Beyond Mere Implementation: Achieving Adoption/Meaningful Use through Clinical Transformation Denise Hammel-Jones, RN-BC, MSN, CSSGB Senior Clinical Management Consultant Lean Black Belt Candidate Greencastle Associates Consulting Dr. Alexander Petron, DO Director of Medical Informatics Atlantic Health Conflict of Interest Disclosure Denise Hammel-Jones, RN-BC, MSN Alexander Petron, DO Have no real or apparent conflicts of interest to report. Objectives Describe how the ARRA creates a need for clinical transformation Provide a description of the patient safety drivers that impact clinical workflow and the process that supports implementation of clinical technology such as CPOE, nursing & physician documentation, and evidence-based medicine Examine areas where practice standards can be addressed to support clinical transformation initiatives Explain the steps that deliberately accelerates adoption of CPOE, nursing & physician documentation, and evidence-based medicine to support meaningful use
Agenda Background Technology Imperative Some reports suggest almost 20% of hospitals have implemented CPOE (HIMSS Analytics at 3.6%) CPOE is indicated as one of the ARRA meaningful use criteria CPOE is sought to improve patient safety and quality indicators Leapfrog, IOM, IHI and quality groups suggest technology as a potential tool to improve safety and clinical outcomes in healthcare ARRA stimulus package addresses need for HIT in healthcare $22.9 billion dedicated for HIT ONC and HHS cite integration/interoperability which has the potential to yield significant cost savings, allow providers to participate in Health Information Exchanges (HIE) The real technology imperative is meaningful use
HIT Spending Focus Financial Forces Significant operating and capital expenses are required to meet EMRAM stages 4-6 47-52% of total capital budget for IT Hospitals often seek consultancy to assist with stages 4-6 progression Economic factors are forcing health systems to re-evaluate selected health information technology initiatives ARRA Incentives Reimbursements diminishing Capital less accessible Patient volumes changes Bond ratings Meaningful use translates to attainment of financial incentives Meaningful Use & EMRAM Meaningful use
Without meaningful use technology yields installs not adoption Technology Implementation Issues Implementation Design and Rollout: Timelines often too long necessitating improvements before full lifecycle complete In-house expertise lacking to perform workflow redesign/clinical decision support Technology focused not patient outcome focused History of failed or inadequate projects plagues organizations Workforce Considerations: Aging workforce lacks aptitude for technology Transformational technologies create disruptive change More technologically progressed organizations need more skilled IT staff Organizations often don t account for decreases in productivity or the financial ramifications of poorly implemented systems Organizational Issues Challenges for Leadership: Change the traditional dynamic of project leadership Create a clear vision for technology projects to drive towards transformation A vision for transformative care Challenges for Methodologies Six Sigma or Lean not completely integrated into organizations partial benefits of these methods Adoption and transformation approaches not well defined or integrated with rollout approach
Technology Solutions Technology has the potential to address these issues: Automation Time spent in direct care Workload/workflow Throughput Connectivity Accessibility, accuracy and timeliness of clinical information Communication/information exchange Decision Support Patient safety Data Mining The Need for Transformation Despite the push for technology: Adoption remains relatively low Patient safety and efficiency gains are minimal Workflow implications from technology implementations are negatively impacting care providers Costs to nursing for duplicate documentation can range as much as $6,500 to $13,000 per nurse* Patient data is segregated and provides little value Costs for performing administrative functions are astounding * Clancy, T., Delaney, C, Gunn, J, Morrison, B. The Benefits of Standardized Nursing Languages in Complex Adaptive Systems Such as Hospitals. The Journal of Nursing Administration. 36 (9) pp 426-434 Background Key Takeaways Competitive market forces, legislation and the economic climate will force hospitals to re-examine approach to key initiatives Technology alone does not make hospitals safer and more efficient Hospitals need transformation to bridge technology with efficient workflow Leadership has the power to position their organization for change
