Healthcare today is inundated with transformation technology. From smartphones to tablets to secure apps and remote access, new technologies bring the potential for greater efficiency in various forms, most notably communication.
No one, including physicians, has been left untouched by this transformational wave. Indeed, a physician’s mandate to deliver the highest quality patient care demands that he/she embrace the best tech tools available. Importantly, such tools enable physicians to facilitate better communication in their role as the chief conduits of information between their patients and the larger healthcare system charged with managing care end to end.
But technology can only improve one’s access to information and ability to disseminate it to others. It still falls to human beings to make value judgments about what information is most important to gather, and how and where to distribute it to improve speed and quality-of-care outcomes. In constantly assessing and iteratively making decisions regarding appropriate patient tests and treatments, physicians find themselves operating at the center of a “crucial outcome zone” where high-tech enterprise management meets high touch treatment. As we will show, healthcare based information technology teams have an equally strong obligation to better understand the daily patient care “rhythm” and information processing patterns of physicians and to then structure a dynamic technology framework that can meet physician needs accordingly.
CPOM: Great value, hidden complexity
Computerized Physician Order Management, or CPOM is a component of electronic medical record systems to help providers place and manage appropriate patient-care orders and facilitate them. EMRs are further woven with clinical decision support, which provides physicians with pertinent information about the order being placed or suggestions for order modification. Support ranges from recent test results, to standard screens and alerts as well as evidence based medical management guidelines. Numerous published studies have demonstrated the value of CPOM in (1) improving coordination of care, (2) increasing standardization, (3) reducing errors and (4) improving resource utilization. Given this value, you might expect physicians to eagerly welcome CPOM and the synergy it affords. But this adoption process is far more complicated than it seems, with two key factors driving complexity…
Resistance to change: Physicians have tended to follow a pattern of care and a workflow that works well for them personally, and to view any change in that process as a negative through adding time and complexity to their existing workload. In order to overcome such resistance to change when launching CPOM, due consideration must be given to its perceived impact on patient care and provider time while maintaining an efficient rounding process. To ensure sufficient adoption, the CPOM implementation scope cannot be limited to transitioning management of information and workflows away from paper. Rather, scope must be defined by a more solid and sweeping strategic vision that strives for overall process efficiency, and positions the underlying CPOM platform to act as an “efficiency hub.”
Ability to quantify "success": While it may seem obvious that organizations benefit immensely from this technology, the lack of an objective success measure often hounds the initiative. Consequently, the ability to demonstrate an initiative’s benefits depend heavily on anecdotal evidence and references. In endeavoring to establish CPOM at Lancaster General Health (LGH) – a 600-pluslicensed- bed, not-for-profit healthcare system in central Pennsylvania – it was critical to recognize how central the involvement of affiliated physicians was to creating a platform that delivered best-in-class care. To help physicians see alignment between the health system’s wider goals and theirs, we took care to show that our CPOM vision wasn’t about adopting some “shiny new toy” technology. Rather, it was driven by deep-rooted safety and process-improvement concerns. The management of perceptions went a long way in helping secure the willingness of physicians to go the extra mile, and to succeed along with the initiative, rather than viewing it as yet another burdensome checklist requiring their signoff.
While physicians may fear that CPOM implementation will rob “every last drop” of productivity and efficiency from them, the enterprise faced an even larger threat: inadequate adoption could mean a potential breakdown of care processes on the day of go-live, and a complete refusal by providers to use the system thereafter. By taking three steps -- forecast, anticipate and remediate -- physicians can be grouped by likeliness to adopt or resist change, and supported in kind. The larger aim here is to ensure minimal impact to workflow and productivity at go-live.
Forecasting: Use the adoption metric
In forecasting success, we began by looking at how to best experientially assess a physician’s CPOM adoption potential. The “Adoption Score,” which is based on both factual and perceptual measures, included these fact-based scoring criteria: (1) practice size, (2) current EMR usage, and (3) number of training sessions attended. Measurement criteria can be further refined into sub-categories such as the physician’s leadership roles in the organization and personal age. Apart from fact based scoring on each physician, the Chief Medical Officer and the Chief Medical Information Officer were also asked to rate physicians based on perception of how comfortable physicians currently were with the use of the EMR (LG Health first implemented the use of EMR in the ambulatory physician practices and then utilized a three phase approach for inpatient implementation). The combined factual and perception score provides the overall “Adoption Score,” which separates physicians into three main scoring categories: Early adopters, middle majority and late adopters.
Anticipating: Put usability to use
In order to anticipate what could be potential roadblocks, nothing is as helpful as a simulation experience that allows physicians to “test drive” while we simultaneously learn how to improve the system prior to go live. In our case, we used the concept of a usability lab for physicians. Such labs have long been at the forefront of better understanding user affinity and the human/computer interface. They are an effective means of evaluating not only basic system functionalities, but also complex related workflows. The biggest advantage, though, is that these labs allow objective measurement of characteristics such as user-friendliness and convenience. Usability Labs included actual clinical information on patients that physicians had treated within the past week. By replicating the upcoming user environment, this test environment allowed us to bring in a wide range of case scenarios so we could effectively study the future state. Following lean principles, usability labs were created to:
Standardize to keep workflow processes repeatable. There’s a tradeoff calculus to consider here. Customizable order sets can make CPOM much more convenient for individual providers to use, for example. Standardized functionality and workflows, on the other hand, make it easier for the majority, which encourages a higher adoption rate. LGH utilized their standing clinical multidisciplinary care management teams to develop consensus for standardized order sets that followed evidence based guidelines.
