physician burnout. This can only be achieved by advancing to the next generation of Clinical Informatics and creating a unified, highly-skilled Clinical Informatics team singularly focused on improving the utility and usability of the EHR with the technical, process and people skills, and insights needed to achieve holistic, integrated solutions.
Clinical Informatics’ Role in Driving Health System SuccessA core Clinical Informatics function is aligning and coordinating the efforts of otherwise disconnected health system resources in the service of efficiency, safety, quality and value.
Organized effectively, Clinical Informatics teams play an essential role at the intersection of a health system’s HR and organizational development functions, clinical IT capabilities and workflow/process owners to address the people, process and technology drivers that need to work together to achieve real clinical IT value:
z People are prepared to use the technology, and the technology is configured to support staff to optimize workflows;
z Workflows are designed to support staff, and staff are ready to make the best use of technology to deliver care; and
z Software and hardware are harmonized with workflows to help people achieve safety, efficiency and effectiveness.
HR & Organizational Development
Information Technology
PerformanceImprovement
Skills and experience
Learning and training
Policies, roles, responsibilities
Technical expertise Configuration/ customization Hardware/software
Process knowledge
Workflow design
Error & waste reduction
CLINICALINFORMATICS
Peop
le are
pre
pare
d to
use t
he te
chno
logy,
and
the t
echn
ology
is co
nfigu
red
to su
ppor
t sta
ff to
opt
imize
wor
kflo
ws.
Workflows are designed to support staff, and staff are ready
to make the best use of technology to deliver care.
Software and hardware are harmonized with workflows to help people achieve safety, efficiency and effectiveness.
A new approach is required that deliberately drives measurable progress in achieving an organization’s strategic and operational priorities...
Page 2
Looking for More Value from Your EHR? An Informatics Program Can Play a Pivotal Role
This intersection of HR and organizational development, IT, and performance improvement are often overlooked. When informaticists are properly recruited, trained, deployed and managed, they marshal and harmonize the efforts of the organization’s workflow, technical and human resources to achieve the benefit entitlement of the organization’s massive investment in the EHR. Benefits range from enhanced clinical quality, improved efficiency and reduced cost of services, higher levels of clinician engagement, reduced physician burnout, and improved reputation in objective and public measures of performance such as Leapfrog and MACRA.
Key Competencies of a High-Performing Clinical Informatics ProgramOur experience has shown that to achieve this benefit entitlement, effective Clinical Informatics programs exhibit these characteristics:
VISIBLE AND ACTIVE
Executive Sponsorship
Skilled, DEDICATED LEADERSHIP
Explicit VALUE
DELIVERY Expectations
STAFFING SUFFICIENT to Scope and
Responsibilities
RIGOROUS ALIGNMENT
with Organizational Priorities and
Operational Plan
LINKAGE to Quality,
Performance Improvement and Change Leadership
INTEGRATION into
Clinical IT Governance
ALIGNMENT with IT and Operations
RELIABLE, PREDICTABLE AVAILABILITY
to All Clinical Sites of Care
Clear ROLE
DEFINITION
Distinct COMPETENCY Requirements
AN EXPLICIT APPROACH, Methods and
Toolkit
INTERNAL TALENT
Recruitment
CLEAR CAREER PATHWAYS with Future
Potential Leadership
Opportunities
EFFECTIVE PROGRAMS ARE INFORMED BY AND TIGHTLY LINKED TO THE ORGANIZATIONAL STRATEGIC PLAN, ANNUAL OPERATING PLAN AND PRIORITIES.
Page 3
Looking for More Value from Your EHR? An Informatics Program Can Play a Pivotal Role
Key ConsiderationsLike any tool or capability, the value achieved from a Clinical Informatics program depends on how it is deployed and managed, how accountability and success metrics are defined, and how effectively it is used in the service of the organization’s operational and strategic priorities. Tight linkage with operations; clear, explicit performance goals; and visible, transparent communication of performance and results are essential.
Consider the Following
How effectively is your current EHR supporting safe and efficient care of patients?
How well does it support your operational processes?
How satisfied are your clinicians and providers with the care delivery experience your EHR creates for them?
How well prepared are clinicians and providers to use the full range of features and capabilities of the EHR to achieve the levels of efficiency, safety and quality the systems can support?
How are you addressing physician burnout and increased demands on physicians?
Are you achieving system-wide consistency in care delivery and documentation, and care quality and efficiency improvements?
How are resources across IT, HR and performance improvement marshalled synergistically to identify, benchmark and potentially adopt industry best practices?
How are the various primary professions that may comprise Clinical Informatics resources (e.g., nurses, physicians, AHPs, pharmacists and others) organized to provide a uniform and efficient level of support to the organization?
Are there tight linkages with the Clinical Informatics team’s priority efforts and the organizational strategic plan, annual operating plan and priorities?
How are accountability and success metrics defined?