Transformation Transformation Defined An act, process or instance of change in structure, appearance or character. A conversion, revolution, makeover, alteration or renovation Webster's A radical change approach that produces a more responsive organization that is more capable of performing in unstable and changing environments that organizations continue to be faced with Earl 1994 Transformation Organizations Organizations/efforts positioned to take on transformation initiatives: Possess a vision of end-state Strong leadership demonstrates the need for change Understand organizational issues driving change and what change has the potential to offer Value data driven approach to initiatives Position change-agents to succeed
Transformation Before undertaking transformative initiatives: Leadership must take lead and create case for transformation Establish a vision for the end-point Allow those with specific expertise to provide the details Think about the most optimal experience for the patient and clinician Do not replicate current state Focus on those initiatives that offer greatest value to organization Small gains have no real impact on transformation Transformational Activities Clinical transformation starts with the clinical vision not with the technology plan Technology serves as a tool in the transformation process but does not encompass the transformation process Although the process of transformation often begins with a review of current state; to accomplish transformation: Think with the optimal end state in mind Avoid replication of paper-based methods Involve all stakeholders early on that will participate in the transformational process Choose activities that have significant impact Transformational Initiatives Transformational initiatives are undertaken to address: Electronic Medical/Health Records Computerized Provider Order Entry Bar-code Medication Administration Clinical Documentation Evidence-based Care Operational Issues (i.e. throughput, cycle times, etc) New business ventures New hospitals/surgical centers/ambulatory care sites Services lines Products
Transformational Change Transformational change begins with organizational change Organizational leaders & culture must ready staff for change In every change initiative, there will be a period of time that productivity will decrease. This decrease in productivity is known as the valley of despair. Good organizational leadership techniques could minimize the breadth and depth of this decrease in productivity. Transformational Change Conditions must be set for groups to engage in outside-thebox dialog Organizational change is the first step in creating an adoption model A deliberate approach with specific actions is created to enact adoption Transformation Key Takeaways Transformational can only be undertaken with strong leadership commitment When tasks can be examined for value change can occur Do not allow technology to dictate the outcome
Technology Adoption Adoption Usage of a clinical transformation technology in a manner that is consistent with achieving the intended benefits Tipping Point The point at which the momentum for change becomes unstoppable.
Diffusion of Innovation The way an idea or product enters a social system and is adopted Characteristics of Adopters Category General Population Characteristics Physician Characteristics Percent of Adopters Innovators Venturesome Cosmopolite Geographically dispersed contacts High tolerance of uncertainty and failure Recent Graduates Practice in urban settings Group practices 2.5% Early Adopters Well-respected opinion leadership Well integrated in social system Judicious and successful use of innovation Board Certified Read medical journals Prescribe more medications 13.5% Early Majority Deliberate Highly interconnected within a peer system Just ahead of the average Rely on personal communication with peers Attend more offsite medical conferences 34.0% Late Majority Skeptical Responsive to economic necessity Responsive to social norms Limited economic resources Low tolerance for uncertainty Lower diagnostic activity per patient Smaller practices 34.0% Laggards Traditional Localite Relatively isolated Precarious economic situation Suspicious Older Overly cautious Excessively negative Prescribe less medications 16.0% Adoption The Opinion Leader Focus Characteristics Of Opinion Leaders Laggards Well- respected opinion leadership Well integrated in social system Judicious and successful use of innovation More education Higher social status Late Majority Greater empathy Greater ability to deal with abstractions Greater ability to cope with uncertainty More exposure to mass media More professional contacts Self confident Modern thinkers Teacher Clear expression Tipping Point Enjoy sharing knowledge High level of clinical expertise Current Caring Early Majority Early Adopters Innovators Time
