Vi Shaffer, research vice president and global industry services director for healthcare providers at Garner, Inc., predicts that by 2015, 20 percent of integrated delivery systems will be investing in new healthcare-targeted customer relationship management (CRM) software. Shaffer’s prediction is part of  “Industry Predicts 2012: Industries Face intensified Consumerization and Technology Disruption,”  a special report released recently by Gartner, Inc.

“We made this prediction to highlight the gap we see in not only how health systems are approaching care management, but their strategic IT plans,” Shaffer tells Inside Healthcare IT. “Very few health systems that are far enough along on the combination of their EHR journey and their move to accountable care management recognize this gap.”

Shaffer says that once care organizations begin laying objectives for accountable care and Meaningful Use, they begin to realize that the biggest opportunity – and risk – lies in assuring that they are conforming to a set of processes and interactions with the patient. 

“Assuring those are happening involves the scheduling system, the electronic health record and also understanding what the gaps in care are,” she explains. “What we do know is that you can’t rely on well-intended people to assure that something is executed and coordinated. There’s a missing piece and that’s where CRM comes in.”

Healthcare is ripe for a sophisticated approach to CRM, given the need for coordinated care management and deeper patient engagement.

“If you look at retail, for example, we’ve seen an evolution into a much deeper and more intimate understanding of and engagement with the customer.  In healthcare, particularly in care management, you want to initiate contacts as well as ensure and track and trigger things that are targeted both at individuals and at groups,” Shaffer says.

As such, the supporting IT technology will need to be adapted for coordination with patients, the patients’ support network, payers, and social services and will encompass not only the sick, but the “not yet sick” and healthy patients as well.

Widening the net signals an enormous paradigm shift in the way healthcare providers think, Shaffer says, since traditionally, care providers have focused on episodic care.

“Providers have focused on managing the quality and workflow and the effectiveness of care with a patient during the course of the encounter,” she explains. “The focus has been on managing applications from the providers’ perspective and managing the physical environment of the care setting, whether it’s a hospital or a physician’s office.”

Now, healthcare organizations and providers are and will continue to be challenged to think about providing care in the context of a patient-centered approach.

“In addition to worrying about a patient when they are physically in a facility, caregivers are going to be challenged to provide services proactively and making sure they offer the best care, which can involve multiple providers as well as things like dietary consultations and prescription renewals,” Shaffer says. 

The opportunity for care providers to have granular information about patients is a fundamental underpinning of CRM – and is a realistic goal given the nation’s move toward electronic records.  “One of the criticisms of earlier attempts to develop effective disease management programs is that they’ve been so broad-brushed and distant that they weren’t effective,” Shaffer says.

Central to the whole idea of implementing and adopting a CRM system is the idea of IT competency in patient informatics.  Shaffer says that care provider organizations will need to keep the needs of patients front and center as they design patient-facing IT systems, such as portals and kiosks.

“Whenever you’re going to create tools for users you need to represent the user intentionally.  We don’t want to forget that we can’t take the patient’s experience for granted in designing applications that directly touch patients.  If you’re a patient in a hospital, what’s your day like?  You have to navigate patient education, doctor questions, family visits. It’s important that the patient doesn’t get forgotten in the process.”

Shaffer says that the reshuffling that will happen in the vendor arena as the healthcare CRM market heats up will be exciting to watch.  “Our pattern in healthcare is that many times, we see entrepreneurs develop new technology, but with CRM it’s more complex – and intriguing.”

In addition to the entrepreneurial players, there are companies that have created disease management programs for payers.  There are also companies that have developed CRM solutions for other industries and see healthcare as a profitable new market.  And, last but not least, are the industry’s existing mega-suite vendors, whose architectures lends themselves to the development of their own CRM solutions, acquiring niche players, or partnering with a non-healthcare company.

“It’s a really unusual landscape because of how it may evolve,” Shaffer notes.” There are many groups of vendors that could decide to play. The application is not small. It needs to be enterprise, scalable, effective, be able to interface with existing systems, be secure and protected, and be able to create and support trusted relationships with providers and patients. This is not something for the faint of heart.”

Healthcare organizations that begin now to plan for how a CRM application will fit into their enterprise architecture and care management plans will have a competitive edge down the road that will benefit them both in terms of patient loyalty and financially, says Shaffer.

“Using a CRM system assures conformance with processes and the organization’s relationship with the patient,” she explains. “In addition to the quality of care you’re able to provide, it also makes sense from a revenue standpoint.  The shrewd organizations will be thinking now about how to guarantee conformance with the things that are measured. Their EHR alone will not get them there, especially when it comes to managing groups of patients.”

Shaffer believes that the emergence of CRM systems will be viewed as a major change in the healthcare landscape.

