On Wednesday, November 18, at the Pacific Northwest Healthcare Innovation Summit, held at the Hyatt Grand Hotel and sponsored by Healthcare Innovation, the Summit concluded with a spirited discussion of EHR/EMR (electronic health record/electronic medical record) optimization, with a panel of CMIO and CIO discussants, under the title, “Winning Strategies for Developing an Inclusive EMR Experience.”
Mitchell Josephson, vice president of the ARCH Collaborative at the Orem, Utah-based KLAS Research, moderated the panel. He was joined by Amy Chaumeton, M.D., clinical vice president of medical informatics and CMIO at Legacy Health (Portland, Oregon); Lee Milligan, M.D., who just recently transitioned from the role of CMIO to that of CIO, at Asante Health System in Medford, Oregon; and Rod Tarrago, M.D., CMIO at Seattle Children’s Hospital.
“When we get to a state where the EMR is empowering physicians and clinicians to deliver better care, and we get past the articles in the media about everyone hating their EMR, and getting exhausted, we’ll be in a better place. My daughter Macy, now eight, was five years old, and inhaled a coin, which got stuck in her esophagus, and she ended up having to have a surgery,” he said, and related the story.
“One of the key findings in our recent research,” Josephson said, “is that I can find an organization doing phenomenally well, with 75 percent of physicians and clinicians totally satisfied with their EHR experience, but I can also find an organization using the same EHR that has 20-percent satisfaction, and that is struggling. Everyone is learning and growing from the research that we’re doing at the ARCH Collaborative,” described on its website as “a provider-led effort to unlock the potential of EHRs in revolutionizing patient care.” “So what are we all doing to change the environment to an empowering one, around EHR usage? In terms of some of the pillars around this, we talk about education for a mastery environment; strong shared ownership or governance; and developing strong opportunities to personalize the EHR. That’s how KLAS thinks about optimization. But how do you think about it?”
“I thought about it as increased efficiency and decreased administrative burden, before our interactions with KLAS,” Legacy Health’s Chaumeton said. “Now we’re also thinking about it as enhanced personal clinician experience. We think about it a little bit differently, because as you guys looked at it, satisfaction turned out to be so important. I think it’s going to be a forever journey, though,” she said. “And for the folks we’re already focusing on, we have much increased satisfaction. But at a system where we have a small group of employed physicians and a large group of affiliated physicians, it’s hard to get satisfaction when providers go form one system to another, and we have a lot of work to do to improve workflows and… if we can reduce the burden on our frontline clinicians who are trying to think about the care—then we’ll do better.”
“Back in 2014 or 2015, and we had been on Epic for about two years at that point, we brought in two additional clinics, and we had some physicians who hated it and wanted to quit,” Asante Health’s Milligan said. “Everybody’s hair was on fire. But I took a bunch of physician IT builders down to Ashland to talk with them. We asked them to keep at least one chart open and show us their workflow. We were amazed. We had one older doc with carpal tunnel splints on each wrist, and he made a number of errors, but was typing out the discharge instructions. And I said, ‘You’re aware that we have pre-created discharge instructions for just about every situation under the sun?’ Another doctor didn’t even start to document until 4 PM, and ended around 9 PM. So we compiled everything, and we focused on education. We did also need to build out some specific workflows. The third thing? Some MAs had prepared the physicians very well, and others didn’t. So we focused on those things before we entered the ARCH Collaborative.
“We’re in the middle of thinking about what optimization should look like,” Seattle Children’s Hospital’s Tarrago said. “We’re in the middle of our 180-day preparation for a go-live; the ARCH Collaborative gave us a really good opportunity to look in the mirror. We spent so much time building everything, and were proud of ourselves. But we found we were in a very low percentile of physician satisfaction. And we looked inward, and realized we really hadn’t trained as we should; and we had demanded that everyone document the same way. How many of us, as consumers, would want to use our smartphones as they’re factory-built? No one. So by looking at these three pillars, and looking at better ways to achieve that optimization, it’s completely changed how we do things.
“This ties into a conversation I had recently with another colleague,” Josephson observed. “I asked him,, ‘Why are you guys making changes now to optimize the EHR?’ He said, ‘Mitch, because we have funding now and we also now how to compare what we’re doing with others around the country.’ So measurement is important. And you can take the questions in our survey and do it yourselves. The point is to measure, measure, measure, to determine where you need to go. So I’d like you to highlight a few themes around what you’re doing in your organizations.”
“When we were looking at our position,” Chaumeton said, “We saw that Kaiser Permanente was doing this incredible thing where they sequestered the providers for three days and trained them, and I dreamed of that, but could never get funded to do that. I went to the leaders for years to do this. We had one-on-one training, but we required that the provider block out one hour of their schedule; they don’t want to do that. And we provide morning, afternoon, and evening slots—they don’t want to do that. But the tipping point honestly was the ARCH Collaborative data that focused on training, satisfaction, and on burnout. We do measure burnout. It looks a little bit worse every time we measure it, which is every other year. So we now have provider-to-provider training. What I see with the provider-to-provider piece is that that provider can give a hook. As a provider, if I say something that makes a difference, and I can draw them in because I’m having the same pain, that hook is all-important.”
