Op mizing the Ambulatory EHR A Systema c Approach to Realizing Value

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1 Op mizing the Ambulatory EHR A Systema c Approach to Realizing Value June 2014 aspen advisors

2 Table of Contents Call for Ac on... 1 EHR Valida on: The Alterna ves and Decision... 1 EHR Value Realiza on Assessment: Planning for EHR Op miza on and Con nuous Improvement... 2 Implementa on: Making the Recommenda ons a Reality... 2 Achieving Results... 4 Successes and Challenges... 5 Conclusion... 5 i

3 It s not the club it s the swing Many believe that if something is not right, the newest technology can fix it. Take golf as an example. Many golfers think that if they buy the next great club technology, their game will improve. They do not think the ul mate inhibitor to performance is the way they execute the swing. Therefore, they spend the money and end up frustrated and embarrassed that they have great clubs and are s ll swinging with the same results. Execu ve leaders faced with user complaints about under-performing EHRs make similar assump ons about technology. Like golf, it is not just about the technology; the health system s business and process structures are o en a large contributor to value realiza on issues. While implementa on of an electronic health record (EHR) establishes bedrock func onality, it is challenging to op mize processes and applica ons to realize the true value from the investments during the ini al install. However, many senior execu ves and boards are asking what they got for the millions of dollars spent as soon as the EHR is up and running. Therefore, it s vital for care providers, administra on, and Informa on Technology (IT) to communicate to everyone that EHR value and op miza on is a journey that requires con nuous effort a er the system is installed so the sooner the hard work starts, the be er. This white paper examines one organiza on s journey towards op miza on, star ng with answering a simple ques on: Should we keep what we have, or is it me for a system replacement to achieve the value from it? From there, an assessment led to the iden fica on of process, roles, and technology challenges that ul mately led to an enterprise-wide op miza on effort. This case shows that no ma er where your organiza on is in implemen ng clinical systems, there should be stage gates iden fied to stop, assess value, and make long-term direc onal adjustments. Call for Action Baystate Health, the largest employer in western Massachuse s, is a three-hospital integrated delivery system serving a popula on of nearly one million people. It is one of the largest health systems in New England with over 10,000 employees. Growing Baystate s ambulatory care services is a strategic organiza onal priority, which involves recrui ng and aligning both primary care physicians and specialists in the region. However, nega ve community percep ons about usability of the EHR challenged recrui ng efforts. Baystate s clinician sa sfac on with the EHR was low because of produc vity concerns, and many clinicians openly communicated their opinion that a new EHR could solve their problems. Several of Baystate s organiza onal priori es centered on ambulatory services including: Growing the Baystate Medical Prac ces; Increasing physician sa sfac on scores through enhanced engagement and EHR usability; and Improving the pa ent experience at the prac ces. Because of the essen al role the EHR plays in the organiza on s efforts to stay ahead of market challenges and regulatory pressures, Baystate had a clear call to ac on to determine its EHR direc on. EHR Validation: The Alternatives and Decision Baystate s journey began with valida ng its current EHR strategy. The project team completed an in-depth func onality and interface assessment and a five year total cost of ownership (TCO) analysis for the following alterna ves: 1. Op mize use of the exis ng EHR; 2. Op mize use of the exis ng inpa ent EHR system but implement a different ambulatory EHR; or 3. Purchase and implement a new integrated EHR system for both inpa ent and ambulatory. The decision was to op mize use of the exis ng ambulatory EHR for several reasons. However, the most compelling reason was the realiza on that the current and replacement systems met Baystate s ambulatory IT func onal requirements. With op miza on and con nuous improvement, Baystate could address a number of workflow, data access, and usability concerns. Lower cost, training efforts, and opera onal disrup on and having the IT exper se inhouse also factored into the decision. 1