“There’s already been a major shift in the primary strategic vendor relationship, which used to be the HIS and is now clearly the EHR,” she observes. “There’s also been a major shift in health systems to larger systems with multiple hospitals and physician practices.  The whole analytics adventure will give healthcare the ability to play like the big boys in other industries and CRM is a central part of the story.”

Copyright 2012 Algonquin Professional Publishing, LLC

However, the study also suggests that providing educational and clinical intervention tools to patients along with a PHR may increase usage.

Personal health records and hypertension control: a randomized trial (Peggy J Wagner, James Dias, Shalon Howard et al., J Am Med Inform Assoc published online January 10, 2012) examines a PHR’s impact in patients with hypertension. Researchers looked at changes in biological outcomes, patient empowerment, patient perception of quality of care, and use of medical services.

Of the 1,646 patients asked to participate in the study, 443 agreed and were put into either a group receiving a PHR or a control group whose members did not receive a PHR.

Physicians were recruited from one Family Medicine and one Internal Medicine ambulatory clinic at a southern tertiary academic medical center. Physicians from both clinics were randomly assigned to either the intervention or control group using a random number generator. Initially, 10 physicians were recruited per clinic, providing five per group. After three months, four additional physicians from Family Medicine were added to increase patient enrollment.  The study used MyHealthLink, a proprietary PHR system from the Cerner Corporation. 

Peggy Wagner, Ph.D., director of research development for the Institute for Advancement of Health Care at the University of South Carolina and lead author of the study, says that patients, physicians, administrators and staff expressed concerns going into the project.  Wagner presented the team’s findings at an AHRQ-sponsored webinar held this month.

Physicians were initially concerned that it would take them too much time to explain personal health information to their patients. Patients reported that in addition to concerns about their inability to understand the information in the PHR, there was also a sense of relief from the erroneous perception that their doctors would be continuously monitoring them.  The IT staff was concerned about the additional work they would have, and administrative leadership was concerned about the cost and potential legal risk and liability.

Patients were trained to use the PHR and researchers met with them four times over the course of the study.

In the intervention group, 31 percent reported not using the PHR at all, while 26 percent indicated they were frequent users. Because PHR use was lower than anticipated in the intervention group, the researchers decided to hone in on those frequent users.

In terms of health outcomes, Wagner says the team had some reason for optimism. “Among frequent users, we did see a reduction in both systolic and diastolic blood pressure between 4 and 5 points.”

However, other findings were surprising. “We saw a decrease in their rating of physician communication,” she says. “We also found that their perception of the usefulness of health IT decreased slightly, which was not the expected direction.”

The team decided to look more carefully at the factors that may predict frequent use of a PHR and found that patients from the Family Medicine clinic, which had adopted an EMR in 1996, were more likely to use the PHR than those from the Internal Medicine clinic. Younger patients were more likely to use the PHR than older patients. Higher self-rated computer skills, higher average diastolic blood pressure, and higher provider communication scores on the CAHPS instrument were associated with greater PHR use. A greater number of inpatient days was also associated with lower PHR use.

Contrary to optimism about PHR impact, PHR access alone failed to activate patients, improve outcomes, increase satisfaction with care, or change the frequency with which patients use medical services. As the authors pointed out, “simply providing patients with a method to access their healthcare information will not ensure changes in patient outcomes.”

Copyright 2012 Algonquin Professional Publishing, LLC

Additionally, Robert Tagalicod from CMS reported to the HIT Policy Committee at its meeting earlier this month that CMS had over 176,000 providers registered for the Medicare and Medicaid EHR incentive programs.

Tagalicod also told the committee that his office is confident that the upward trend will continue into 2012.

“Rather than get ahead of the announcement of Secretary [Sebelius], I just want to give you a sense that we are advising her and her office that some of the numbers that we initially projected we probably will meet and more than meet,” he said.

As of December 2011, $1.38 billion had been paid out under the Medicare Meaningful Use incentive program and $1.15 billion had been paid out under the Medicaid Meaningful Use incentive program.

Tagalicod noted that the final payout totals could be higher because eligible professionals can wait until as late as February 2012 to attest to meaningful use for the 2011 calendar year.

Also during the Health IT Policy Committee meeting, officials announced that CMS has launched a website containing monthly reports and data on the Meaningful Use incentive program.

Additionally, National Coordinator for Health IT Farzad Mostashari announced the creation of a public use file containing de-identified data from Meaningful Use attestations.

The file contains information such as the date and state of attestations; and the health IT vendors or modules used in demonstrating Meaningful Use. The file is available at http://www.data.gov/communities/node/81/data_tools.

Copyright 2012 Algonquin Professional Publishing, LLC

Six months after implementing a Web-based pre-op system, Presidio has lowered operating costs by substantially reducing day-of-surgery cancellations, reclaimed valuable nursing time and increased patient satisfaction.