Meanwhile, Chaumeton noted, “The other thing is that our operating margins are very slender. But we tried to treat the providers well. We actually gave out prizes for people participating, we had games for participants, and we offered really good food and wine. We treated them well. But we learned from Kaiser to treat them well. We took them to a nice resort. The reason to sequester the providers,” she said, “is that they’ve driven somewhere that’s far enough away from home, that they won’t go home at night. And what’s great is that close to two-thirds came back for a second day. All in all, the retreat involves a total of around 11 hours of training. How do I know It’s a success? Partly because of the data we’ve seen through the ARCH Collaborative; and 100 percent said they’d recommend it to a friend. We still offer the one-on-one and two four-hour sessions; but we’re trying to meet them where they are. But the three-day training has been highly successful. And we don’t pay them for their time to come to class; they can use their CME. They’re motivated; it’s fascinating.”
“We’re uncovering in the research that it’s about giving the clinician time—that they feel they have the time to sit and learn,” Josephson observed. “In the fast-paced world of care delivery, they don’t feel they have the time.”
Chaumeton said she felt compelled to share comments from physicians who had participate din the training. Among them: “I can’t say enough about the meeting; it was the bomb.” “Best CME ever. And I thought that the [Epic] tool was incredibly rigid. But I realize it’s actually flexible.” “The course absolutely improved my efficiency. I’m sleeping longer, seeing friends, and even working out. I’m a success story, and I haven’t even implemented all the pieces you’ve taught me.” And, she noted, “Somebody’s eight-year-old noticed they were picking them up earlier in the afternoon.”
The leadership element
Later in the discussion, referencing what kinds of leadership are needed, Josephson noted that “We use the term bilingual leadership—for a leader to speak both the language of IT and of clinical workflows—and for themselves to be deeply entrenched in care delivery—it allows them to really help translate things; and they also become an advocate.”
“This is a soft skill, but they can call out the BS of other docs,” Milligan said. “For a doc to say to one doc, that’s BS, but to another, that’s legitimate—that totally changes the dynamic of the conversation.”
Turning to Tarrago, Josephson said, “Rod, you took a baseline. We probably have maybe 10-15 out of 250 surveyed who started out with a baseline measure of satisfaction. What has that given you?”
“We had a little bit of a perfect storm,” Tarrago said. “We got our results back and realized we had pretty terrible satisfaction. But we found out that the EHR was not the top cause of burnout; it was second. The top cause in our organization was bureaucracy and complexity. You couple those results with launching this project, and it’s very cool. You lift up that rock, and you get the data, and you can talk about things. And the results have been amazing, because now we’re able to build this new system and benefit not only from the features and functions of the software, but from everything,” he said. “That’s what I’m most excited about, and when we re-measure sometime in late 2020 and look at our data, and see what measures have changed, and how many have improved because of training, or because of engaging people more. I’m super-excited.”
Peering into the future
“In terms of what a strong EHR environment should look like, the ARCH Collaborative realizes that if we just look at what satisfies physicians today, we might lose some opportunity” to create change, Josephson said. “The next phase of research involves the fact that KLAS has now released some new questions around, is the EHR helping to manage opioid stewardship? We’re asking questions around clinical decision support; around getting information about certain populations. So as I share that, what’s that next phase for EHRs, in terms of the EHR’s proving its worth? What does the EHR need to be delivering?”
“I see it as involving two elements,” Tarrago said. “One, it would be nice if the EHR got good enough that we stopped talking about it, because it was so easy to use and was used by everybody, that we didn’t even talk about it. A few years ago, ago, Chris Longhurst”—Christopher Longhurst, M.D., CIO at UC San Diego Health, but previously, CMIO at Stanford Children’s Health—published a paper on practice-based evidence at Stanford Children’s. They looked into their EHR and said, what happens if you choose A or B? And they had about 200 cases of that exact situation and found a dramatic difference in outcomes, and created their own protocol based on their own data. That’s where I envision this going. Using that EHR data in a way that doesn’t increase people’s entry burden, but that will allow us to benefit from the data. We’re all doing the same thing in parallel. How can we use that to innovate?”
“Someone said earlier at this conference, doctors want the time to be able to interpret what they’re seeing, and not just documenting it,” Milligan added. “So the EHR needs to move forward to facilitate better workflow, to support that. And voice recognition needs to go from simply documentation, to command and control, so I can say, bring up Mrs. Smith’s last four sets of vitals and graph it out. And we need to decrease the EHR’s complexity. Physicians have to figure out how to make physicians’ workflows match their screens; and finally, mobility.”
“As the clinician,” Chaumeton said, “you walk into a room, and on the screen is the information you need, information that’s transparent to you and to the patient in the room. I find it interesting that people are sharing OpenNotes, but don’t necessarily notify the patient. It really is about walking into the room and talking to the patient, and the burden of documentation goes away. When we were on paper, we simply accepted the burden of documentation, but [we’re more conscious of it now]. We need to be able to concentrate on the clinical care, deliver the best patient care, and the patient believes that we’re delivering the best possible care to them.”