At CHI Franciscan Health, an integrated health system based in Tacoma, Wash., that encompasses nine acute-care hospitals and 600 employed physicians in about 60 clinic locations (among a total medical staff of around 2,000), Dean Field, M.D., vice president for informatics and operations, and the organization’s de facto CMIO (no one at the organization carries that precise title), has been leading a variety of change initiatives there. He has been in his current position for four years, with one year under his current title. Prior to that, he had served as the health system’s medical director of ambulatory informatics on the outpatient side, and medical director of clinical informatics, on the inpatient side. Field practiced as a family physician for over 20 years.
Following his participation on a discussion panel entitled “Analytics: Integration, Standards, and Workflow,” which was presented Aug. 18 during the Health IT Summit in Seattle, Field spoke not long afterwards with HCI Editor-in-Chief Mark Hagland, about advances being made at CHI Franciscan Health. Below are excerpts from that interview.
Tell us about some of the clinical informatics work you and your colleagues have been doing at CHI Franciscan.
What we’ve done at CHI here in Tacoma is that we look at the EHR [electronic health record] as the leverage to create change, whether using it as a tool to promote consistency and practice transformation across our clinics, or with regard to how we can use it for population health management across our system. The advantage we have is that we’re a fairly large system in a concentrated area. We have nine hospitals in five counties; so it’s fairly compact.
Even though you have the title “vice president for informatics and operations,” you are in effect the CMIO at CHI Franciscan, correct?
Yes, essentially. CHI nationally, we’re a very large organization, and locally, no one has CMIOs; we have application-based CMIOs. We have a CMIO responsible for Epic for four states. I’m responsible in the local market.
And how long have you been with CHI Franciscan altogether?
For 15 years. For 10 years prior to that, I was with Samaritan Health, now called Banner Health, in Phoenix.
How would you describe your organization’s journey around clinical informatics, clinical transformation, and population health?
Like many organizations, we’re an organization that’s been growing by affiliation. And you’re bringing together hospitals and medical clinics that had their own direction, their own way of doing things. So developing an electronic platform created that burning platform to really transform the organization, so that we could create more consistency, and more standards in how we did things. Historically, how physicians documented in their EHR didn’t really impact others, but now it’s clear to everyone that ordering, documentation, sharing clinical data, all of those needed to be standardized. And CPOE [computerized physician order entry] and order sets and reporting and structure of documentation, those were areas we began to focus on. Now, two or three years into the journey, we’re beginning to focus more on workflow and assignment of work, and more at the bedside level.
What are the challenges you’ve been dealing with, the obstacles, as you begin to address the mechanics of clinical workflow?
Everybody is doing what works for them. And that means that anytime you’re looking to change workflow, there’s a transition trauma, and whatever changes you make have to add some value. Because whatever a person or care team are doing, is a process that they believe is working for them. And you’re disrupting their workflow, and when you disrupt their workflow they become impatient, and they might be embarrassed in front of patients or peers, so you really have to have a good reason for making any changes.
Right now, we’re in the midst of working through our documentations standards, and we’re trying to come at that work from two angles. First, we want to make sure we tell the appropriate clinical story; we want to have good warm handoffs; we want to have some standardization around styling and vocabulary. So if we say a patient has stage-two kidney disease, for example, we want to make sure anyone touching that patient will understand what that means. And clear documentation improves case mix index, improves CDI and reimbursement, but none of those things add value for the physician per se, so we want to make sure that there’s a compelling reason for the physicians to go through that transition.
Second, the other part of that journey is that there is a real realization that our patients, our customers, are expecting more transparency. Cleveland Clinic is doing it, and Providence Health has announced it’s doing it this year, and we want to go to open notes and documentation transparency, but first, you need a style guide; and the sooner you work on the foundation of the not structure and the architecture—a patient doesn’t want to see a cardiologist from the organization, and see five different styles of notes.
EHRs are making the inconsistency of physician documentation patterns clearer, correct?