“We had a problem that’s very common among free standing surgery centers,” Scott tells Inside Healthcare IT.

Prior to implementing One Medical Passport from Medical Web Technologies, Presidio relied on a full-time nurse to manage its pre-op process.  Calls took 20-25 minutes per patient to gather medical histories.

Because patients weren’t always prepared for calls, medical histories were often incomplete or inaccurate. Consequently, it wasn’t uncommon for day of surgery surprises to result in surgeries being delayed or cancelled, which cost Presidio time and revenue.

Scott says that once the system was implemented and the doctors’ offices became familiar with telling their patients to go online to fill out the pre-op forms, Presidio began to see the benefits.

“Because patients fill out their medical histories online, at their convenience, information is more complete and accurate. As a result, cancellations caused by day-of-surgery surprises are no longer an issue, saving us an estimated $46,000 a year,” Scott says.

When patients are added to Presidio’s schedule, they receive an auto-generated telephone message asking them to go to Presidio’s website to fill out their pre-op forms.  Once the forms are completed, the forms are automatically forwarded to the pre-op nurse who reviews them for potential problems.

"Most of our patients don’t have health issues, so she’s able to go through the forms quickly, flag those who do and spend more time getting those issues resolved with the patients in a timely manner,” Scott explains. 

While Scott says that in general, computer literacy among patients hasn’t been an issue, there have been a few instances where a patient has needed assistance.  “Every once in a while, we’ll have a patient who either can’t fill out the forms online or doesn’t want to. In that case, the pre-op nurse calls the patient and fills out the form with him or her.”

Scott says that on the front end, both patients and doctors have accepted the system as a matter of course.

“We’ve had just a few complaints from patients about having to fill out the paperwork online, but it’s been pretty limited. We have an average of 500 surgeries per month and over the six month time frame that we’ve been using the One Medical Passport, I’ve had three complaints. Other than that, I don’t think patients really think about it too much.”

And Scott says that the response from members of the surgical team, particularly the anesthesiologists has been positive. “The anesthesiologists like the system because they’re the ones who have to be concerned when the patient has health issues. And it’s made things much easier for our staff.”

Presidio has been able to reassign tasks, enabling caregivers to focus on patients. “The nurse who was previously doing pre-op information gathering full time is now doing it part time and spending the remainder of her time in the pre-op/post op unit with patients,” Scott says.

While Presidio’s experience with One Medical Passport has been a positive one, it hasn’t been without challenges, particularly when it came to integrating it with other systems in the center.

Scott says that Presidio, which is uses paper charts, has a number of standalone systems that address specific tasks within the center.

“One Medical Passport has functionality where it’s possible to prepopulate the online forms with name and address information,” she explains. “We’re not using that because we use another system called ScanChart which enables us to print out barcoded chart packs for individual doctors. When we scan the charts back into the system, because of the barcoding the system knows exactly whose chart it is.  I wish there was a way to integrate the two systems.”

Despite the challenges of integrating the different systems, Scott says that the benefits far outweigh the challenges.  “We know that more people are coming to our website because of the online forms. The system is making the experience of pre-op scheduling less frustrating and more efficient for our staff, and most importantly, it’s creating a safer environment for our patients.”

 Copyright 2012 Algonquin Professional Publishing, LLC

But what does “buy-in” really mean?  And how does it differ from the idea of “ownership?” And does the distinction really matter?

The answer is “yes”, according to Debra Sims, RN, Clinical Supervisor, The Children’s Hospital at Providence, a 2010 Eisenberg Award Recipient, and Jack Jacob, MD, Staff Neonatologist, Pediatrix Medical Group.

Sims and Jacob recently discussed their successful effort to eliminate central line infections in the neonatal intensive care unit at a Patient Safety webinar sponsored by National Quality Forum and their example of teamwork in a clinical setting has some valuable lessons for those in other departments. They contend that the success of a team-centered approach to any problem must take “ownership” and “buy-in” into account.

“Ownership” is when you own or share the ownership of an idea, a decision, or an action plan; it means that you have participated in its development, that you chose on your own accord to endorse it. It means that you understand it and believe in it. It means that you are both willing and ready to implement it.

On the other hand, “buy-in” is the opposite. Someone else or some group of people has done the development, the thinking, the cooking and now they have to convince you to come along and implement their ideas/plans.

What is wrong with “buy-in”, Sims and Jacob say, is the notion that it is perfectly okay for a few to make the plans and decisions and then to impose them on all the others. It’s an illusion to expect that those others will be willing and able to implement them perfectly as if they had made the decisions themselves.

With so many initiatives coming at CIOs, it’s important to understand the difference between ownership and buy-in. There’s simply no time to waste on re-energizing stalled efforts and taking the steps up-front to achieve ownership, rather than buy-in, may be the difference between success and failure.