Conditions to Meet for Each Phase of Adoption Awareness Target of change has some idea about EHR functionality Exposed to project branding Aware of the organization s level of commitment Position Target seeks additional information Personal attitudes formed Target has not made a commitment New information is merged with prior experience / lessons learned Formal and informal communications channels are established Evaluate Target is engaging or being engaged with EHR tools Target observes EHR in use Target receives training Trial Use tool to mimic old world / existing workflow Use with patient encounter (full functionality) Functionality in use is more than minimal or limited use (not just viewing) Adopt Change workflow to optimizes tool use Change tool from it s original rollout design Critical Dynamics of Adoption Relative Advantage The degree to which a technology is perceived better than the current state Trialability - The ability to try out an innovation without total commitment and with minimal investment. Observability - Seeing how an innovation works by watching someone else use the innovation and acknowledging that it is safe and/or beneficial Compatibility - Familiarity and compatibility with the existing environment Adoption S Curve relative to the implementation life cycle Readiness Action Plan Project Kick Off Pilot Rollout Initiate Plan Execute Close Awareness Position Evaluate Trial Adopt Tipping Point Adoption S Curve
Application of the Physician Adoption Model Implementation Methodology Clinical Transformation Adoption Assessment Clinical Transformation Adoption Awareness Seminar Implementation Methodology Defined as incorporating Organizational Change Management Improvements Take Hold. To realize the benefits, the clinical & administrative users must embrace the outcome of the project Process Improvement Do the right work. Ensure the project will have a tangible impact on mission; clinical or business Project Management Execute Flawlessly. The project should be conducted efficiently & effectively, which will reduce the cost of implementation Clinical Transformation Adoption Assessment Identification of Strengths Obstacles Watch Areas List of Opinion Leaders Readiness Action Plan
Reaching the Vision Reaching the Vision Increasingly there is a realization that: The process surrounding the technology is often more important for patient safety than technology itself Without the appropriate infrastructure technology initiatives can not move forward The current financial climate and the introduction of ARRA is forcing organizations to re-examine priorities: More effective ways to meet technology goals Achieve operational efficiencies Creating a stronger link between technology usage and improvements on quality measures Evolutionary vs. Revolutionary Change Evolutionary Change: Technology implemented only to support selective improvements Incremental alterations Modest gains Systematic approach Revolutionary Change Undertaken with the infrastructure to support re-modeling Large alternations over short periods of time Potential for significant gains
Change Approach Evolutionary approach to clinical IT: Phased implementation of technology Patient care goals clearly articulate Data driven Radical approach to clinical IT: Full scale implementation of technology Product implementation is goal IT plan driven Change Management The People Side of Change In transformation projects, participants are encouraged to: Identify it! Communicate it! Change it! Anchor! Breaking Down the Barriers to Technology Embracing a transformational approach to technology implementation requires key questions: Is data segregated into disparate sources for retrieval? How much effort is required to tell the patient s story? Redundancy in documentation or tasks? Does the task add value? How much processing is involved to complete a task or series of tasks? Can I demonstrate the value of technology through data?
The Vision In an economic downturn climate and millions at stake through ARRA, hospitals must eliminate waste through: Lean operations Smart implementation of technology Think with optimal outcomes in mind: Competitive business practices Smart and strategic use of IT to enhance operations/performance Approach critical technology projects with a strong adoption model: Maximize use Minimize disruption Summary Transformation is not just an approach but necessary for optimal results to achieve meaningful use Challenging economic factors result in organizational change and different implementation techniques Pressing patient safety drivers and quality outcomes will move technology implementation in process-focused direction Stronger adoption models can engage the clinical expertise necessary for re-design References Bauer, J, PhD, Hagland, M. (2008) Paradox and Imperatives in Health Care; How efficiency, effectiveness, and e-transformation can conquer waste and optimize quality, Productivity Press. National Research Council (2009) Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions. National Academies Press. Campbell, E., RN, MS, Guappone, K. M.D., PhD., Sittig, D., PhD., Dykstra, R., M.D., M.S., Ash, J., MBA, Ph.D., (2008) Computerized Provider Order Entry Adoption: Implications for Clinical Workflow. Journal General Internal Medicine, 24(1):21-6. Krizner, K. (2004). Clinical Transformation Initiatives Starts with a Total Vision. Managed Healthcare Executive. American Hospital Association (2008). Trendwatch: Redundant, Inconsistent and Excessive: Administrative De