Page 4
Looking for More Value from Your EHR? An Informatics Program Can Play a Pivotal Role
Understanding the current state of a Clinical Informatics program as compared to leading practice is an effective starting point. An important added benefit of the exercise is reinforcing to all stakeholders the importance of the people and process side of realizing value from the significant investment in the EHR. It also helps define where the program needs to evolve to in order to achieve organizational goals. A maturity model like the one depicted below can be useful in assessing the current program and defining the future state vision.
A Pragmatic Starting Point To continue the evolution of your Clinical Informatics program and drive further value from your EHR, start with a thorough assessment of current capabilities, systems and structures using these steps:
z Assess the current state, including resources, roles, responsibilities, chartering procedures and skill sets;
z Work with key stakeholders to define the requirements and engage their support in the development of the informatics program;
z Formulate a future state program that includes support for all sites delivering clinical care and identifies the functions to be performed along with required competencies;
z Develop a comprehensive plan to implement the program. This should include the roles, responsibilities, staffing, management and reporting structures, value proposition and tracking, linkages to the EHR vendor and IT governance, collaboration model with Performance Improvement, IT, and Quality Improvement; and
z Gain approval for the overall informatics program.
Level 1:CI has not been established in the organization. Operations and IT are responsible for workflow and system design.
Level 2:CI staff is present in some areas, but there is no organizational approach to utilizing and developing CI staff and competencies.
Level 3:Leadership views CI as a critical organizational competency; strong executive sponsorship. Deployment and integration is incomplete but progressing.
Level 4:CI is a valued and effective presence in all clinical areas; workflows are routinely optimized.
FOUNDATIONAL ASPIRATIONAL PROFICIENT TRANSFORMED
System-wide CI team with executive sponsor and skilled, dedicated CI leader
Clinician-generated enhancement requests are numerous; limited prioritization; IT viewed as a “Black Hole”
IT analysts are responsible for workflow analysis, design and enhancements
Pockets of proficiency such as Nursing CI team
Limited or no senior executive CI sponsorship and alignment with annual operations plan
CI resources are available to all clinical areas
Clear and effective collaboration with Quality, Performance Improvement and Change Leadership resources
Little or no systematic harmonization of digital and physical workflows
Some chartered projects and influential areas receive CI support
Variable, limited ad hoc CI skills development
Tight alignment of CI work with system operational priorities
CI resources are partners in care delivery and present in all clinical workspaces
Structured CI competencies, professional development and career path
CI fully integrated into all processes and workflows; “the way we do it here”
PRO
DU
CTIV
ITY
& Q
UAL
ITY
HIGH
LOW HIGH
LOW
PEOPLE, POLICIES, TECHNOLOGY ADOPTION
RISK
& W
ASTE
Value is quantified, expected, routinely delivered and transparently reported
No identified CI resources
Page 5
Looking for More Value from Your EHR? An Informatics Program Can Play a Pivotal Role
Clinical Informatics programs are valuable levers in moving organizations forward, but they can easily diverge from organizational priorities unless program leaders maintain persistent disciplined focus on value. It is essential that in the next generation of Clinical Informatics, program leadership is accountable for assuring that the program delivers tangible, substantive value as viewed from the perspective of organizational leadership. This requires a structured approach to value tracking and reporting and intentional, consistent focus on value delivery and strong partnership and validation with key stakeholders including the executive team and particularly, the Chief Financial Officer. Success is achieved when the value of the Clinical Informatics program to the organization is substantial, well-understood by stakeholders and is responsive to organizational priorities.
Clinical Informatics and ValueValue is in the eye of the beholder. Examples of meaningful value can include financial return, improved physician engagement and satisfaction, increased safety and quality, improved ability to manage complex care or other impacts. Illustrative examples are included below:
THE CHALLENGEPlateau in provider EHR proficiency at subsistence level performance
THE INTERVENTIONThree-day intensive advanced EHR training for physicians
THE OUTCOMEThirty providers per session trained
THE VALUEUse of Smart Tools 58% → 84% of Encounters
Time in EHR Outside of Clinic > 1hr 77% → 38%
Confident in Use of EHR 33% → 86%
EHR Improves My Job Satisfaction 28% → 87%
Work Life Balance (Good+Very Good) 41% → 71%
THE VALUE
THE CHALLENGEProvider documentation not adequately meeting clinical or business needs
THE INTERVENTIONPhysician-led provider documentation redesign initiative
THE OUTCOMESubstantial engagement by clinicians in improving multiple aspects of chart usability and completeness
Claims Denials/Physician/Month $3500 → $460
Chief Complaint Completion 92% → 98%; Accuracy 44% → 64%
Problem List Completion 50% → 86%
Encounters Closed Timely 86% → 99%
CMI 1.58 → 1.74
Discharge Med Rec 46% → 86%
Admission Assessment (nursing) 34% → 60%
Page 6
Looking for More Value from Your EHR? An Informatics Program Can Play a Pivotal Role
THE CHALLENGEDecision support alerts creating alert fatigue and important clinical conditions meriting alerts being missed
THE INTERVENTIONSystematic review of decision support alert performance. Triage and termination of ineffective alerts. Addition of missing alerts.
