In this panel discussion, Win Vaughan, Managing Director Markets, Advisory Services, sat down with Nordic physician experts Dr. Craig Joseph, Nordic's Chief Medical Officer; Dr. Laura Copeland, Chief Medical Information Officer, Healthtech, A Nordic Global Company; and Dr. Michael Augustyniak, Chief Medical Information Officer, S&P Consultants, A Nordic Global Company to discuss ways to provide a positive clinician experience during an EHR consolidation.
As a part of their discussion, Drs. Joseph, Copeland, and Augustyniak cover important topics, including:
- Prioritizing change management processes early on
- Setting up clear governance structures
- Data governance
Win Vaughan: Hello and welcome to the Nordic Global Panel Discussion. I'm Win Vaughan. I'm the Managing Director of Markets for Nordic's Advisory Services. Today we're going to talk about EHR consolidations and specifically how to ensure a positive physician impact during a system consolidation. Joining me today, we have three of our physician leaders and starting with Dr. Laura Copeland. I'd like for each of them to introduce themselves.
Dr. Laura Copeland: I'm Dr. Laura Copeland. I am an emergency physician and a practicing medical psychotherapist, and I'm the Chief Medical Information Officer for Healthtech, which is Nordic Global in Canada.
Dr. Craig Joseph: Thanks, Laura. I'm Craig Joseph. I'm a primary care pediatrician and the Chief Medical Officer for Nordic.
Dr. Michael Augustyniak: I am Michael Augustyniak. I'm the Chief Medical Information Officer of S&P Consultants, a newly acquired member of the Nordic Global family. I am anesthesia by trade, but full-time CMIO presently.
Win Vaughan: Great. Thank you all for being here and thank you all for digging in on this topic. To start off with, and Craig, maybe we'll start with you. What can leaders do to ensure a positive experience for physicians as they're entering into these complex EHR integration projects?
Dr. Craig Joseph: Well, it's a good question. I think the most important thing is to communicate and then when you're done, communicate some more and then when you couldn't possibly communicate anymore, communicate some more. It's very important that clinicians understand what they're getting into. I can almost guarantee they're not going to like everything, but surprises are bad. So really laying out that this is the plan, this is how you will be involved or your colleagues will be involved, this is how we deal with problems that we might encounter, and just making sure that they're along with you. Again, not so that they approve of everything, that would be nice, but that doesn't typically happen. Just so that they're not surprised and they know when things are going to get busy, when training is going to be happening, and when Go-Live is scheduled for those kinds of things.
Win Vaughan: Laura, jump over to you.
Dr. Laura Copeland: Along those same lines, I think it's important to remember that communicating is a two-way street and you can tell a lot about the plans and the intentions, but you also need to do a lot of listening. And I love the saying that if you give everybody the information that you had when you made a decision, they're likely to come to the same decision. And when it's something that they do themselves, you have a lot more invested in that particular change. So I would say listen to what they want. I mean, certainly here in Canada, some of the first forces of, "Hey, we want to all join on and use the same EHR" are the physician voices because it's better for the doctors and it's better for the patients.
So you could have a lot of physician champions if you allow them to speak their minds. And then if you have some people that aren't so thrilled. Maybe you've picked the EHR that they wish you hadn't picked and they wanted theirs picked. No doubt there will be some kind of losers and winners in feeling that way. If you allow them to express themselves, they might tell you and let you know some of the fears and barriers, which is gold information from a change management perspective. Because if you can address those fears and barriers, you'll help all of the people who are feeling those things to move through it.
Win Vaughan: Yeah, Mike.
Dr. Michael Augustyniak: Listening and communication are absolutely important. So thank you Laura and Craig for that. But I think we also need to keep in mind and be sensitive to the physicians and the clinicians from the acquired hospital because oftentimes the acquired hospitals are the hospitals that are going to have their technology changed, and therefore workflows and processes are going to change. We've got to be cognizant of that throughout the entire project. We have to understand that these docs are going to go through a major change sometime in the near future, and we have to level expectations early and often throughout the project.
Win Vaughan: Excellent. Thank you all. So communication is the foundation for change management, organizations have change management processes in place. But as you're all saying, this is a new way of working. And I guess how do you see empathy coming into change management processes?
