The evolving IT landscape has presented the healthcare industry with an unprecedented number of challenges and opportunities. Many brave attempts by clinical and IT leaders to become change agents for better care delivery have resulted in frustration as failed deployments perish in the graveyard of lessons learned.
Often, the missing link between success and failure is tied to clinician leadership and governance. Well-thought out leadership and governance strategies have become a foundational component to fully leveraging the value of health IT investments and positioning facilities for compliance and success under new risk-bearing reimbursement models.
Recognizing the critical role of clinician leadership to any clinical IT process, SwedishAmerican Health System (SAHS) created a governance model that provides a successful framework for its IT roll-outs. Headquartered in Rockford, Ill., SAHS serves 12 counties in northern Illinois and southern Wisconsin. The organization operates the nationally recognized, award-winning SwedishAmerican Hospital as well as a cancer center, a network of 30 primary care and multi-specialty clinics and the regions largest home healthcare agency.
Health ITA Day in the Life
Like many integrated health systems, SAHSs IT department has been hit in recent years with an onslaught of requests for new technology to improve care delivery and workflows. Alongside internal requests, high-level IT projects for initiatives such as Meaningful Use and ICD-10 regularly consume time and resources.
Healthcare organizations face many challenges to IT deploymentsthe big picture of workflow impact being primary. Consider this typical scenario in which many healthcare organizations find themselves:
* Emergency department clinicians request installation of a best-of-breed system. After considering such important factors as cost, physician satisfaction and network capacity, the organization moves forward with a new system. However, without a system-based governance model, the impact of a stand-alone EDIS on the flow of information across the ambulatory and acute care areas may not be considered. As a result, while the new EDIS might end up satisfying the ED staff, it could simultaneously create frustrations for other departments and minimize the effectiveness of data sharing.
* CPOE and order set roll-outs are also prime examples of projects that must consider the bigger picture of workflows and system-wide impact. Driven by informatics and requiring tremendous cross-functional clinical collaboration and management, there are hundreds of facets to these complex projects requiring a huge draw on resources.
SAHS identified the critical role of clinician leadership to success several years ago during the roll-out of its Meditech CPOE project in tandem with the organizations clinical content management system ProVation Order Sets, supported with UpToDate Decision Support. Without solid clinician-led governance, the notable time and resources put into the implementation could easily result in just one more botched statistic.
Leadership and GovernanceThe Bedrock of Success
SAHSs governance model is based on two bedrock principles: (1) decisions about clinical IT will be informed by the needs and opinions of clinical users, and (2) the IT decision processes will be standardized, transparent and responsive. Key to developing the framework was the establishment of two advisory councils: the Physician Advisory Council and the Interdisciplinary Advisory Council. Membership for these two groups is drawn from cliniciansdoctors, nurses and technicianswho use the system every day to care for patients.
These councils review and decide on day-to-day tactical issues including changes in order sets, nursing assessments and electronic documentation templates. They report to an eHealth Oversight Council, co-chaired by the Chief Medical Officer and Chief Nursing Officer. It is at this level that clinical needs for IT are prioritized and reconciled with available resources. Those who participate in the governance process agree to adhere to common expectations for core behaviors covering such issues as attendance, participation and voting privileges.
A number of guiding principles were applied to the models framework including:
* The primary focus of all IT investments is the patient.
* Unless there is a compelling business case to do otherwise, use the functionality provided in the system-wide HCIS (in other words, choose an integrated solution over best-of-breed).
* Clinical users are required to use the EHR (for example, CPOE and electronic documentation are not optional).
* All initiatives derive from evidence-based content and standardization.
* All changes to clinical systems are subject to a change control process to identify and mitigate potential risks to care delivery and workflows. A general process flow was created for health IT projects that commences with a request being entered into a form on the organizations intranet. The request is then referred out to the appropriate council (Physician Advisory Council or Interdisciplinary Advisory Council). Once received by the council, the request is reviewed, and additional information is requested or an approval or denial is issued. If approved, the request is referred for further action which could include 1) sending the request for build, test and implementation; 2) establishing a workgroup for further development; and/or 3) escalating the request to a higher group for additional input.
At SAHS, one real-life example of this process started with the request for a pre-operative order set. It had been noted that a number of patients were showing up in the OR without necessary orders. The request asked that an order set be created that matched the pre-operative checklist, with items such as blood bank orders, pregnancy tests, perioperative antibiotics and IV fluids.
Upon review, it was noted that such an order set already existed. However, usage data showed that only 20 percent of OR patients had their pre-op orders entered via the order set. When this was discussed at the Physician Advisory Committee, the Chief of Surgery recognized it as an opportunity to educate his surgeons on the benefits of using order sets.
The governance model established by SAHS was kicked off in August 2013, and the first committee meetings were held in September. As of late December 2014, nearly 600 EHR requests have been received, more than 75 percent of them resulting in changes being made to the EHR or associated workflows.
Attendance within the Interdisciplinary Advisory Council has been in line with the health systems goal of having 70 percent of core committee members present at meetings, and there is an increased involvement of clinical leaders including the CMO and CNO in health IT decisions. When attendance at the Physician Advisory Committee declined, the decision was made to bring the meeting to the doctors. The CMIO, as well as IT and Clinical Informatics staff attend and are on the agenda at all medical department meetings, ensuring that the voice of the physicians is still heard in the decision-making process. The organization also continues working on change management strategies to shift the culture from IT owns this to IT facilitates clinician priorities but clinicians still own the process.
While all governance models require ongoing process improvement, SAHS has laid a solid foundation for ensuring that health IT deployments are successful and implementations are leveraged to their fullest potential. Technological advancement holds great promise for improving care delivery and outcomes, and forward-looking healthcare organizations like SAHS understand that the role of clinician leadership and governance will be critical to forward momentum.
Michael Polizzotto, M.D., is CMIO of SwedishAmerican Health System.
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