Copyright 2012 Algonquin Professional Publishing, LLC

Robert Booz, vice president and distinguished analyst in Gartner’s Industries Research area and a 30-year industry veteran, says he’s seeing a growing number of  healthcare payers acquiring healthcare providers, spanning the continuum from individual physician practices up to and including large multi-facility hospitals. 

Booz’s analysis was part of Top Industry Predicts 2012: Industries Face Intensified Consumerization and Technology Disruption, a recently released report from Gartner, Inc. In the report, Booz predicts that by 2014, 30 percent of U.S. private healthcare payers will acquire providers, forcing integration of application suites as delivery and finance merge.

However, Booz says that he believes that number may be too conservative. “We know that there’s been about $1.5 billion already committed. We’re talking about significant money and a significant shift in the marketplace.”

Why the shift?

Booz says there are three reasons to explain the phenomenon.

The first has to do with supply chain. “At a very fundamental level, payers purchase physicians and hospitals at wholesale prices. Then they repackage and remarket at retail through premiums,” he says. “Unless there is a steady stream of provider accessibility, there’s no product to offer. From a supply chain point of view, assuring access is an essential part of the picture of why payers would be interested.”

The second reason is that acquisitions allow payers to broaden their service lines, much like investors who diversify their portfolios. “When you have the many unknowns of healthcare reform, there is a fear among payers that they will become very much like regulated public utilities,” Booz tells Inside Healthcare IT. “By spreading out the services that they’re able to offer, they provide a greater breadth of business opportunities and greater protection for their mission and ownership.”

The third major reason for the shift is what Booz calls service segment. “This means that payers are taking an opportunistic look at things like geography or delivery methodology so they can offer a broader range of services,” he says. “Those services might include things like neighborhood health centers, retail medicine, etc.” 

Booz says that he’s seeing two types of acquisitions: those that he terms “rescue” acquisitions and those that strategically enhance a payer’s ability to deliver a service.

Rescue acquisitions, such as the recently announced West Penn Allegheny-Highmark deal, happen when healthcare providers get in over their heads financially, due to low reimbursement levels, high overhead costs, and/or failed risk sharing.

“When hospitals and physicians take on too much economic risk and can’t spread that risk out far enough, they get into trouble. One of the concerns I have about Accountable Care Organizations is whether their risk bearing elements will be too much for physicians and hospitals to accept and manage,” Booz says.

Moving forward, Booz says it’s this combination of supply side, service line, service segment and the elements of rescue and opportunity that will broaden the relationships between providers and payers, bringing the financing and delivery sides of healthcare closer together.

But is the industry ready for yet another paradigm shift?

Booz says that both payers and providers will have no other choice than to be ready to think beyond their traditional relationship.  “Speaking candidly, have payers and providers had an adversarial relationship with each other? At times, yes.  But I have to say that the moral high ground has been lost. Both sides have been equally guilty in adding to healthcare access problems, healthcare financing problems, and healthcare quality problems and so the idea of ‘I’m not to blame, they are’, is no longer a sustainable position.”

Booz sees some major implications for healthcare IT vendors as more payers move to acquire healthcare providers that may ultimately provide some benefit for vendors.

“We’re seeing a broad trend of ‘a consumer of one.’ Consumers want what they want when they want it in a way that they want it,” Booz says. “They want things like mobile apps to access appointment scheduling systems or to tell them where they can get a flu shot or what they should be doing about their diabetes. Those areas of investment that providers and payers are making are costly but from an IT infrastructure standpoint, you automatically have broader access to capital when you’ve got payers and providers working together.”

Booz says he expects to see the trend toward provider acquisitions of payers continue.  “I think we’ll see more big purchases and that the size of those deals will be larger.”

Copyright 2012 Algonquin Professional Publishing, LLC

When leaders at Virtua Health, a four-hospital health system serving southern New Jersey, looked at the organization’s strategic plan a few years ago, they saw a gap that needed filling.

“EMRs are meant to be tools to help with workflow and patient safety and one area that we saw was missing was our ability to capture all the data pouring out of those biomedical devices that sit next to the patient’s bed or in the OR,” Al Campanella, vice president and chief information officer at Virtua Health, tells Inside Healthcare IT.

Without that information readily available, clinicians used paper to track values. “Even though we’ve taught clinicians to use a computer for everything else they do in the hospital, without an easy way to capture the data from the biomed devices they still have to carry graph sheets where they’re scribbling down the values they’re getting from the devices. Or worse, they’re not tracking the data at all,” Campanella says.

As part of its commitment to patient safety, Virtua Health began searching for the right connectivity tool and compared products from iSirona, Capsule, GE and Nuvon before it eventually decided to partner with Nuvon.

Nuvon’s vectored event grid architecture (VEGA) enables interoperability across disparate devices, networks, and systems and makes patient data available in real-time, at the point of care. 