Dr. Laura Copeland: If you don't allow people to have emotions about the change process, and if you don't name those emotions and give space for them, they are still going to be there whether you like it or not, and they can be big barriers. So empathy is important. It's important to recognize that people are struggling. It's important to take into consideration. As Mike said, when you're the one that has to change, you're taking that 90% of what you normally do on autopilot every day, and you're that taking away. You're saying, "Okay, now you have to think about all of that and the 10% that you normally thought about in the first place, and that's going to slow you down and it's going to hurt" so be honest about that, it will hurt. And how can you support those people. I always use the Jealous and J-curve for implementations.
I don't know if you know about the Jellison J-curve. Basically, it says you're going along at the status quo and you implement something and everybody thinks it's supposed to be an efficiency curve like this because why implement it if it's not going to make things better, right? So you have all these expectations and then people forget, and say "Wait a minute, I have to learn how to do this and I have to rewire my entire brain." And so what really happens is that productivity goes like, well, and it dips really far down, and then slowly it starts to come up and it's always way too slow because of the expectation gap. And so we use the Jellison J-curve all the time as part of our communications to say, "Hey, this is going to hurt. These are the supports we're going to give you to get through this, but at the end of the day, we're all going to be happier because X, Y, Z."
Dr. Michael Augustyniak: Well, I just wanted to kind of piggyback on my earlier statement. Again, these acquired hospitals are typically the ones that go through a major change. And we are coming out of a history in this world that none of us have ever lived through before, coming out of the pandemic, the great resignation, workforce shortages. These doctors, these nurses are overburdened, overworked at times and a lot of them are feeling burnout. So a merger or an acquisition is going to change the lives of many of these providers. And it goes back to listening to them, understanding what they need, and again, leveling those expectations early and often to help for a smoother transition and a better adoption echo live.
Win Vaughan: Craig, anything to add on that?
Dr. Craig Joseph: Well, I would say, again, kind of doubling down on what we've already said, I'm certainly more likely to be upset and anxious and scared when I don't understand the why. And so the why is so important, kind of getting back to that communication part, not just telling people what's going to happen, but why. And I think as Laura said earlier, if you understood why or what information I had when that decision was made, you are much more likely to agree with that decision, or at least to understand, well, it's not the way I would've done it, but I see what you were trying to do. And that often can take the level of stress way down because again, at that point you're like, "Okay, well, that's not what I would've wanted in my emergency department, but I do understand that it's not just my emergency department that's being affected, so I guess we're going to have to take this one." And that makes sense, and I can explain it to people as opposed to, "Yeah, I don't know. It seems clearly dumb and that's what they're doing, period." That's going to increase your stress level, that's going to increase your anxiety.
Win Vaughan: Well, I think we're kind of touching on the training, education, adoption program space, but thinking about what we're talking about here, about what the physicians are going through on these transitions, how can leaders that run those training programs, those providing the education, pre-implementation during GoLive, post-GoLive, what should they take into consideration when they're working with this specific physician audience?
Dr. Laura Copeland: The Arch Collaborative study is kind of your foundation for how to support your docs through this. And the Arch Collaborative is a survey and they've had over 200,000 clinician participants. And the questions they're asking all have to do with clinician satisfaction with their health information systems. And out of all of these places and clinicians that have been surveyed, they have identified that there are three things that correlate very strongly with satisfied folks. And the very first one there is education and the quality of the educators. The second one is personalization, being able to make the system work for your own personal workflow. And the final one is this relationship between the clinical and IT, and I think that dives into governance, it dives into change request processes, support desk kind of stuff. So I would say focusing on all of those are really important to come up with the successful plan.
Win Vaughan: I love that, that really talks about the collaboration required between your education teams and your build and implementation teams. They really need to be in sync about that personalization so they understand how the users, the physicians, are going to be interacting with the systems. Anything Craig that you wanted to add to that?