Well, there’s so much do with an electronic record. And whether you’re using note templates or Dragon or documentation templates, or allowing physicians to create their own templates—you’ve given them so many options, and if we don’t create some rules of the road or style guides, you could have 2,000 different styles with 2,000 different clinicians. And as an end-user, one of the hardest things for me was finding the key information and as a family physician, I needed to know what was important and what I needed to follow up on. There were critical things I needed to know, and yet everybody has a unique and different style, and where do you find the critical three lines. We don’t want to be so draconian that a person doesn’t feel they can tell the patient story. And yet at the same time, we want to be able to pull the critical elements out, for a good, warm handoff. Documentation evolved away from telling the patient’s story, to meeting a lot of third-party carrier expectations, which is fine, but don’t necessarily tell the story.
We certainly recognize that there are compliance issues, and payment issues, and we know those exist, but we’re trying to develop a standard style guide, and we’ve actually developed the guide itself and the structure of the documentation on what we’d like a standard history and physical note to look like a standard discharge note, were working on the encounter notes in the ambulatory environment, so, what should a primary care note look like in an average visit?
And what next steps did you and your colleagues take after that?
Well, now that we have this style guide, it’s about the journey that we’re on around socializing it, and getting buy-in. And that will take time. But the way we would approach it is how we would approach the auto-release of lab data. We made the decision a year ago that patients have the right to see their lab results and diagnostic imaging results. In fact, the reality is that failure to notify patients of results is the second-biggest leading cause of malpractice cases in the state of Washington. So we made the decision that we would release all results, normal and abnormal, to patients, within a three-day interval. But many physicians were fearful that they wouldn’t have the time to speak with patients.
So we staged this, in order to move in phases from a seven-day lag to a five-day lag, to a three-day lag, for results reporting, allowing care teams in the practices to get up to speed. So we’re at the five-day lag now, and the next change will occur right after ICD-10, we’ll be at a three-day lag. We’re at automated release now. Abnormal results have a five-day lag. After October 1, it will be reduced to a three-day lag. The greatest obstacle we see in most physician offices is that many practices still practice in a provider-centric model, meaning, I’m Dr. Field, my patients love me, and if I’m going to tell Susie Smith has an abnormal mammogram, I want her to get that from me. And yes, Susie may like me, her doctor, but she wants her results sooner. So it’s less about a physician-centric decision and more about a patient-centric decision. And if Dr. Field is out, who will follow up? Because in many clinics, it wasn't standard for one physician to deliver abnormal results for another physician.
But an example is that I had prostate cancer myself a year-and-a-half ago, and the reality is that for me, as much as I respect my urologist and think the world of him, I had to wait for seven days to get my results from my biopsy, and there was that built-in lag, and I didn’t want to wait an additional seven days. For me, it was easy, because as a physician, I can say to the fellow working for the urologist, I respect that my urologist is out, but I want my results today. But there shouldn’t be a separate standard; results should be available to patients.
And think of it in context—if you don’t want to provide same-day or three-day results, how long would you want your mother or sister to wait? And if I can articulate it that, way, the buy-in is there, but physicians have to report results for each other. And population health is about team medicine, about a system providing care, it’s no longer just about Dr Field providing care.
What have you learned so far in all this EHR optimization work?
The greatest learning so far is that, despite the goals being noble, that fear or angst of not being prepared, has been the greatest barrier we’ve had to face. And because I’m results-driven, I’ve had to pace myself a bit, in helping us to get down to a three-day release in an organization that historically hadn’t had clear standards for results release, that was a big stretch for physicians, to give up that ownership and allow somebody else to deliver the results of a test. So I had to accept a six-month delay in that process. And we’re in the same process with the documenting the templates, structures, style guide, are worked out. They’re just not ready yet, so we need to spend the next three to six months to educate and socialize on the style guide. There may be some things in the style guide that don’t meet their needs, so we may need to help them understand why.
Do you have any concluding advice for fellow CMIOs, CIOs, and other healthcare IT leaders?
Yes: listen more than you talk.