THE OUTCOMEFewer annoyance alerts, increased relevance of alerts that fire
Provider Efficiency
Provider Satisfaction
Provider Alert Fatigue
Quality and Safety
THE CHALLENGEOffice-based agile optimization and personalization
THE INTERVENTIONAgile team deployed to provider office, address ordering, smart-tools, medication reconciliation, personalization, Inbasket, check out workflow
THE OUTCOMEImproved EHR workflows, enhanced provider proficiency, improved documentation and data capture
Provider EHR Rating
Staff EHR Rating
Provider Burnout
THE CHALLENGEFive medical staffs – unable to standardize order sets
THE INTERVENTIONActivate and lead new physician advisory group
THE OUTCOMEConsensus order sets, expanded to other important priorities (e.g., e-health)
Ability to Advance Order Sets
Physician Engagement
THE VALUE THE VALUE THE VALUE
PHYSICIAN BURNOUT COSTS AS MUCH AS
$150 BILLION PER YEAR. That formidable sum amounts to more than 4.7% of the nation’s $3.2 trillion expenditure on health care — an enormous sum that could have great consequence for the future of our health care system and the directions of health reform, were there a way to save or redeploy those dollars.”1
Page 7
Looking for More Value from Your EHR? An Informatics Program Can Play a Pivotal Role
THE CHALLENGEOne hospital of 4 dropped to Leapfrog level C – failure to resolve
THE INTERVENTIONNew CMIO focused on problem, identified data entry inconsistency due to lack of clinical awareness
THE OUTCOMERestored Leapfrog level A
THE VALUEHealth System Reputation Preserved
THE CHALLENGEProvider documentation – note bloat, copy paste errors, etc.
THE INTERVENTIONCI supported, medical staff-led style guide and template development initiative involving 30 physicians
THE OUTCOMEMedical staff section-level standardized templates with enhanced data capture and efficiency
THE VALUECMI (along with CDI)
Physician Satisfaction
Physician Efficiency
HIM/Coding Time
THE CHALLENGEIT viewed as a “black hole” for enhancement requests, IT unsure of relative priority of requests and overwhelmed with volume
THE INTERVENTIONCombined clinical workgroup prioritizes enhancement requests, sole channel for clinical requests, IT commits to “x” enhancements per month
THE OUTCOMEClinician-governed clinical enhancement process, predictable, trackable enhancement flow
THE VALUEClinician – IT Relations
Relevance of Enhancements
Load balancing for IT Analysts
The national numbers on death and harm in hospitals have alarmed us for decades. What we see in the new round of Safety Grades are signs of many hospitals making
SIGNIFICANTIMPROVEMENTS IN THEIR PATIENT SAFETY RECORD,” said Leah Binder, president and CEO of Leapfrog.2
Page 8
Looking for More Value from Your EHR? An Informatics Program Can Play a Pivotal Role
Sources: 1 The Blue Ridge Academic Health Group (Winter 2017 - 2018). The Hidden Epidemic: The Moral Imperative for Academic Health Centers to Address Health Professionals’ Well-Being. Retrieved from http://whsc.emory.edu/blueridge/publications/archive/blue-ridge-winter2017-2018.pdf.
2 The Leapfrog Group. (2018, April 24). Five Hospitals Progress from “F” to a First-time “A” in the Nation’s Leading Scorecard on Hospital Errors, Accidents and Infections. Retrieved from http://www.hospitalsafetygrade.org/about-us/newsroom/display/663012.
About the Author
Dr. Mark Van KooyPrincipal, Clinical Informatics & [email protected]
Mark Van Kooy, MD is a Principal with The Chartis Group and a leader in the Informatics and Technology practice. Dr. Van Kooy has over 30 years of experience in healthcare as a family physician and consultant. Dr. Van Kooy was the Chief Medical Information Officer and Director of Clinical Applications in a regional integrated delivery system prior to joining Chartis and has served as an interim CMIO in client organizations. Dr. Van Kooy’s recent work has focused on advising organizations on clinical IT governance, physician engagement in the oversight and evolution of clinical IT systems and integrated clinical informatics strategies. Dr. Van Kooy is a board-certified family physician with sub-specialty boards in Clinical Informatics from the American Board of Preventive Medicine. He received his medical degree from New Jersey Medical School where he graduated Magna Cum Laude and has a Bachelor of Science in chemical engineering from New Jersey Institute of Technology.
© 2019 The Chartis Group, LLC. All rights reserved. This content draws on the research and experience of Chartis consultants and other sources. It is for general information purposes only and should not be used as a substitute for consultation with professional advisors.
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About The Chartis Group
The Chartis Group® (Chartis) provides comprehensive advisory services and analytics to the healthcare industry. With an unparalleled depth of expertise in strategic planning, performance excellence, informatics and technology, and health analytics, Chartis helps leading academic medical centers, integrated delivery networks, children’s hospitals and healthcare service organizations achieve transformative results. Chartis has offices in Atlanta, Boston, Chicago, New York, Minneapolis and San Francisco. For more information, visit www.chartis.com.