4 EHR Value Realization Assessment: Planning for EHR Optimization and Continuous Improvement The next leg of the journey was iden fying the changes that would be included in the op miza on effort to ensure success. Baystate started by assessing the six founda onal core competencies for realizing value from EHR investments, using the methodology and toolset developed by Aspen Advisors. Aspen subject ma er experts par cipated in the assessment and assisted in transla ng the findings into the ensuing op miza on effort. Training and Educa on IT Services User Experience Governance Change Leadership Those six competencies are: User Experience: Configure the system for ease of use, learnability, and efficiency within the end user s workflow. Governance: Implement a governance structure and processes for making efficient, effec ve, inclusive, and prac cal decisions that are in turn implemented. Change Leadership: Create a culture and a framework to make change decisions and implement those decisions faster, smarter, and more efficiently. Training and Educa on: Train the end users where they are, readying them to meet any challenge and priming them for con nual learning. IT Services: Deliver state-of-the-art IT capabili es following industry-accepted procedures for changes and implementa ons, while mi ga ng risks and maximizing sa sfac on. Performance Improvement: Define the requirements and metrics, measure the performance, analyze the gaps, improve the processes and technology, and lock in the gains. The assessment team collected materials and conducted interviews to understand the current state prac ces and compared them to best prac ces. Discussions with the team and the subject ma er experts iden fied how they needed to advance to support the organiza on s goals and objec ves and success metrics within the framework of IHI s Triple Aim. With these findings clearly documented, Baystate turned their a en on to priori zing the op miza on ini a ves and developing a roadmap. Performance Improvement Implementation: Making the Recommendations a Reality Baystate started to implement recommenda ons by crea ng an ambulatory EHR op miza on enterprisewide program called aehro (pronounced arrow ). The aehro program established nine Tiger Teams to redesign the following areas: chart naviga on, health maintenance, auto provider communica on, triage workflow, folder structure redesign, founda on playbook, ambulatory CPOE strategy, medica on reconcilia on, and provider documenta on workflow. The mul -disciplinary Tiger Teams had representa on from lab, imaging, referral services, prac ce users, prac ce managers, specialty physicians, clinical informa cs, technical support, and the EHR vendor and worked closely to streamline the inefficient processes. aehro Governance Structure Baystate leadership recognized from the beginning that long-standing behaviors of independent or non-inclusive decision-making and loosely defined accountabili es must change. Change begins at the top. From the onset, Baystate s senior leadership officially announced the program and has con nually supported it through numerous communica ons and ac ve par cipa on. Furthermore, the Physician Leadership Team has endorsed the physician program par cipants to represent the interests of Baystate Medical Prac ce physicians. 2

5 The commi ees and processes to execute the aehro program required a new governance model. The governance structure has five levels, as depicted below in Figure 1. Each ini a ve had a Tiger Team, chaired by an ambulatory physician, with IT, care delivery, and opera onal involvement. An IT clinical analyst lead from each Tiger Team reports to the PMO team whereas the physician chair reports to the Program Steering Commi ee. The Program Steering Commi ee, chaired by a physician, has more than 50 percent physician membership to assure non-it design decision making. This commi ee reports to the Execu ve Steering Commi ee, which includes the COO, CFO, CQO, CIO, and CMIO. Informa on & Technology Execu ve Commi ee Execu ve Steering Commi ee (monthly) Exec Steering Commi ee Chair and selected members on ITEC Program Sponsors, Program Steering Commi ee Chair on Exec Steering Commi ee collaborate to provide the highest care quality and to promote wellness for our popula on, supported by advanced clinical systems and efficient workflows. At the aehro program kick off, the COO (who is also the execu ve sponsor of the program) spoke to over 200 program team members about the importance of the ini a ve and shared his strong support for change. The CQO, CIO, CMIO, and Senior Director of IT Enterprise Applica ons also each spoke about their passion and support for change. Prior to individual Tiger Teams first mee ngs, physician chairs and clinical analyst leads met to explain their roles as leaders in each chartered focus area. Leaders and program par cipants were encouraged to step out of their comfort zones and engage in new program prac ces, tools, and processes working with members of other departments that they had not worked with before, using new tools despite familiarity with other tools, and challenging exis ng conven ons par cularly if different from industry best prac ces. Tiger Team Chairs (MD) and MD members on Steering Commi ee Program Steering Commi ee (bi-weekly) Program Sponsors, PMO, Cerner Exec, PMs, Program Manager on Steering Commi ee Tiger Team CIS analyst leads and EHR vendor a end project management mee ngs Tiger Team Tiger Team Tiger Team Tiger Team Figure 1-Baystate Health Ambulatory Op miza on Governance Structure Program Mgmt. Mee ngs (weekly) Program Mgmt. Mee ngs (bi-weekly) As Tiger Team mee ngs began, physicians and other prac ce providers brought issues related to the charter and some unrelated issues. This spawned a parking lot process, which became the building block for priori zing incoming requests. Ambulatory clinical informa cists gathered specifica ons and reason-for-priority and priori zed the list for the IT PMO. Change Leadership Tactics Change leadership was cri cal for success. Baystate teams were comprised of members having over years of familiarity with current processes and prac ces, so the organiza on knew that change would be difficult. To address this challenge, Baystate undertook a mul pronged approach. Examples of change leadership tac cs taken include the following: Baystate created a mission statement to align expecta ons: Baystate Health team members will To deliver and support new behaviors, a first step forward for leaders and program par cipants was to adopt a WE mindset, as opposed to an I mindset to engage each other in addressing program issues from the standpoint of determining what was best for Baystate Medical Prac ces. Open, construc ve, and nonpuni ve communica on was encouraged and ul mately engrained, so teams could proac vely collaborate to improve workflows and resolve issues. Process Improvement Integration Five of the nine Tiger Teams completed an in-depth analysis of current state and future state to iden fy waste and measure improvement. Baystate assigned a process improvement resource to assist with chart naviga on, communica on (including auto-fax) to referring providers, health maintenance enhancements, medica on reconcilia on, and CPOE. Training and Communication Baystate training and clinical informa cs teams agreed on a schedule to rollout new features every two to three months to reduce the impact on opera ons and training. Baystate s communica on strategy included sending out an all-encompassing awareness bulle n to the prac ces four weeks prior to go-live to let them know what design changes were in progress for implementa on. Key to the communica on strategy was the actual training efforts, whether aids, ps, or classroom training, which occurred two weeks prior to go-live (see Figure 2). 3

