Northwestern Medicine’s Top MD Informaticist Dr. Thomas Moran, on Cognitive Burden and Other Challenges

Dec. 19, 2019
Thomas Moran, M.D., the chief medical information executive at the Chicago-based Northwestern Medicine, shares his perspectives on subjects including cognitive burden, note bloat, and care delivery standardization

Following a roundtable meeting held on September 18-20 in Chicago, with participation from the CMIOs and CNIOs of 26 major patient care organizations, the leaders at the Scottsdale Institute, a not-for-profit membership organization, produced a report entitled “Care Standardization: Why and How to Make this Work.” The report covers a range of issues that CNIOs and CMIOs are focused on in their patient care organizations nationwide.

Among the major concerns discussed at the meeting were care delivery standardization, reducing the cognitive burden on frontline clinicians, content management and clinical decision support, and clinician engagement and a culture of accountability.

The report that was published following the meeting included this finding:

“CMIOs joined the CNIOs on Day 2 to expand the discussion regarding how clinicians spend time in the EMR on documentation and other activities that add clinical value. Nursing generally is less concerned about the number of clicks than about workflow. Still, a consensus was reached among the nurse and physician informaticists that the EMR is already clogged with unnecessary tasks and has become cumbersome to use. What can we take away?

EMR vendors still have a long way to go when it comes to predictive analytics tools—not just in their reliability, but how the data can enhance patient care… With every EMR vendor represented among the participants, CNIOs and CMIOs eagerly shared their perspectives on training, education and EMR mastery. Again, the goal: less is more without sacrificing quality. Quality, the group agreed, is a matter of managing change well and implementing priorities through the right governance. Some of the blame for poor progress in care standardization, said several clinicians, is due to the meaningful use program. They view the meaningful use era as one in which health systems focused on getting EMRs implemented and stabilized without enough regard for deriving clinical value from them. Now we’re in a new era in which deriving value from the EMR investment is paramount.”

Among those participating in the meeting was Thomas Moran, M.D., the chief medical information executive at Northwestern Medicine, the 10-hospital integrated health system based in Chicago, with facilities and clinics across northeastern Illinois and into southeastern Wisconsin. Dr. Moran, who practiced emergency medicine for decades, has been chief medical information executive at the health system since early 2015, when the system came together.

Recently, Dr. Moran spoke with Healthcare Innovation Editor-in-Chief Mark Hagland regarding the meeting and the broader implications of the discussion among the CNIOs and CMIOs present. Below are excerpts from that interview.

What were your biggest takeaways from the September gathering?

That, overall, it’s really important to have a collaborative, peer relationship between nurses and physicians. It’s not just a doctor’s work or a nurse’s work; it’s work around a patient encounter, ambulatory visit, or acute visit. And you need to make sure that the actions a physician triggers, are efficiently and effectively communicated. It’s not necessarily the EMR itself, but the things we put into the EMR, that cause frustration. And collaboration cues up questions around what you expect from this order. And from the nurses’ standpoint, what is necessary to be put in the record. Something has to have value, otherwise, we’re just doing busywork.

Cognitive burden was a major subject of discussion at the meeting. What are your perspectives on that issue?

There’s too much information to sort through, to find out what’s relevant or timely, to find what you need to help your patient at the time.

How do you fix that?

You have to listen to what individual clinicians are saying they need. Everybody talks about usability; a lot of it is getting rid of things that don’t matter, so you can actually see things that do matter. We try to put so much into the record, that you end up doing “Where’s Waldo?”—and that shouldn’t happen. If it’s important, it should float to the top. And we still use rows and columns of numbers. A lot of times, we just

Note bloat remains a huge topic of discussion among physician informaticists. One of the concerns around moving to drop-downs in documentation is that he patient’s story gets lost. Your thoughts?

Yes, absolutely. We’ve made clinicians the programmers of the bill, instead of clinical communicators. And if we clinically communicate with each other, we’ll say, here’s Mrs. Smith, she has a 30 percent eject fracture, she’s on this is the medication she’s on, and that’s is what we need to do. That’s what you need to know. But we do it almost robotically. I know she has CHF, I know her health status, but I don’t know Mrs. Smith. And that’s what physicians are getting so frustrated about; they’re doing so much billable work that we’re losing the patient story. In medicine, we used to tell stories that communicated things clearly.

How do we reform physician documentation to help physicians?

We’ve been investing so much money and effort into communication documentation and AI, etc. HC is the only industry in which, as we advance in technology, we get less efficient. McDonald’s is putting in kiosks. Guess what? You still need a doctor, nurse, and staff, to do an encounter. It’s still one to one. And we’ve made the systems ,,,, Doctors and nurses are the programmers of the bill. We’ve built the system in such a way so that we’re almost engineers. Let us be clinicians, and let the computers help us. So let’s focus our communication intelligence on clinical communication, and develop systems that extract the information in order to drop the bill.

What specific strategies might be leveraged, in that regard?

Yes, we’ve focused so much on putting more in that we haven’t focused on what Ii call the minimal-maximal. What’s the minimal amount you can put into the record that gives us the most and most important information? We should be starting to take stuff out of the workflow and the record. Legal world, doctor world. The courtroom has a judge, two lawyers, a plaintiff, court reporter, bailiff. A doctor’s office has a doctor, nurses, staff. If a courtroom worked the way a doctor’s office did, the judge would have to do everything—interview witnesses, record the hearing, file the report, etc. But the judge does what the judge was trained to do. Things get done, and people do what they were trained to do. If a doctor were able to review, ask clarifying questions of patients and patients could enter information and nurses and front desk could do their work, and the doctor could write just an assessment and plan—we should use a computer to update the patient’s physical progress. We would be much more efficient. We don’t value your work—your assessment and plan for the patient. And it’s frustrating for us. I think we should start comparing ourselves to other industries.

What do you think CMIOs and CNIOs should think about care standardization?

I think we need to be really transparent here: we’re talking about pathways that can be used. It doesn’t mean every patient gets the same thing. I think that’s a disconnect for doctors; we always go to the one-off. We’re not saying you have to do everything the same: we’re saying there are branching logic points in the pathway based on the needs of your individual patient. And then we start throwing in personalized medicine, and guess what? That’s non-standard. So what we have to get everyone to understand is that this is the way we wash a patient, this is the way we prep a patient, this is the way we order labs, this is the team that responds. Standardization of procedures. But for CNIOs and CMIOs, we also have to understand that we have done a disservice across the nation by taking vendors who say, do it however you want. And we have evidence-based medicine. There are studies that say, for the population as a whole, this is the norm, but with exceptions. We haven’t come up with a clinical informatics best practice, meaning the workflow and care standardization. So when we talk about interoperability, that’s really hard to do, because we’re not producing the same data the same way. CCDs—you realize that the CCD is just an outline format; the content varies from one organization to the next.

So this care standardization has to be aligned with the workflow of the tools. Evidence-based medicine shows how things have been done correctly. At we at least have a starting point and decision tree that’s more digestible and understandable than everyone having a personalized order set.

What would your advice be for colleagues working to move their organizations forward towards greater standardization?

I think the cleaning up of the user interface to make it less busy and more useful, will help. And docs in general feel a lack of control over the tool, the tool being the EMR. They need some individualized settings. So now I do something again or order something in repetition. It’s not about the workflow, it’s about the information availability, the presentation layer, and the workflow, all working together.

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