VEGA’s functionality set it apart from the competitors at the time Virtua Health was evaluating systems.

“Nuvon’s devices had a patient authentication function to ensure that the right data flowed into the right person’s EMR,” Campanella explains. “Additionally, the system allowed us to monitor the devices from a central station.  While the other vendors have since caught up, at the time we were making our selection, those were the differentiators.”

But even before the vendor selection process began, Virtua Health looked carefully at its needs.  It conducted a thorough inventory of all its medical devices and developed a “must have” list and a “nice-to-have” list, allowing leadership to set organizational priorities and implementation plans -- something that Campanella says was a crucial step.

“One of the takeaways we learned was that it was important strategically to prioritize which devices would bring the most value if we integrated them and then, to make sure we kept that front and center when we selected our integration vendor.”

On the inpatient side, Virtua Health’s immediate priority included making data from ventilators and physiological monitors feed into its Siemens Soarian EMR.

 In the OR, the hospital wanted to ensure that data from ventilators, brain monitoring systems, anesthesiology machines, and physiological monitors fed into its Picis Perio-Operative System. 

Campanella says that one of the challenges in the implementation has been ensuring that the hospital’s clinical systems kept pace with the VEGA technology. 

“These systems weren’t really designed to take in thousands of bytes of data per second,” he explains. “They’re used to human beings going to a screen and typing in data.”

The hospital system just completed a major upgrade of its Picis Peri-Operative System and on January 24, plans to go live with the integration after four months of testing.

It will go live on the inpatient side in June 2012. “The Siemens EMR has a module that catches the data coming off the biomed devices and upgrading that module is on our calendar for the middle of the year,” Campanella says.

Implementing and adopting the Nuvon technology meant ramping up and improving communication between the clinical engineering and IT departments.  “Many times, those functions within a hospital used to be standalone. However, because the biomed devices are now on the hospital’s main IT network, there’s more dialogue and interaction between the two departments,” Campanella says.

Virtua Health outsources clinical engineering to GE Healthcare and Campanella says it was important to work through the support functions to clarify roles.

 “In a nutshell, we had to work through what the support model would look like,” he explains. “We basically ended up with a joint support model. It’s important that CIOs consider the support that’s necessary because you’re basically creating another domain of IT that requires both clinical engineering and IT expertise.”

Additionally, Campanella says that it’s important to work with the EMR vendors to ensure that their products can manage the huge influx of data that will come from the biomed devices.

Campanella says that the clinicians are looking forward to the go-lives and the anticipated efficiencies the technology will bring.

“The folks in the OR are very excited because it takes a huge burden off them in terms of documentation,” he explains. “On the inpatient side, the clinicians spend a lot of time looking at monitors and hand copying the values.  This new technology takes away something that they hate doing.  Compared to the other clinical systems we implement, this one is an easy add.”

Sidebar:

When selecting a connectivity solution, Virtua Health relied on 9 strategic principles to guide its decision-making process.

•           Patient safety – matching the right device data with the right patient

•           Ease of system set-up for end user

•           Can accommodate any workflow

•           Offers device integration in all departments and units

•           Flexible to work with different clinical systems

•           Device vendor-neutral

•           Can capture all device data outputs

•           Robust to minimize downtime

•           Ease of maintenance and trouble shooting

Copyright 2012 Algonquin Professional Publishing, LLC

“Bigger hospitals may have started before we did but they’re still working on meeting Meaningful Use,” says Craig Wells, IT director at George C. Grape Community Hospital in Hamburg, Iowa.  “In bigger hospitals, you often don’t find the interaction between departments that’s important for technology adoption.  I don’t think it’s surprising that smaller hospitals are leading the pace on becoming Meaningful Use certified.”

Grape Community Hospital, a 25-bed Critical Access Hospital, expects to qualify for several hundred thousand dollars in incentives, which the hospital plans to use to help cover the costs of acquiring its EHR system.

While Grape Community Hospital has had various forms of health information technology since 2003, implementing a clinical system was something new.  The hospital originally planned to demonstrate Meaningful Use by 2014 or 2015, but accelerated its timeline when offered the opportunity to beta test Healthland Centriq, an EHR system designed specifically for small community hospitals. 

In early 2011, the hospital began installing high-speed fiber, new computer hardware, installing and testing new software, staff training, and new audit processes with the goal of achieving Meaningful Use by the end of 2011.  In October 2011, the hospital successfully attested to and qualified for Stage 1 incentives.

Wells credits the effort’s success to thoughtful planning and teamwork.  To ensure that everyone who would be impacted by the implementation and adoption effort was represented, the hospital created what it called the Beta team, which included over a dozen staff members, clinicians, and administrators.

“People from our CEO on down were involved,” Wells explains. “At the time we were implementing and going for Meaningful Use, we were meeting every day for 2-3 hours per day.  It was a huge commitment.”

