looking for more value from your ehr? an informatics ...€¦ · clinical informatics’ role in...

On the vanguard of thought. The future of healthcare requires nothing less.

While the EHR and other clinical IT resources present tremendous value potential, health systems struggle with wringing value from these tools. Success in achieving the intended transformation required by advanced care models has been elusive.

Many healthcare leaders expected meaningful benefits to quickly follow once the EHR was installed. Yet, successful installation of the EHR does not equate with effective integration of the tools into the workflow and culture of a healthcare organization.

TO GET REAL VALUE FROM THE EHR, ORGANIZATIONAL COMMITMENT AND CLINICIAN INVOLVEMENT ARE CRITICAL, AND AN ORGANIZED CLINICAL INFORMATICS PROGRAM PLAYS A PIVOTAL ROLE.

Looking for More Value from Your EHR? An Informatics Program Can Play a Pivotal RoleAuthor: Dr. Mark Van Kooy

Looking for More Value from Your EHR? An Informatics Program Can Play a Pivotal Role

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Most health systems employ a traditional approach to Clinical Informatics (CI), focusing informaticists on unit-specific workflow efficiencies, increasing individual clinician adoption levels and responding to often-disconnected requests for system enhancements. While this approach has resulted in steady progress in improving usability and access to patient information, more advanced system potential remains untapped.

Instead, a new approach is required that deliberately drives measurable progress in achieving an organization’s strategic and operational priorities—one that operates in support of clinical excellence, quality and safety, clinician experience and engagement, and the organization’s operational and financial success.

True progress arises from a coordinated focus on achieving system-wide consistency in care delivery and documentation, care quality and efficiency improvements, reductions in cost of care delivery, higher patient engagement and effective population health, as well as reduced physician burnout. This can only be achieved by advancing to the next generation of Clinical Informatics and creating a unified, highly-skilled Clinical Informatics team singularly focused on improving the utility and usability of the EHR with the technical, process and people skills, and insights needed to achieve holistic, integrated solutions.

Clinical Informatics’ Role in Driving Health System SuccessA core Clinical Informatics function is aligning and coordinating the efforts of otherwise disconnected health system resources in the service of efficiency, safety, quality and value.

Organized effectively, Clinical Informatics teams play an essential role at the intersection of a health system’s HR and organizational development functions, clinical IT capabilities and workflow/process owners to address the people, process and technology drivers that need to work together to achieve real clinical IT value:

z People are prepared to use the technology, and the technology is configured to support staff to optimize workflows;

z Workflows are designed to support staff, and staff are ready to make the best use of technology to deliver care; and

z Software and hardware are harmonized with workflows to help people achieve safety, efficiency and effectiveness.

HR & Organizational Development

Information Technology

PerformanceImprovement

Skills and experience

Learning and training

Policies, roles, responsibilities

Technical expertise Configuration/ customization Hardware/software

Process knowledge

Workflow design

Error & waste reduction

CLINICALINFORMATICS

Peop

le are

pre

pare

d to

use t

he te

chno

logy,

and

the t

echn

ology

is co

nfigu

red

to su

ppor

t sta

ff to

opt

imize

wor

kflo

ws.

Workflows are designed to support staff, and staff are ready

to make the best use of technology to deliver care.

Software and hardware are harmonized with workflows to help people achieve safety, efficiency and effectiveness.

A new approach is required that deliberately drives measurable progress in achieving an organization’s strategic and operational priorities...


This intersection of HR and organizational development, IT, and performance improvement are often overlooked. When informaticists are properly recruited, trained, deployed and managed, they marshal and harmonize the efforts of the organization’s workflow, technical and human resources to achieve the benefit entitlement of the organization’s massive investment in the EHR. Benefits range from enhanced clinical quality, improved efficiency and reduced cost of services, higher levels of clinician engagement, reduced physician burnout, and improved reputation in objective and public measures of performance such as Leapfrog and MACRA.