Build on existing functionality. Begin by asking, “How do patients flow through the system?” Lean team members started by following multiple different care provider types during the rounding process to map their workflow. We observed that when proposed workflows must naturally follow the addition, modification and collation of patient information in the current state, impacted processes tend to mistake-proof themselves.
Think like the "user," not like a textbook. During a CPOM build, the tendency is to take an over-scripted textbook approach to facilitating input collection. This approach confuses users. Case in point: A communication order to a nurse regarding a change in patient condition may make the very generic demand that the user “notify physician” for any sort of change, when what the physician really means is, “call me only in case of” a very specific change in the patient’s condition.
Consider fewer “functionalities” but keep them powerful. Usability does not stem from having a lot of “bells and whistles” but from being hyper-efficient in the use of a few. An ability to prioritize and multitask is most important. This helps keep the core structured, and the rest customizable. Multiple features add to the learning load on already time-pressed physicians. While training for basic functionality is essential, the key to using physician time well is to understand what gives the best coverage for frequent tasks.
Then there’s the question, “Do we to test CPOM usability in ‘one shot,’ or in phases?” It depends on the organization. We launched and ran the usability lab in three phases for several reasons. First, the system was being built in phases, starting with documentation, then CPOM. Secondly, phasing allowed testing for functionality at multiple times, and for different usage patterns. Consider the use of an electronic checklist to ensure workflow is completed for discharge. The discharge process is followed by a sub process drill down to medication reconciliation and post discharge follow up care. Thirdly, phasing allows the team to collect feedback, analyze work and address identified issues during the build, and allowed for mediation, revalidating and “re-launching” functions, or a particular workflow.
“How many users do we need to test usability?” Historically, tests in the development phase had few users. But it must be noted that usability testing with small groups hardly helps to understand the entire user group. Granted, with systems that have severe usability concerns, even a few users are liable to readily illuminate trouble spots through their expression of low comprehension and/or high confusion. A clinical system is altogether different. Physicians are more likely to struggle through complicated interfaces for their most crucial information needs and then shelve usage of more “need-based” apps. The key to usability, and hence longevity, is to quantify this “struggle.” This is why we decided a diversified group of physician provider users representing multiple specialties was key.
Remediating: Doctor-led IT governance
At LGH, physicians supported by executive leadership are integral to all decision making and guidance involving information management. The CPOM adoption initiative was no exception. Physicians have multiple opportunities to be engaged in work and decision making involving the electronic medical record through the Physician Advisory Committee, which is a large interdisciplinary team that includes members from varied specialties, including primary care, nursing, administration, and e-health leadership. Together, these groups partner to guide the build and use of the electronic medical record, and provide documentation of clinical care for all patients in the LGH system, both inpatient and in the ambulatory practices.
The adoption metric gives considerable insights into physician categories, specifically those of late adopters. These insights enabled the assembly of a specific plan to support physicians at go-live, ensuring that each physician category had ample support allowing them to focus on providing the highest level of care to patients while the transformation is underway. Usability Lab findings dealt with matters ranging from the amount and layout of information on the screen, interference with workflow, lack of visual cues and system feedback, to missing navigational prompts. The common thread though was this: key findings must be reviewed in the right forum, by the right audience and promptly taken up for action. When building a state-of-the-art EMR, such a rigorous approach to governance is the only real way to make sure initial successes in adoption don’t give way to eventual user rejection as hope for needed improvements wanes.
Last steps: In measuring success, key metrics were closely followed including percentage of patient orders placed electronically and number of core documents created using the EMR. As with any EMR and CPOM launch, even one done with the best intentions, a big question looms: Will this transformation be adopted easily by all? Moreover, one must ask: Is the transformation taking us closer to our institutional vision?
The underlying “system sustainability” challenge that remains going forward is one that must be met continuously. After go-live your long-term CPOM usability and acceptance goal – and ours – is to perpetually strive to optimize processes and technology. It must be persistently adapted as needed to meet changing environmental, medical, operational or regulatory conditions that users confront daily, always doing so while keeping the impact of change on user-friendliness and convenience top of mind. Remember, technology is merely a means to an end. And realizing your ends, whatever they are, will always be critically dependent on the physicians and nurses who leverage the EMR platform. They are the real drivers of change and patient outcomes, and must thus be kept forever centered at the heart of the vision.
This has been co-authored by Raj Mathew, who leads healthcare transformation at Genpact, and Dr. Michael Ripchinski, Chief Medical Information Officer of Lancaster General Health, PA.
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