Even the most renowned patient care organizations face challenges when it comes to process change. That was a key takeaway from the presentation made by Karl Poterack, M.D., medical director, applied clinical informatics, in the Office of Information & Knowledge Management at the Mayo Clinic health system. The Phoenix-based Dr. Poterack spoke on Thursday afternoon at the Health IT Summit in San Francisco, sponsored by Healthcare Informatics, under the headline, “Provider Spotlight: How the Mayo Clinic is Advancing Applied Clinical Informatics to Improve Patient Care.”
Speaking to an audience of healthcare and healthcare IT leaders at the Palace Hotel in downtown San Francisco, Dr. Poterack walked his audience through some of the recent clinical informatics history at the Mayo Clinic health system, which encompasses 20 hospitals in five states, as well as 2,900 staffed beds, 130,000 annual hospital admissions, and 1.3 million annual clinic visits, 66,484 employees, 4,590 physicians and scientists, 2,434 residents, fellows and medical students, 59,460 allied health professionals, and a portfolio of $11-12 billion in gross revenue. He himself works out of the Phoenix region of the organization.
Poterack shared Mayo’s experiences around the process of unifying is electronic health record (EHR). As he noted, “We had three different EHRs across those 20 hospitals; in Rochester, we had an amalgamation of a bunch of different systems. The primary one was vended, while there were a number of home-built systems. To an extent, each EHR was attuned to different individual practices or regions,” he added.
“Why change? A strategic decision was made,” Dr. Poterack told his audience, “to converge workflows, order sets, onto best practices. For years, Mayo had operated a bit like a holding company, with regional groups. Florida had evolved to do things Florida’s way, Arizona to do things Arizona’s way, etc., etc., and there was a recognition that perhaps we could develop [more universal] best practices, and that, when patients with the same symptoms and issues come to different facilities, they should get the same care. So the decision was made to converge on best practices. And so converging on the same EHR, with the same order sets, the same build, was seen as a way to build convergence. And there was some time pressure, because the vendor support for the key vended system in Rochester was going to end. So we realized that this was a good time to get onto the same system.”
Given that background situation, Poterack said, “We decided to undertake what’s been named the Plummer Project, after Henry Plummer, one of the six original physicians who established the Mayo Clinic. It was Dr. Plummer who really invented what we think of as the patient-centered record. At the time he did so, medical records were facility-focused, and entered into ledger books. There was no patient record centered on the patient; the record was centered on the clinic; and he basically flipped that. So because of his standing, we named our project of unifying our EHRs after him.”
That said, Poterack continued to say that, “Obviously, there were barriers we had to face. We’re a very distributed practice, with 20 hospitals in five states. We’ve got multiple stakeholders: neurosurgeons in Rochester, neurosurgeons in Jacksonville, anesthesiologists in Arizona, anesthesiologists in Eau Claire, and so on and so forth. And every doctor thinks he knows the best way to do things, and also that he’s in charge. So getting everybody on the same page and to converge on best practices, was a challenge.”
What’s more, Poterack said, “Cultural differences were a problem. Variations in practices were allowed, and that was cultural. And culture is influenced by geography.” Another major obstacle? “The ‘we can’t possibly change the way we do things’ argument. There can also be legitimate issues around resource differences.”
Process issues: past and present
One advantage that he and his colleagues had in making this change, Poterack said, is that the Mayo Clinic has a robust committee structure and a long-term track record for how to initiate changes. “We had a process for change, on which to build. What was our process? Essentially, it was to get together and talk about things. I will put our committee structure up against the structure of any organization.” And that, he said, has been a real strength.
In addition, Poterack said, “One of the things we’ve tried to bring into the discussion is informatics core content. There really is a science behind some of these things, there really are best practices. There’s core content to medical informatics; after all, it’s now a boarded medical specialty.”
Still, many things had to be worked out, and process had to be pursued in an organized, systemic way. For example, he noted, “One could ask the question, how many records can one user be allowed to open at one time? And a loud voice could say, ‘We should be able to have as many open as we want!’ But the reality is that there are actually published guidelines around this, there’s published evidence. So I’ve tried to regularly remind people that there is [a literature with evidence] behind this, that it’s not just all whim. And that’s true of many things, for example, good graphic design, which plays into this. There’s a science around how you lay out a screen, what you put on it, etc. And a lot of people are demanding things.”
With regard to timelines, the plan for the creation of a unified EHR was created in January 2015. Then, Mayo Clinic health system in Wisconsin went live in July 2017, followed by Mayo Clinic health system in Minnesota in November 2017, with Mayo Clinic health system in Arizona scheduled to go live in October of this year.
“What have we learned?” Poterack asked. “That you really have to identify the stakeholders. Who are the people who really have the authority to identify and make changes? You need people who know what the process actually is” around specific elements of physician and clinician workflow. “Department chairs may not know what the workflow really is, what the process on the ground looks like. Then, you need people who are going to be able to help effect the change, people who can help roll it out in their area and get people on board. It might be the people ‘in authority’; or it might be more informal persuaders. And then you really have to get them all in a room. Out of necessity, we do a lot of teleconferences and videoconferences, but there’s no real substitute for getting everyone in a room, physically, and saying, OK, we have a patient who comes into the ED, what’s our process, and what’s the best practice? And then you’ve got to be careful of the ‘loudest voice in the room,’ the person who’s louder and more forceful than others, or who does the largest number of procedures. They may or may not have the right way of doing something.”
In addition, Poterack said, “You need a set of principles for saying ‘no.’ And you need to keep ‘eyes on the prize,’ to keep the end goals in sight.”
Also, “You’ve got to be aware of the amount of time it will take” to plan and implement such a major change. “You also need people with expertise. And, when it comes to EHRs, you need help physicians and clinicians train to use the system, and to personalize it correctly for themselves. The reality is that EHRs are still not intuitive. Perhaps they will be someday. Remember what Adobe Photoshop was like years ago? You had to take a course in it and be trained; you couldn’t just pick it up and use it. Now, the programs on smartphones are so intuitive that 14-year-olds can just pick up a phone, take a picture, and do a better job editing that photo in the phone, than professionals did with Photoshop years ago.”
Finally, Poterack said, “The truth is about the ‘secret sauce’ to this is that there is no secret sauce.” Instead, he said, “You need to have appropriate expectations, and you need to know how to sometimes say ‘no’ to doctors.” In summary, he said, “Know your goals; get the right people involved; set the right expectations; and utilize the best practices, informatics expertise,” and so on. And keep moving forward with “eyes on the prize.”
