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Hospitals want to improve patient outcomes and save cash. Docs want to avoid reporting systems that pry them from their patients. It’s not an impasse.
11 months before the University of Mississippi Medical Center (UMMC) rolled out their new Epic electronic medical record (EMR) in response to a government mandate, they hired John Showalter, MD, as their Chief Medical Information Officer. Showalter did everything he could to provide training for the center’s 10,000 clinicians, and worked hard to dispel rumors that the implementation would disrupt their workflow.
But when Epic rolled out, physician complaints rolled in despite his efforts. Even though thousands were less than thrilled with their new EMR, the UMMC judged Showalter’s effort as a success.
“As long as I persuaded docs not to quit, I was doing my job,” he said.
John Showalter, MD
It’s easy to understand why the bar for success was set so low: The Epic rollout was UMMC’s reactionary response to a government mandate, and not a proactive measure to improve patient outcomes. The hospital’s underlying mission was to check off a box, satisfy the mandate, and move on. Trying to find a piece of tech that could support their mission of improving patient outcomes was an afterthought, if it came up at all.
But that’s not the case anymore, Showalter said during a presentation at HIMSS 2018. New technologies are rolling out more quickly than ever, providing seemingly endless opportunities for hospital systems to get a leg-up. But even if you can sift through the noise, identify technologies that live up to the hype, and stomach writing the big-figure checks needed to purchase them, a big challenge remains — how can you convince doctors that they're worth using?
According to Trey La Charité, MD, Medical Director for Clinical Documentation and Coding at the University of Tennessee Medical Center (UTMC), and Showalter’s presentation partner, any approach that involves an “or else” — like a government mandate – is likely to fail. Instead, hospital systems should center their implementation strategies on tapping into their end users’ motivation, keeping in mind that it differs from one healthcare provider to the next.
La Charité only shifted to this strategy after a lengthy period of trial and error. A few years ago, UTMC had a major readmissions problem that he called “clinically inexcusable.” The organization set out on a search for a tech solution, and came up with a machine learning program that could not only identify patients who were at the highest likelihood of being readmitted within 30 days, but could also offer clinical recommendations that might prevent their readmission.
“We thought we had this great thing,” La Charité said. “We rolled it out, and it fell absolutely flat on its face.”
The program’s demise was 3-pronged. First, there was almost no buy-in from the hospital’s case managers, who didn’t believe that the program was capable of living up to its promises. Second, leadership at the hospital couldn’t dispel the entrenched belief among clinicians that the program just wasn’t needed (some docs said that after decades of experience, they could determine which patients would be readmitted better than any algorithm).
Finally, many case managers and physicians held fast to the belief that their work was done the moment a patient leaves the hospital. If that was true, why should they need a program that lengthened the continuum of care, for better or worse?
The hospital system and its staff were at an impasse, with one side hyper-focused on improving processes and patient outcomes, and the other doing everything in their power to avoid yet another reporting mechanism that pried them from their patients.
Trey La Charité, MD
According to Showalter, the log jam can only by unclogged if a hospital system is ready to study and harness the power of their staff’s internal motivations. It’s about persuasive, versus compelling strategies.
“Internal motivation to adopt is huge,” Showalter said. “I have this mantra that I tell myself when I’m with a really difficult physician. If I could convince them that [the tech we’re adopting] would truly benefit their patients, they would let me hit them with a sledgehammer.”
After a 6-year stint spent encouraging adoption of the new Epic EMR at UMMC, Showalter discovered that each healthcare provider had a unique reason for entering their profession. All are patient focused, but there’s still a lot of nuance to take into account. For instance, Chief Financial Officers want to improve patient outcomes so they can avoid penalties and save money. Nurses are driven by a seemingly inextinguishable, selfless desire to provide the best care possible. Physicians are in the same boat — they want to achieve the highest quality of care they can.
“That’s the great thing about healthcare—we all have the ‘Why?’ already figured out. We’re here for patients. We’re all here to make them less sick,” Showalter said. “I’m amazed at how buried that gets in the adoption motivation. If you can get them to agree that ulcers are bad—that they should be reduced and that your tech will help them do that—you get a lot of buy-in.”
It also takes quality leadership. That means bringing all the key stakeholders on board form the get-go, La Charité said, from mid-level early adopters who break down walls of resistance, to upper level management, who should lead by example. Along the way, health systems must proactively measure physician feedback, stay flexible, and avoid dictating workflow. These 3 strategies help mitigate change fatigue and the gradual trickling-off of comprehensive implementation.
When done correctly, hospital systems can expect to see ROIs from new tech investments in about 4 months, Showalter said. It took La Charité and the leadership at UTMC much longer than that, but the results are convincing, even if they took a while to achieve — the national hospitalist turnover rate is 20%, but since shifting strategies, UTMC’s is just 4%.
“Your organizations can learn from my organization’s mistakes, and hopefully not repeat them. I don’t think there should be anything proprietary about trying to improve patient outcomes and patient care,” he said.
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