Dr. Craig Joseph: I think what Laura said was spot on. The Arch Collaborative comes from data. So it's not just what we think, it's what people are telling us. And certainly, having your training team very closely aligned with the builders helps a lot and making sure that those trainers also have some clinical background. I've seen a training program quickly go bad when a trainer's trying to show an example of putting an order in and simply says, "Imagine you have a patient in the clinic who's got a viral upper respiratory tract infection and you want to order antibiotics." Well, the point was just to show you how to order antibiotics, but now the physicians are, "Well, why would I order antibiotics for a viral URI?" And so those little tiny things can make a big difference. And so just making sure again, that your trainers have some clinical experience or can be taught about specific scenarios can really eliminate unnecessary diversions and unnecessary problems.
Dr. Michael Augustyniak: Great point, Craig. For me, and Laura and Craig both touched on it, physician satisfaction is directly linked to the quality of training, but also at GoLive support. Having a robust team, and again, having people with that clinical background that can speak to the physicians, all the clinicians in the hospital at GoLive to walk them through areas where they're having difficulty placing orders, ordering x-rays, completing their clinical notes, dropping charges, that support is key in my eye and in my experience. How often do we remember everything that we learned in a two and three-hour training class? Especially when we're not going live for two or three weeks, you don't retain that much. Having those bodies at GoLive for multiple weeks is key for adoption and an improved physician satisfaction.
Win Vaughan: Well, this kind of goes to a broader need of just having an IT department's relationship with the physician community and it flows through to the education program, it flows through obviously to the support at GoLive. But what else in terms of planning and preparing, how can an IT department establish this relationship with the physician community to ensure that all these processes that have to happen during these consolidations all flow smoothly?
Dr. Craig Joseph: I think one thing that you really want to focus on during this kind of a transfer is just to emphasize over and over that this is a clinical project and not an IT project. IT doesn't lead it. It's led by operations and clinical folks, but IT enables it. And so that often again, eliminates unnecessary stress because it doesn't feel like something's happening to the clinicians. It feels like they are involved and when they're told they're in charge within certain parameters, of course, you get a better product and it's a lot less painful.
Dr. Michael Augustyniak: To me, it begins with the CMIO, the Chief Medical Information Officer and the informatics department. Now I know some of the smaller, more rural hospitals might not have a CMIO, so we need to get physician champions in place and preferably a champion from each of the specialties so they can be involved with the IT team in that design and build and rollout process. They can also give feedback as to how best that training should be performed. Getting physicians involved early on in the process is one key to success.
Dr. Laura Copeland: Yeah, I love both of those points. The importance of the clinicians owning the system and getting that message through very much up front. And then the importance of having clinician informaticists, and I know we're still struggling with that in Canada. I know that the U.S has a medical informatics specialty and recognize that is a specialty in and of itself. That hasn't happened here [in Canada], and we are probably a long way away, so we've got some work to do. I think in addition to that, it's really important to be clear about the processes and the rules of engagement between the two.
What I see so often is what I call the post-implementation blues where the clinicians are asking for everything and the IT folks are trying to deliver on everything. And you have nothing but good intentions happening, but everybody's totally unhappy with each other. And I think the cure for that is to work very hard on clinicians prioritizing what they want to do with the system and understanding that they can't have everything and they certainly can't have it all at once. Now how can they ask for things that make sense and how can they use their IT colleagues to help everybody make the decisions about how resources are spent? And that is a very clear process that needs to be established. And if you do it up front, you're going to be much happier after.
Win Vaughan: Well, Laura, let's continue on that. We're kind of getting into the governance space and the Canadian perspectives maybe a little bit different than governance structures that we deal with in the U.S. So maybe we can shift over to governance for a little bit.
Dr. Laura Copeland: Sure. Well, I'll do my little Canadian speech for a second here. Words like mergers, acquisitions, consolidations, these are not things that we talk about up here because we're not companies taking over of other companies. We're all socialized medicine. So what we talk about when we're doing the exact same thing is we talk about having hubs or hosting. And what will happen is you have collections of hospitals with different governance structures, so completely different senior teams who say, "Hey, our patients, they all kind of go to all of us, we refer to each other. And it would be really great if we all shared one information system for the benefit of our patients." And also here in Canada, physicians tend to wander between hospitals if they're close and they'll work a little bit over here and a little bit over there. They don't just stick to one place.