6 Each Tiger Team had a designated trainer who brought the design decisions to the IT training group and acted as another level of confirma on to assure the change fit with workflow overall. The trainer then incorporated the change into future training sessions and documenta on. Many of the requests providers brought forth in the team actually already existed, but providers were not aware of them, so training became a key focus as important as new designs. Each prac ce named super users and explained changes to super users using awareness bulle ns in weekly calls and monthly face-toface mee ngs, so that they could take these forward to prac ce users. The goal was to increase awareness of change; encourage standardiza on of prac ce; increase supportability by the super users, IT, and informa cs teams; and increase the overall sa sfac on with the EHR. Program Steering Commi ee aehro Training and Release Communica on Analyze Results Prac ce Champion Communicates Figure 2-aEHRO Training and Release Communica on IT Services The coordina on of implemen ng the change releases and communica ng status and issues is complex. aehro governance approved a new release management program that captured the design work of the Tiger Teams and set in mo on the processes for shared design, build, tes ng, risk assessment, training, communica on, and execu on of the change to support key clinical workflows. Support of a systema c and thorough process has proven to be more manageable from an opera onal perspec ve; it also highlighted the work of the providers. The level of accountability for the design has increased with provider leaders allowing for more peer-to-peer collabora on. As we go down this road of striving to improve the quality and user experience of our EHR, it is becoming clear that technical solutions alone will not solve our problems. Our EHR is a powerful but imperfect tool, requiring continual improvement. However, we as providers have the responsibility to become expert users of this tool, and to work together with our peers to develop and adhere to best practices for its optimal use...the ultimate goal is for the creation and the consumption of clinical documentation to be as effi cient as possible and most importantly to support our efforts to improve the quality and safety of care for our patients. Physician and Tiger Team Chair Achieving Results The ambulatory EHR op miza on program has been successful in crea ng a forum for shared decision making, increasing sa sfac on, and improving usability of the EHR. The aehro program achieved specific and measurable objec ves using Gallup, employee sa sfac on, and Clinician and Groups Consumer Assessment of Healthcare Providers and Systems (CG- CAHPS) surveys to reach the goals for the provider experience and the pa ent experience: Provider Experience Improve provider engagement Improve provider sa sfac on with IT services Improve EHR response me Improve the referral process and referring provider sa sfac on Improve Gallup scores Pa ent Experience Improve CG-CAHPS scores In the first four months, overall ambulatory and physician extender sa sfac on increased.35 from 2.3 to 2.65 towards the one-year goal of 3.15 (the scale: 1=Poor and 5=Excellent). This was a turnaround from scores that were declining to now scores that are increasing. 4

7 Successes and Challenges Every program has lessons learned from both its successes and the challenges that iden fy gaps and different approaches for the next program. Some of the challenges encountered during this journey include the following: Inpa ent Impacts: While design decisions for aehro focused on ambulatory workflow, some system changes affected the inpa ent environment, making cross con nuum communica ons a must. For example, inpa ent clinicians needed to know that tobacco, alcohol, and substance abuse data was made available in a new social history screen. Circumven ng the Help Desk: The team parking lot items took on addi onal scope as providers a empted to use the Tiger Teams as extensions of the help desk. Some of the successes achieved during this journey include: Physician Engagement: Physician a endance and collabora on at each weekly Tiger Team mee ng was excellent. Physicians ed each other between weekly mee ngs to gain consensus on items for workflow, policy, or other approval, which resulted in very produc ve and spirited decision making during the mee ngs. Physician payment for their me required consistent a endance, and all of the nine Tiger Teams met a endance requirements for compensa on. Enterprise Prac ce Leadership Sponsorship: The sponsor and co-sponsor of the aehro program were not from IT. IT accounted for less than 50 percent of each Tiger Team and in all commi ees to re-enforce that decisions were physician ones, not technologybased. Collabora on Tools: An aehro SharePoint site and Yammer provided communica on updates and discussions. Tiger Team physician chairs posted mission statements, decisions, training, and other items for review, approval, comment, and educa on through Yammer. The project manager used the SharePoint site for project mee ng updates to all 200+ project team members, including all prac ce super users. Consistent Templates and Tools: Tiger Team mee ngs used the following tools to keep a structured standard agenda, ensuring progress on open items: Dashboard of approved items from previous mee ngs and updates on implementa on Parking lot items transferred to the Help Desk Training-only items that were handled immediately due to no IT system changes Scorecard showing vendor and Baystate progress on solu ons Baystate remains focused on con nuous improvement. A solid founda on has been laid, which consists of the six core competencies for realizing value from the EHR investment, sustained decision making, and improved usability. Conclusion As health systems make strides toward achieving Meaningful Use and establishing the bedrock func onality with EHRs, it is essen al to op mize systems and processes ongoing. No ma er the star ng point, there is an opportunity to assess current state, iden fy where your gaps are across the core competencies, and determine the necessary changes to support your organiza on s goals and objec ves. It s not the club it s the swing As in golf, where success is not solely about the clubs, realizing the value of EHR investments is not just about the technology. It takes a combina on of people s ability, processes or workflows, and technology changes to improve performance. Unlike golf, healthcare IT op miza on is not a game. Pa ent safety, care quality, cost effec veness, and popula on health are at stake. 5