Key Competencies of a High-Performing Clinical Informatics ProgramOur experience has shown that to achieve this benefit entitlement, effective Clinical Informatics programs exhibit these characteristics:

VISIBLE AND ACTIVE

Executive Sponsorship

Skilled, DEDICATED LEADERSHIP

Explicit VALUE

DELIVERY Expectations

STAFFING SUFFICIENT to Scope and

Responsibilities

RIGOROUS ALIGNMENT

with Organizational Priorities and

Operational Plan

LINKAGE to Quality,

Performance Improvement and Change Leadership

INTEGRATION into

Clinical IT Governance

ALIGNMENT with IT and Operations

RELIABLE, PREDICTABLE AVAILABILITY

to All Clinical Sites of Care

Clear ROLE

DEFINITION

Distinct COMPETENCY Requirements

AN EXPLICIT APPROACH, Methods and

Toolkit

INTERNAL TALENT

Recruitment

CLEAR CAREER PATHWAYS with Future

Potential Leadership

Opportunities

EFFECTIVE PROGRAMS ARE INFORMED BY AND TIGHTLY LINKED TO THE ORGANIZATIONAL STRATEGIC PLAN, ANNUAL OPERATING PLAN AND PRIORITIES.


Key ConsiderationsLike any tool or capability, the value achieved from a Clinical Informatics program depends on how it is deployed and managed, how accountability and success metrics are defined, and how effectively it is used in the service of the organization’s operational and strategic priorities. Tight linkage with operations; clear, explicit performance goals; and visible, transparent communication of performance and results are essential.

Consider the Following

How effectively is your current EHR supporting safe and efficient care of patients?

How well does it support your operational processes?

How satisfied are your clinicians and providers with the care delivery experience your EHR creates for them?

How well prepared are clinicians and providers to use the full range of features and capabilities of the EHR to achieve the levels of efficiency, safety and quality the systems can support?

How are you addressing physician burnout and increased demands on physicians?

Are you achieving system-wide consistency in care delivery and documentation, and care quality and efficiency improvements?

How are resources across IT, HR and performance improvement marshalled synergistically to identify, benchmark and potentially adopt industry best practices?

How are the various primary professions that may comprise Clinical Informatics resources (e.g., nurses, physicians, AHPs, pharmacists and others) organized to provide a uniform and efficient level of support to the organization?

Are there tight linkages with the Clinical Informatics team’s priority efforts and the organizational strategic plan, annual operating plan and priorities?

How are accountability and success metrics defined?


Understanding the current state of a Clinical Informatics program as compared to leading practice is an effective starting point. An important added benefit of the exercise is reinforcing to all stakeholders the importance of the people and process side of realizing value from the significant investment in the EHR. It also helps define where the program needs to evolve to in order to achieve organizational goals. A maturity model like the one depicted below can be useful in assessing the current program and defining the future state vision.

A Pragmatic Starting Point To continue the evolution of your Clinical Informatics program and drive further value from your EHR, start with a thorough assessment of current capabilities, systems and structures using these steps:

z Assess the current state, including resources, roles, responsibilities, chartering procedures and skill sets;

z Work with key stakeholders to define the requirements and engage their support in the development of the informatics program;

z Formulate a future state program that includes support for all sites delivering clinical care and identifies the functions to be performed along with required competencies;

z Develop a comprehensive plan to implement the program. This should include the roles, responsibilities, staffing, management and reporting structures, value proposition and tracking, linkages to the EHR vendor and IT governance, collaboration model with Performance Improvement, IT, and Quality Improvement; and

z Gain approval for the overall informatics program.

Level 1:CI has not been established in the organization. Operations and IT are responsible for workflow and system design.

Level 2:CI staff is present in some areas, but there is no organizational approach to utilizing and developing CI staff and competencies.

Level 3:Leadership views CI as a critical organizational competency; strong executive sponsorship. Deployment and integration is incomplete but progressing.