So it makes a lot of sense to all share the same EHR. But the big challenge is that now you have to align all of these different senior teams. And so they have to create regional governance for the health information system, and then they have to remain aligned. So after they go live, one site might say, "It's really important for us to focus on senior care this year." And the other site says, "Well, we're really focusing on pediatrics," or they have different priorities. And then how do you align the resources that you have to all of these separate priorities while still keeping the lights on and having cyber resilience and all these other things. It's not that simple getting everybody a little aligned. So that's some of the challenges that we have here in Canada.
Win Vaughan: Any other comments you have on just governance, the importance of setting that up?
Dr. Craig Joseph: Well, it's essential, and it's also one of the things that KLAS Arch Collaborative found is a key differentiator between successful implementations, whether it's a first one or whether you're extending to another organization. Having clear rules about how decisions are made, recording those, that information, making it available to everyone. Again, it's important that everyone's working from the same playbook, so otherwise, you're going to be making decisions again and oftentimes changing your mind for no good reason. And so I think governance is helpful. It's also can be exceedingly important to make sure that you're not changing things too quickly. So once you go live, certainly lots of folks are like, "Hey, this isn't working for me. I've been using it for a day now and I can't possibly make it work." Well, oftentimes it's just that they're not used to it. Their muscle memory needs to be rewired.
That's only going to take time. So it's often a good idea to kind of throw a little bit of a speed bump there with governance process to say, "Okay, well, we're going to take that to the group or the committee that's meeting." And sometimes with a larger group with more experience, they can say, "Yeah, we had those same problems when we extended to this other facility Southern Hospital and it got better, so let's give it another week or two or a month and see where we're at." As opposed to, "Wow, we didn't know that. That was a big miss of during our implementation, these things happen, we're going to change that tomorrow."
Dr. Michael Augustyniak: Things can go sideways quickly without a strict change control process in place. As Craig mentioned, one doc finds that an order set isn't meeting his needs on day one. You can't just jump into the system and make that change. Communication to the entire organization when a change to order sets or documentation templates are going in place, that has to be key and that has to be set up early for successful sustainment of the system.
Win Vaughan: Yeah, I think that's a great point. I think governance structures are set up during the planning phase and everybody's really focused on governance during implementation. But if you're not planning for that post-implementation governance ahead of time, you're just like....
Dr. Michael Augustyniak: "Why didn't you do it?"
Win Vaughan: Right, exactly. That's a tremendous point. Maybe drilling down a little bit in governance, we talk about data governance, and a lot of times this seems to be an IT need as we're looking at integrating systems and bringing data in from multiple places. But let's talk a little bit about the physician impact from data governance. And Craig, I'll start with you.
Dr. Craig Joseph: So physicians often will tell you that they're not going to any meeting with the words data and governance. That's something for computer nerds, and that's not of interest to them. I've been successful by asking them if they think that it's important to know when the patient was admitted. And they say, "Well, of course, yes, we have lots of metrics that we're judged upon from a quality perspective, making sure that the patients are discharged in a timely fashion or they're seen on the floor, orders are written in timely fashion." And when I explain to them, "Well, the time or date of discharge can vary widely between different hospitals or different decisions that are made when implementing or pushing out an electronic health record," and they become much more interested. And say, "Oh, wow, I didn't realize that those were the kinds of decisions you're making because that definitely affects how I'm reimbursed or that affects how I'm judged from a quality perspective."
And I want to be in that conversation so I understand and can contribute meaningfully when something seems like it's going to affect me or my colleagues. And so from that perspective alone, just getting clinicians, doctors and nurses and therapists involved and to say, "Hey, we're not going to be getting into tiny little issues. These are important questions that you need to either try to help us answer or at least be aware of them so that you understand how our calculations are going to change." If we have a huge system and we're all rowing in the same direction and using the same definitions, then most likely that hospital that's now being onboarded is going to be also required to make those changes. And to understand them and to do whatever you need to do to kind of correct them and be able to compare apples to apples will be very helpful.