The team, which still exists, continues to meet twice weekly.

Meeting the CPOE requirement was one of the more challenging aspects of the attestation process and Grape Community Hospital took advantage of ONC’s loose definition.

“The ‘P’ in CPOE has traditionally meant ‘physician’ but it’s evolved to mean ‘provider,’” explains Wells.  “We met the CPOE threshold using nurses.  While some of our physicians are using CPOE, not all of them are.”

To encourage reluctant physicians to adopt CPOE, Wells says his hospital relies on other physicians who are already using it successfully.  “Some of the doctors who are already on board have really taken ownership of the effort to show their colleagues what they can get out of the system.”

Wells says that involvement by nursing has been critical to the success of the project.  To anticipate nursing’s concerns about workflow, training, and workload, the hospital created a new clinical IT specialist position.

“Our Clinical IT Specialist is someone who’s a nurse, who’s worked in the hospital for a number of years and she’s now under the IT wing,” Wells explains.

The Clinical IT Specialist is responsible for training and serves as the go-between and the first level of support for the nursing staff, which Wells says in retrospect was one of the smartest investments the hospital made.

“Her major focus is on the whole process of patient care and how it’s done electronically. To spend dollars on someone who can focus solely on nursing has been critical,” he says.

In addition to training and support, she supported the implementation effort by building the system’s master tables and converted the existing paper workflow to electronic.

“She really had to understand process flow upfront and to be able to interpret that now in new employee training or retraining is really important,” Wells says.

System training at Grape Community Hospital is run by the Clinical IT Specialist and involves each shift for a few hours at a time.  Nurses use computers in a dedicated testing environment where they are able to do scenario-based training. Wells says the hospital intends to continue the position permanently.

The hospital also relied on its vendor for support.

“Healthland’s primary focus is on Critical Access Hospitals,” Wells says. “As a company, in the last few years they’ve made some changes in their direction and have a real commitment to the Centriq product. While they’re not perfect, since no software company is, for what we had to get done for Meaningful Use, they were right on.”

Wells, who had previously worked in software development, found that being upfront with users about what the software could do, as well as what it couldn’t do, was critical to success.

“We set the expectation that the software wasn’t going to be perfect and that we would need to stick with it because things wouldn’t necessarily work perfectly out of the gate. Having those expectations help set the tone for our experience,” he says.

While Wells says the pace of the hospital’s implementation was difficult, in retrospect, he wouldn’t have done it any differently. 

“While it would have been nicer to move at a slower pace, it really showed us how important working as a team was to the process.  When we sat down at our meeting, each person made contributions from his or her perspective.  Success is definitely a team effort.”

Sidebar:

In the midst of its Healthland Centriq implementation, hospital workers from Grape Community Hospital pitched in with the rest of their community in an effort to hold back the Missouri River floodwaters. By early June 2011, washed out roads and highways had left Hamburg, IA virtually cut-off from surrounding communities. Thirteen employees living in the flood zone had to evacuate their homes. Staff members commuting from Nebraska saw their travel time to work increase from 20 minutes to two hours each way.

“While the floodwater didn’t physically impact our building or the town of Hamburg, the stress of the disaster took a toll on everyone in the community,” said Lynda Cruickshank, marketing and development director at Grape Community Hospital. “Every able member of the hospital staff volunteered to help people evacuate, or sandbag homes, or prepare food for other volunteers. Many staff already volunteer year round with the fire department or on the county emergency response team or both, but this event became a summer-long commitment. It was very reassuring to see how this team performed under that kind of pressure. The flood response would have been exhausting on its own, but our staff did whatever was needed to keep the EHR project on schedule as well.”

In July 2011, as floodwaters and road closings continued to cut off the town, the hospital mounted a major communications campaign to let people in surrounding communities know the hospital remained open and ready to serve their healthcare needs. This was also a key time for the hospital as it was going through its mandatory 90-day reporting period to qualify for Meaningful Use incentives.

Copyright 2012 Algonquin Professional Publishing, LLC

While most in the industry would agree that Meaningful Use has helped raise awareness about the positive impact electronic medical records and health information exchange can have on healthcare, there have been unintended consequences.

One of those consequences is a focus on implementation and installation rather than adoption, says Heather Haugen, Ph.D., corporate vice president of research at The Breakaway Group, a Xerox Company. “I think one of the things we’re seeing out there is that the unrealistic schedule set by Meaningful Use is contributing to an EMR whiplash effect.  Healthcare organizations get into the mode of fighting fires instead of thinking about the real issues around EMR adoption.”

Successful EMR adoption happens when users are empowered, when executive leadership champions the effort, when clinicians are prepared for productivity loss and workflow rethinking and redesign, and when the organization overall is ready for and understands the system-wide commitment necessary for success. But as Meaningful Use becomes a driver for strategic planning in some organizations, those pieces that lay the groundwork for successful adoption are often overlooked.