Level 4:CI is a valued and effective presence in all clinical areas; workflows are routinely optimized.

FOUNDATIONAL ASPIRATIONAL PROFICIENT TRANSFORMED

System-wide CI team with executive sponsor and skilled, dedicated CI leader

Clinician-generated enhancement requests are numerous; limited prioritization; IT viewed as a “Black Hole”

IT analysts are responsible for workflow analysis, design and enhancements

Pockets of proficiency such as Nursing CI team

Limited or no senior executive CI sponsorship and alignment with annual operations plan

CI resources are available to all clinical areas

Clear and effective collaboration with Quality, Performance Improvement and Change Leadership resources

Little or no systematic harmonization of digital and physical workflows

Some chartered projects and influential areas receive CI support

Variable, limited ad hoc CI skills development

Tight alignment of CI work with system operational priorities

CI resources are partners in care delivery and present in all clinical workspaces

Structured CI competencies, professional development and career path

CI fully integrated into all processes and workflows; “the way we do it here”

PRO

DU

CTIV

ITY

& Q

UAL

ITY

HIGH

LOW HIGH

LOW

PEOPLE, POLICIES, TECHNOLOGY ADOPTION

RISK

& W

ASTE

Value is quantified, expected, routinely delivered and transparently reported

No identified CI resources


Clinical Informatics programs are valuable levers in moving organizations forward, but they can easily diverge from organizational priorities unless program leaders maintain persistent disciplined focus on value. It is essential that in the next generation of Clinical Informatics, program leadership is accountable for assuring that the program delivers tangible, substantive value as viewed from the perspective of organizational leadership. This requires a structured approach to value tracking and reporting and intentional, consistent focus on value delivery and strong partnership and validation with key stakeholders including the executive team and particularly, the Chief Financial Officer. Success is achieved when the value of the Clinical Informatics program to the organization is substantial, well-understood by stakeholders and is responsive to organizational priorities.

Clinical Informatics and ValueValue is in the eye of the beholder. Examples of meaningful value can include financial return, improved physician engagement and satisfaction, increased safety and quality, improved ability to manage complex care or other impacts. Illustrative examples are included below:

THE CHALLENGEPlateau in provider EHR proficiency at subsistence level performance

THE INTERVENTIONThree-day intensive advanced EHR training for physicians

THE OUTCOMEThirty providers per session trained

THE VALUEUse of Smart Tools 58% → 84% of Encounters

Time in EHR Outside of Clinic > 1hr 77% → 38%

Confident in Use of EHR 33% → 86%

EHR Improves My Job Satisfaction 28% → 87%

Work Life Balance (Good+Very Good) 41% → 71%

THE VALUE

THE CHALLENGEProvider documentation not adequately meeting clinical or business needs

THE INTERVENTIONPhysician-led provider documentation redesign initiative

THE OUTCOMESubstantial engagement by clinicians in improving multiple aspects of chart usability and completeness

Claims Denials/Physician/Month $3500 → $460

Chief Complaint Completion 92% → 98%; Accuracy 44% → 64%

Problem List Completion 50% → 86%

Encounters Closed Timely 86% → 99%

CMI 1.58 → 1.74

Discharge Med Rec 46% → 86%

Admission Assessment (nursing) 34% → 60%


THE CHALLENGEDecision support alerts creating alert fatigue and important clinical conditions meriting alerts being missed

THE INTERVENTIONSystematic review of decision support alert performance. Triage and termination of ineffective alerts. Addition of missing alerts.