Dr. Laura Copeland: You're totally right, Craig. When you say data and governance, everybody runs away. And yet this is something that we're not unfamiliar with. I mean, all of us have learned how to read a journal article and how to assess it critically. And I think it's really important that physicians engage in data governance, especially as we move into more artificial intelligence. So the more information we have and the more we're depending on computers to come to some conclusions or trends based on sets of data, the more critical we need to think about, "Is that relevant for my patient population?" And if we aren't validating these truths that are coming out of AI, then we could be perpetuating systemic bias and none of us want to be doing that. So I think it's important that we get more clinicians engaged in data and actually writing up criteria for how do we validate data. And that's an important part of governance.
Dr. Michael Augustyniak: I couldn't agree more guys. Explaining to the physicians what data governance is really defining what it is and the importance of the integrity of a patient's chart, the data in the patient's chart. Oftentimes, we get called into organizations and problem lists are a mess. And the docs say, "Well, I didn't put that problem in there. The patient doesn't have it, but why should I be the one to take that out of there? How does that benefit me?" Really educating these docs on the importance of data integrity and what gets driven downstream from something as simple as the problem list. I think that helps them to understand the importance and will hopefully make them take a little more time and care in ensuring the patient's chart, especially that problem list is up to date and accurate.
Win Vaughan: Thank you all. And before we wrap up for today, I don't know if there are any last thoughts that you all have about the physician experience going through these complex transformations that you'd like to share with our audience before we wrap up.
Dr. Craig Joseph: We're in a different place than we were 15, 10 years ago in terms of implementing electronic health records and moving from one to another. And I often try to point to the clinician's phones that's in their pocket, and that often can buy me a little bit of understanding in terms of saying things like, "Hey, I understand you don't like this change that happened when we turned down the system or with our monthly update. But oftentimes, it's just like your phone when you wake up in the morning and an application has updated and the buttons aren't exactly where they were, and you think it's the most horrible thing that's ever happened and you hate it. And two weeks later, if someone asked you if you'd like to revert back to the way that app worked previously, typically you say, What are you talking about? It's always been like this."
You adapt quickly and then you kind of move on and overcome. And so I think a lot of the changes that are there just like that, it's not how we used to do it. Well, do it this way for a little bit and then it'll get better. And much like it works on your phone, personalization's another thing, Hey, you don't want to take the time to personalize the EHR within the limits that we give you? That's fine. I've seen someone say, "Can I borrow your phone for a second?" "Yeah. What are you going to do?" "Oh, I'm going to take it all back to the factory settings because you said personalization's not that important to you, so I assume it's not that important on your phone as well." Yeah, that's not well received. So again, trying to kind of draw a metaphor there I think is very helpful.
Dr. Laura Copeland: I think looking at the positives of this kind of experience, I mean, when you're coming up with the new health information system on your own as an organization and not joining on to another health information system that's already up and live, everything is very theoretical. You don't have a system until it's built out. And making the decisions and establishing new workflows can be really challenging because again, you're asking people to imagine what it would be like and they're never going to get that right. But when you're joining on to another health information system, you can go in there and you can kick the tires and there's nothing more awesome than having this kind of a merger. When you have a situation where the physicians have already been working in the other hospital a few shifts and they're like, "Oh, yeah, and I just do it like I do it over there." That's like the slickest, easiest, most relieving kind of transition that you can have. So I would say look to a lot of the positives in these situations.
Dr. Michael Augustyniak: And I'd like to go back to my first point around being sensitive to the clinicians, to the entire hospital staff for that matter. Whether you're a consulting firm like Healthtech or S&P, or Nordic assisting organizations with this merger or acquisition, or if you're part of the hospital administration, you've got to be sensitive that the lives of these clinicians are going to change significantly if they are the ones absorbing the new EMR. We're changing workflows, we're changing technologies, there's going to be a steep learning curve. And think about everything else they already have on their plate. Overloaded clinics and full units and the staffing shortage. We've got to be sensitive to them in this process. It's my parting word.
Win Vaughan: Well, thank you all so much. We've covered a lot of ground today. I look forward to further conversations. I think everybody's fired up to move forward with their next transformation, Dr. Copeland, Dr. Augustyniak, Dr. Joseph, thank you so much, and thank you all for joining. We'll see you again soon.