Adoption is critical, not only to moving forward on the Meaningful Use escalator, but also in achieving a safer, more efficient healthcare care delivery system.

Haugen is seeing first hand the impact of the focus on implementation. In a recent study, The Breakaway Group asked CIOs of large and mid-sized hospitals and a sampling of physician practices whether they had installed and were using specific functionalities such as clinical decision support and clinical documentation.  The study found that while over 90 percent of those surveyed had installed clinical documentation, only 40-55 percent were using it according to their organizations’ accepted best practices.

“What that tells us is that we can’t get the quality of care out of these EMR applications until we’ve adopted the functionalities,” she tells Inside Healthcare IT. “Just because an organization has the functionality installed doesn’t mean users have had the time or the ability to adopt it. That’s why many times they’re reacting to a sense of  not getting anywhere – this whiplash concept of maybe they’re doing something wrong and need to get a different vendor or change staffing.  I’m seeing them getting into a mode of making decisions based on a real lack of information about what’s going on and why.”

Marsha George, a former hospital CIO and now principal of Consulting by George, an executive search firm, warns that implementing technology with little or no thought for organizational needs is doomed from the start.

“Quite frankly, a lot of these organizations don’t have the bandwidth to do this well.  They don’t have the talent to slam this stuff in and make it work, much less get any efficiencies out of the software.  These organizations are going out and installing stuff with very optimistic timelines and their operational and IT staffs are already stretched to their limits.”

Haugen fears that without proper planning and preparation, there will be a number of organizations who will stall out at Stage 1.  “I think we’re going to see folks who qualified for Stage 1, but who can’t qualify beyond that.  We don’t have the data yet to say this, but when we start seeing people not qualifying for Stage 2 is when we’ll be able to say that organizationally, they probably weren’t ready to begin with.”

And that can cause some major problems for already stressed CIOs, who are getting pressure from all sides.  “I’m seeing a lot of really tired CIOs,” says George. “Leadership wants to jump on board Meaningful Use, but they’re so anxious to get the systems in that they’re not doing some of the fundamental work upfront to redesign processes to make sure it’s all going to work in the end.”

That upfront work can make a real difference to success, says Haugen. Both she and George say that organizations that take a system-wide approach will be the ones who ultimately benefit.

“The best thing I’ve heard people say is that they’re going to hold off on trying to get Meaningful Use dollars until it makes sense for them so that they can benefit clinically,” says Haugen.

Haugen says that clinician input and empowerment is the key to success. “That leadership piece is the on/off button,” she explains. “When people have the right clinical leadership in place and understand what the issues are around adoption and are empowered to make those decisions, then adoption can happen.”

While clinicians are typically invited to be part of the process, Haugen says it’s critical to integrate and empower them. 

“Maybe we use the term ‘user involvement’ too generically.  What we really need to be doing is informing them about how the software is going to impact workflow and how it will affect the way they care for a patient.  It also means giving feedback that informs IT how to improve the system for clinical benefits,” she says.  “The bottom line is that it means more than just being on the receiving end of information or sitting on a committee once in a while.  It means getting a clinician to buy into the workflow changes and helping to determine how the organization is going to use a particular system to fit into its defined best practices.”

But what if your organization has already passed the point of no return and is running into trouble?  Haugen recommends using metrics to pinpoint where the trouble lies.

“When things are not going well, our tendency, especially in hospital environments, is to find blame.  We’ve created a model in our research that uses metrics to take an organization’s pulse and really pinpoint where the problems are.”

“If organizations can pinpoint the things that are derailing their adoption, then they can figure out what to do to address them. For example, if one of those things is physician adoption around CPOE and when they look at metrics around clinical usage, they find that the biggest problem is around the doctors that are in the hospital once or twice a week.  Well, that tells them they need to develop some new ways to engage those doctors.”

George suggests that already-stretched-to-the-limit CIOs get some outside help.  “If I were still a CIO, I would look for one or two very senior consultants that I could bring in to take some of the workload off so that I could have some time to think about long term strategies.  It’s important for CIOs to not just get caught up in what needs to happen this year, but also to be thinking about the long term business needs of their organizations.”

In addition to looking carefully at the short and mid-term issues around implementation and adoption, Haugen says CIOs also need to also look at long term adoption and use strategies.

“CIOs have to be thinking more about the ability to sustain an EMR for the life of the application.  They need to be thinking very strategically about how to keep everyone at a high level of adoption for the next five to ten years, not just to meet Meaningful Use or until the go-live is over.  Adoption erodes over time without constant attention.”