THE OUTCOMEFewer annoyance alerts, increased relevance of alerts that fire

Provider Efficiency

Provider Satisfaction

Provider Alert Fatigue

Quality and Safety

THE CHALLENGEOffice-based agile optimization and personalization

THE INTERVENTIONAgile team deployed to provider office, address ordering, smart-tools, medication reconciliation, personalization, Inbasket, check out workflow

THE OUTCOMEImproved EHR workflows, enhanced provider proficiency, improved documentation and data capture

Provider EHR Rating

Staff EHR Rating

Provider Burnout

THE CHALLENGEFive medical staffs – unable to standardize order sets

THE INTERVENTIONActivate and lead new physician advisory group

THE OUTCOMEConsensus order sets, expanded to other important priorities (e.g., e-health)

Ability to Advance Order Sets

Physician Engagement

THE VALUE THE VALUE THE VALUE

PHYSICIAN BURNOUT COSTS AS MUCH AS

$150 BILLION PER YEAR. That formidable sum amounts to more than 4.7% of the nation’s $3.2 trillion expenditure on health care — an enormous sum that could have great consequence for the future of our health care system and the directions of health reform, were there a way to save or redeploy those dollars.”1


THE CHALLENGEOne hospital of 4 dropped to Leapfrog level C – failure to resolve

THE INTERVENTIONNew CMIO focused on problem, identified data entry inconsistency due to lack of clinical awareness

THE OUTCOMERestored Leapfrog level A

THE VALUEHealth System Reputation Preserved

THE CHALLENGEProvider documentation – note bloat, copy paste errors, etc.

THE INTERVENTIONCI supported, medical staff-led style guide and template development initiative involving 30 physicians

THE OUTCOMEMedical staff section-level standardized templates with enhanced data capture and efficiency

THE VALUECMI (along with CDI)

Physician Satisfaction

Physician Efficiency

HIM/Coding Time

THE CHALLENGEIT viewed as a “black hole” for enhancement requests, IT unsure of relative priority of requests and overwhelmed with volume

THE INTERVENTIONCombined clinical workgroup prioritizes enhancement requests, sole channel for clinical requests, IT commits to “x” enhancements per month

THE OUTCOMEClinician-governed clinical enhancement process, predictable, trackable enhancement flow

THE VALUEClinician – IT Relations

Relevance of Enhancements

Load balancing for IT Analysts

The national numbers on death and harm in hospitals have alarmed us for decades. What we see in the new round of Safety Grades are signs of many hospitals making

SIGNIFICANTIMPROVEMENTS IN THEIR PATIENT SAFETY RECORD,” said Leah Binder, president and CEO of Leapfrog.2


Sources: 1 The Blue Ridge Academic Health Group (Winter 2017 - 2018). The Hidden Epidemic: The Moral Imperative for Academic Health Centers to Address Health Professionals’ Well-Being. Retrieved from http://whsc.emory.edu/blueridge/publications/archive/blue-ridge-winter2017-2018.pdf.

2 The Leapfrog Group. (2018, April 24). Five Hospitals Progress from “F” to a First-time “A” in the Nation’s Leading Scorecard on Hospital Errors, Accidents and Infections. Retrieved from http://www.hospitalsafetygrade.org/about-us/newsroom/display/663012.

About the Author

Dr. Mark Van KooyPrincipal, Clinical Informatics & [email protected]

Mark Van Kooy, MD is a Principal with The Chartis Group and a leader in the Informatics and Technology practice. Dr. Van Kooy has over 30 years of experience in healthcare as a family physician and consultant. Dr. Van Kooy was the Chief Medical Information Officer and Director of Clinical Applications in a regional integrated delivery system prior to joining Chartis and has served as an interim CMIO in client organizations. Dr. Van Kooy’s recent work has focused on advising organizations on clinical IT governance, physician engagement in the oversight and evolution of clinical IT systems and integrated clinical informatics strategies. Dr. Van Kooy is a board-certified family physician with sub-specialty boards in Clinical Informatics from the American Board of Preventive Medicine. He received his medical degree from New Jersey Medical School where he graduated Magna Cum Laude and has a Bachelor of Science in chemical engineering from New Jersey Institute of Technology.

© 2019 The Chartis Group, LLC. All rights reserved. This content draws on the research and experience of Chartis consultants and other sources. It is for general information purposes only and should not be used as a substitute for consultation with professional advisors.

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About The Chartis Group

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