In our series that addresses maximizing ROI through the use healthcare information technology, we’ve focused a lot of the discussion on clinical systems. There are a variety of clinical systems, but we’ve talked primarily about the electronic medical record (EMR). The reason for this is the central role the EMR plays in the clinical systems infrastructure. An EMR is the system that is most directly involved in patient quality and patient safety and the easiest place to capture a large and quick return on your optimization efforts. Therefore, we find it to be the lowest hanging fruit when it comes to realizing the benefits of optimization. So, how do you approach an EMR optimization? We’re so glad you asked…

If you’ve followed the other posts in the optimization series, you’ve gathered your multi-disciplinary team, led by clinicians, and you are ready to get started. Now what?

Expectation Setting

We recommend that one of the key activities in the initial meeting of the clinical systems optimization team is education. It’s important to make sure that the team understands the importance of the effort to the organization, and to the everyday activities of the members of the patient care and revenue cycle teams.

We also suggest that the initial meeting be used to set expectations about how the members of the optimization team should approach the project. The team should establish guidelines that address the following areas:

• A common and agreed upon set of goals for the optimization. This typically involves the improvement of patient safety and care, in addition to realizing financial benefit directly through revenue enhancement or indirectly through increased efficiency of the care process.
• No blame should be cast for the current situation. It’s important that the team accept that the system is what it is, and focus on moving forward.
• Communication to the entire user base. This is a critical part of the success of the project. End-users need to hear about the goals and progress of the optimization project. This is even more effective when one of their own delivers this information.
• EMRs demand new processes. How you have always done something is a valid explanation for why something is the way it is, but it doesn’t define what is best. Many current processes have roots in previous situations that are now resolved, or that made far more sense in a paper chart environment.
• Every idea for improvement must be supported with observable facts. In many cases, some members of the healthcare team have mistaken beliefs about the functionality of the system, or they may not understand that some issues have already been resolved.
• Everyone’s ideas are valuable and everyone at the table is a specialist in their area of expertise. Cardiologists are experts at the care of diseases and conditions of the heart, but coders and pharmacists are equally experts at their scope of practice.
• Solutions that customize the coding of clinical systems should be avoided. These solutions have a distressing tendency to break whenever there is a system upgrade, and will require additional testing and maintenance over the lifetime of the system. They should be avoided when possible.

Getting Started

The first task in a systems optimization is identifying the opportunities and their relative values to the organization. Often, the larger team will break up into smaller teams, with each subgroup addressing a set of concerns.

Key steps in the identification of opportunities include:

Data gathering – this starts with a series of brainstorming sessions, and requires members of the team to answer questions about their interactions with the system. These questions might include:

• What about the system doesn’t work correctly or efficiently?
• What are your greatest annoyances with the system (i.e. pain points)?
• What, from your perspective, would be the most important thing we could do to the system to make the users you represent happier?

Research – Once ideas have been identified, research is required. The team presenting the opportunity to the group should be ready to describe:

• What is happening that could be improved?
• What are the root causes of this behavior in the system? Is this item caused by the system working incorrectly, or is the system working as designed, and users, processes, or understandings are at the core of the issue.
• What would be the benefits of changing the behavior of the system?
• At least one suggestion as to how the change could be effected – including the possibility of leaving the system alone and choosing end-user education as a strategy.

This portion of the data process needs to focus on observable and measurable facts. There is a big difference between the statement, “This is happening a LOT” and the actual measurement, “An audit of the last six months shows two examples with a total lost revenue value of $125.”

An example from a recent project demonstrates the level of understanding required:

The identified problem is that items are being placed on the problem list as a resolved problem that can’t be changed to a current problem. Further investigation showed that when problems are added in the past medical history, the problems are set as resolved, but not when added as current problems, or in the review of systems. This causes items to be on the problem list as resolved, which requires the nursing staff to enter the problem again as a current item to produce a correct problem list. This happens on every patient. The system is working as designed – this is the way the system was configured by the vendor, but the nursing staff was not educated on it. Options include changing the behavior of the system or educating the workforce. It may be advisable to allow problems to be “re-activated” from the resolved status if they are placed there in error.

Ranking and prioritization – It is true in healthcare IT in general and certainly in the optimization process in particular that not everyone is going to get everything they want. By using a ranking process, the healthcare system can insure that the issues that get attention are the ones that benefit the patients and the organization the most. Some priorities, like direct financial gain, can be easily measured, with the high-dollar items obviously bubbling to the top of the list. There are other priorities, however, that still should be relatively important in determining the ranking of opportunities to be addressed, including:

• Hot-button issues that can serve as high-profile wins.
• Issues that can be resolved quickly with minimal resources, including those which are truly systems issues and would end up being repaired by your vendors with little resource cost to you.
• Compliance issues, where significant pain may be associated with non-compliance.
• Issues that can be resolved as part of another issue.

One area that merits special attention is patient safety. In many organizations, “This is a patient safety issue” is the hot-button phrase that is used to move anything remotely clinical up on the list. More properly, each potential patient safety issue has to be assessed from a risk perspective. In this case, the following questions make sense to ask:

• How likely is it that this bad thing will happen? If the proposed change is to something that rarely comes up, a system change may not be the most effective way to handle it. Similarly, if there are other controls in place that should prevent something from happening, the likelihood of the event happening is reduced.
• How bad would it be if this happened? An accidental second flu shot is obviously far less serious than a second dose of chemotherapy.

In future installments of this series, we will discuss other considerations in the decision making process, look at what activities the team should undertake during the implementation of changes, and discuss ways you can adapt this optimization decision framework to ongoing IT operations to support ongoing ROI based decisions.

The assessment of clinical systems and processes as they interact is complex. Phoenix consultants can help in setting up the structure for a clinical optimization process and guiding the process to completion. If you’re interested in talking to one of our experts, let us know.