Can CMIOs and their fellow clinical informaticists make quick progress in improving physician documentation processes and helping to lift some of the burdens of documentation, for their organizations’ physicians? They absolutely can, as a recent initiative at Emory Health, an integrated health system in Atlanta, demonstrates.
At Emory, CMIO Julie Hollberg, M.D., has been helping to lead an initiative to improve the documentation process for its doctors. The initiative, which is being referred to as a “physician optimization project,” is being rolled out across the health system’s four acute-care hospitals and 80 outpatient locations. Among other accomplishments, the initiative has:
- Removed up to one-third of clicks from its ambulatory workflow
- Led to physicians spending, on average, 36 percent less time finishing charts from home
- Achieved strong adoption, with 71 percent of physicians adopting the new documentation tool, and with order entry increasing by 74 percent, and transcription usage decreasing by 29 percent.
Dr. Hollberg, who has been the organization’s CMIO for over four years, and who still practices actively as a hospitalist both at Emory University Hospital and at Emory University Orthopedic and Spine Hospital 20 percent of her time, helped gather together the organization’s clinicians, clinical informaticists, and IT staffers, to move forward with the project, working with support from the health system’s electronic health record (EHR) vendor, the Kansas City-based Cerner Corporation.
Below are excerpts from the recent interview with HCI Editor-in-Chief, Mark Hagland. Below are excerpts from that interview.
Tell me about the process that you and your colleagues engaged in, in order to reduce the number of clicks that practicing physicians are required to perform in order to document in your electronic health record (EHR).
We have 37 subspecialty sections within the EHR, representing 37 different physician specialties and subspecialties. We worked with all 37 subgroups of physicians in order to craft a more optimized screen view and presentation for each of those, with individual data flow for each specialty and subspecialty involved. Then we allowed for each individual physician to take the view based on her or his specialty from among those 37, and customize that view for himself/herself as an individual doctor. The third element in this is that Cerner allows you to bolt review documentation while at the same time building your note. Previously, you had to go to the radiology report, open your note, and copy and paste the report into your note, using toggling functions. Now, you can review your chart and build your note at the same time. That is also a huge saver in terms of clicks, and also in terms of cognitive processes.
So in that regard, you’ve eliminated complicated toggling?
Yes.
And with regard to the optimization for the different specialties and subspecialties, and then the customization you’ve allowed the individual physicians, each of those represented about half of the lift that you’ve given the doctors?
Yes. One of the big things about the benefits of the EHR, is you want to bring the right data to the right person at the right time. And each specialty got to pick, by specialty, which data was brought to them. So we designed 37 different views when you log into the chart, and each, further, has an inpatient view and an outpatient view. So each specialty got their own data. Then we did further specialization once we were live, we had coaches and they worked with physicians on an individual level. Some like to review the old notes first; others like to review vital signs. So at the specialty level, we picked which data would go onto the screen, and then at the individual level, each physician would pick what order they see the data in, on their screen.
Importantly, the specialists within each specialty helped to design their view themselves. There were several elements involved: one was the workflow flow, allowing them to review the chart and start to build their note with Dynamic Documentation, the semi-structured documentation tool. They also got another screen with most common lab, radiology, medical orders, and typical professional fee charges and procedure codes. There was also a search function to search the procedure codes and charges from a catalog. Here’s an analogy: each specialty chose which checker pieces to include, and each individual physician got to pick the order of their checkers.
What has the practicing physician satisfaction been like?
I think that we’ve made significant improvements in terms of physician satisfaction, but we’re by no means done. It’s a little bit like, if you let them a little bit into the candy store, they like it but they want even more. So we’re onto phase two of provider optimization—wave two. And we’ll never be finished optimizing electronic health records, particularly when we’re in version 1 or 2 of that. So we’ve made some things a lot better, and some a little better. And in wave 2, we’re working to make things even better.
What have your biggest lessons learned been so far?
I think early on, we underestimated the value of high-touch leadership. When you have 37 different go-lives that are going to be happening, you can imagine that when you’re meeting with the first 10 and then the second 10, the final 17 will feel abandoned. So we used our patient financial services team to do ICD-10 documentation preparation for those specialists still waiting.
And we talk over and over again about the importance of hearing feedback, learning from it, and actively making changes. So we listen, we learn, and we incorporate feedback appropriately. You’ll always have things to go back and pick up on, but you always want to get the feedback and incorporate it.
How many informaticists were working on this?
The three key operational sponsors or Emory leaders were myself, the chief medical and quality officer in the outpatient clinic division, and a leader on the clinical operations side; we were the sponsors. We had a large team of people working with us, from information services, the business side of things, and clinical operations. Over 300 people were involved when you include the section-level go-live people as well.
How big is your core clinical informatics team that reports to you?
Our clinical informatics team at Emory is smaller than I’d like it to be. We have myself and two other physician informaticists, who dedicate 10 and 20 percent of their work hours to informatics; meanwhile, our chief nursing informatics officer has a team of four, including himself. So we work hard!