8 About the Authors Marty Belscher Principal, Aspen Advisors Marty Belscher has 30+ years of healthcare opera ons, consul ng, and CIO exper se with significant exper se in assessments, strategic planning, program management, physician adop on and organiza onal change management. Marty s CIO experience includes academic medical center, IDN, and community hospital se ngs. As a Vice President with First Consul ng Group, Marty collaborated with clients across the U.S. and in Europe to solve problems and implement change. Marty is also an adjunct faculty member in Simmons College s MHA Program. Claudia Blackburn Senior Manager, Aspen Advisors Claudia Blackburn is a results-oriented PMP with over 15 years of progressive experience in direc ng healthcare technology projects in both health system and physician prac ce environments. A strong leader with proven organiza onal skills, Claudia has been an effec ve link between the opera onal business side and technology interests of healthcare organiza ons. Claudia is a Six Sigma Green Belt. Claudia brings experience helping organiza ons realize value from their EHR investments and planning for technology and clinical integra on for popula on health ini a ves. Heather Nelson Sr. Director of Enterprise Clinical Applica ons & IT Opera ons, Baystate Health Heather Nelson is responsible for strategic and opera onal leadership in the design, development, implementa on, and management of Baystate s enterprise clinical applica ons as well as the HIE, device interoperability, imaging, and all applica on integra on. She is responsible for opera ons for the en re IT division, overseeing opera onal mechanisms, value metrics, program and organiza on performance reviews, and processes that enable IT to deliver its daily func ons. Heather is an adjunct professor at Elms College in Chicopee, Massachuse s. Fran Turisco Director, Aspen Advisors Fran has a diverse background that includes consul ng, research, and hospital IT line management. Known as a highly produc ve problem solver, Fran o en volunteers to lead complex and novel assignments. She has published and presented on numerous topics rela ng to emerging healthcare trends and technologies and is o en quoted in industry trade journals on all aspects of systems strategy, selec on, contract nego a ons, implementa on, and support. Clients include IDNs, academic medical centers, health plans, large community hospitals, hospital and professional organiza ons, pharmaceu cal firms, and charitable organiza ons. Joel Vengco VP of Informa on Technology and CIO, Baystate Health Joel Vengco oversees the technology strategy and opera ons of the en re Baystate Health system, one of the largest in Massachuse s. Previously, he was VP of one of the four global businesses that make up GE s $1.58B Healthcare IT business unit. Prior to GE, he served as Director of IT and Chief Applica ons Officer at Boston Medical Center where he oversaw various enterprise HIT applica ons and technologies. Vengco is a senior fellow at the Health Policy Ins tute at Boston University and has lectured at universi es, including BU, Harvard, and MIT. 6

9 About Aspen Advisors Aspen Advisors is a professional services firm with a rich mix of respected industry veterans and rising stars who are united by a commitment to excellence and ongoing dedica on to healthcare. We work with healthcare organiza ons to op mize the value of their informa on technology investments. Our experienced team is highly skilled in all aspects of healthcare technology. We understand the complexi es of healthcare opera onal processes, the vendor landscape, the poli cal reali es, and the importance of delivering projects successfully the first me. Every client is important to us, and every project is cri cal to our reputa on. Established in 2006, the firm has earned accolades for our culture, service delivery, and growth. We were named one of Modern Healthcare s Best Places to Work in Healthcare in 2011, 2012, and 2013 and one of Consul ng Magazine s Seven Small Jewels in Our hallmarks are top quality service and sa sfied clients; we re proud of our KLAS rankings and that 100% of our clients are referenceable. Contact Us: or Follow Aspen on Twi 7

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