Copyright 2012 Algonquin Professional Publishing, LLC

1.  Take a walk in a clinician’s shoes.  Right now, doctors in particular feel threatened and what’s happening in their world impacts what happens with IT. There’s a great deal of uncertainty among doctors about what’s happening with health reform and the effect it will have on their reimbursements.  Additionally, younger doctors are coming out of medical school with enormous debt, making a conversation about healthcare IT investment and adoption a very personal and financial one.

Mark Anderson, founder of the AC Group, says that technology implementation isn’t necessarily a top priority for physicians. “If Medicare cuts their reimbursement, most of these guys could care less about computers. They just want to keep their doors open and have some major concerns about how they’re going to do that with less income.”

Anderson says that it’s important for CIOs to understand where doctors are coming from and why a CIO’s top priority may not be theirs.  Once that happens, CIOs can take steps to educate and communicate with physicians about the ways in which technology can benefit both patient care and safety – and the physician’s bottom line.

2. Communicate expectations from the beginning. CIOs who have done a good job at minimizing clinician pushback have laid the groundwork for change well before the go-live.

One way to do that, says Nicole Mohiuddin, MS, RN-BC, is for hospital leadership to be clear about what organizational expectations are and the benefits of the system.

“The really successful hospitals make sure everyone knows what’s coming and make it clear to everyone that if they want to work here, this is what you’re going to have to do,” she explains.

3. Be prepared for pushback.  Once the expectations and benefits are communicated, they need to be enforced. “That’s where a lot of organizations stumble,” says Mohiuddin, who has worked extensively with systems implementation and workflow redesign. “The doctors push back and the effort loses steam.  Leadership needs to convey that everyone is part of an organization that needs to do this because it cares about patient safety, it needs to differentiate itself from the competition, it knows that this is the coming trend and this is what patients expect.”

Successful hospitals know that losing physicians is a real possibility but have made a commitment to reaching organizational goals. “While it’s usually a very small number that walk, it’s still critical that the hospital communicate to clinicians that this is what you have to do because  it’s what our patients expect and who we want to be as an organization,” advises Mohiuddin. “That big strategic vision needs to be communicated and when that happens, people get it right.”

Formalizing the expectations can be a big help, Mohiuddin says, and she suggests that these expectations be codified and added to the medical staff bylaws. 

4. Understand the reasons for pushback are real. One of the biggest complaints about technology that clinicians have is that it takes more of their time.

 “They’re used to writing their orders and then giving it to someone else take care of it while they’re heading out the door and especially with CPOE, that’s not the way it works,” says Mohiuddin. “There are more steps and they just don’t understand that.”

System usability is often another reason for pushback.

“These solutions are not necessarily user friendly for the doctors or the nurses. There are a lot of clicks, a lot of steps and some of it doesn’t make sense,” says Mohiuddin. “You have to tell people that what you see on paper isn’t going to be the same as what you see on the screen.  You have to bring them to that water and show them.”

Finally, clinicians may not understand how to use the system and may be frustrated by ineffective training. To address that frustration, Jon Roberts, a consultant with Portland, OR-based Rule 4 Consulting says that the most successful training is done when it is focused on specific tasks that users need to know to do their jobs.

“The most effective way to do that is to break into small teaching sessions based on tasks, not on segments of the technology. In other words, instead of having classes on Chapters 1 through 4 of the manual, we tell our clients to design classes around what people need to learn to do, like admitting or transferring a patient,” Roberts says.

5. Be honest about the time that involvement in the process will take. The nitty gritty details of systems implementation aren’t something that clinicians are generally very interested in. “They get lost in the details,” says Mohiudden. “They get bored and they don’t want to go through all the little decisions. The problem is that those little boring decisions have to be made.”

6. Don’t pull the plug on support and training once go-live is over. In their role, CIOs must be able to be strong advocates for investing in ongoing training and support.  “It’s important that organizations have the resources and right people available to ensure that adoption and use stay high,” says Heather Haugen, Ph.D., corporate vice president of research at The Breakaway Group, A Xerox Company. 

Studies have shown that adoption erodes over time, especially when the only training available to new users is from experienced users.  “The ‘let me show you how to use the system’ method means that the experienced users teach new users both what they do well, and also what they don’t do well.  That inattention to training leads to less than efficient levels of use,” Haugen says.

7.  Know your users. Mohiudden says that CIOs should act as the intermediary between the clinicians and the IT folks and that’s one of the biggest challenges.  “A lot of CIOs really don’t have a good understanding of the way technology fits into the workflow. They think ‘we got this technology for you to make your job easier so why aren’t you using it?’  A smart CIO is out on the floors with his or her staff, listening to users and learning about what they need to do their jobs.”  

8.  Don’t create false expectations. CIOs who have done well are honest with users. They know their systems can only do so much and they’re honest about that, says Mohiudden. “They’re out there living and breathing it.  The ones that approach the limitations of the systems head on do well.”

Copyright 2012 Algonquin Professional Publishing, LLC