Though there is a surge in COVID-19 cases, many organizations are adjusting to the ‘new normal’ or at least the ‘normal for now’. Many of us are now going back to revisit what was on our list of 2020 projects. I would hazard a guess that many have ‘EHR optimization’ on that list in some format. Now might be a good time to address the what, why, and how of making that ‘EHR optimization’ happen AND yield positive results!
What is EHR optimization?
There doesn’t seem to be a clear definition of ‘EHR optimization’. If you search online, you can find the following definition: “EHR optimization is the process of fine-tuning an EHR to meet a practice’s individual needs and to improve clinical productivity and efficiency.”
For years, optimization often consisted solely of addressing the configuration of the EHR. It was typically done by IT EHR analysts with input from the providers and other clinicians. Some have been known to call this format the ‘optimization fallacy’ or a ‘false notion’. Many CMIOs will report that these optimization tactics yielded mixed results, thus the fallacy or false notion.
In recent years, due in part to the findings from the Arch Collaborative which has shown that user satisfaction correlates with strong user mastery, shared ownership, and personalization; many have come to think about effective EHR ‘optimization’ a bit differently. Successful optimizations have transitioned to being done WITH the clinicians. The process includes some configuration changes including ‘cleanup of EHR build’, with a hefty dose of EHR education and personalization. This also may be a good time to re-evaluate workflows that have proven to be troublesome. Of note, others have observed that success tends to come more from the training as opposed to the EHR configuration changes.
Below is a high-level playbook for planning and executing an EHR optimization effort.
‘What are we trying to achieve?’ is a key question to pose when doing any planning. In this case, it is well known that the ‘EHR burden’ is a dissatisfier for many physicians. The goals probably include the following: optimize efficiency, improve user satisfaction, improve functionality, improve patient care, and mitigate against burnout. You should also ask, ‘what are we trying to achieve?’ to make sure the optimization endeavor is focused.
In short, the goal is to develop an educational curriculum, select configuration changes from a standard recommended set/process, ascertain if there are any particularly problematic workflows that should be revisited at this time, and hold education sessions. Each ‘EHR optimization’ should occur at the specialty level as the EHR is typically built out at the specialty level. Of note, this is NOT a spectator sport – this endeavor is done WITH the providers. Let’s break it down into concrete steps:
Appoint a physician lead/champion: You will want a physician lead/champion for each specialty. This role will assist with curriculum development and design, be responsible for gaining consensus from the group for build changes as well as be the contact with the EHR team. An additional potential benefit is that this role can evolve into a physician expert for the specialty. They can continue to function as a clinical lead and continue to interact with the EHR team long after this effort. Looking ahead, they can be leveraged for input on upgrade functionality, prioritization of requests, and other work. When available, I also strongly recommend having a physician informaticist involved as they are adept at translating requests into technical or educational solutions.
Engage operations: We want operations involved to establish the goals, identify which clinics or specialties go in what order, and appoint a physician ‘lead’. In addition, operations may choose to allocate time for participation and, make participation required for all providers – both of which I highly recommend.
Develop a standard process for the development of education curriculum, selection of build changes, and education options.
Development of education curriculum: I recommend shadowing in the clinic as well as leveraging any data that may be available from the vendor. Such data may include information surrounding utilization and/or efficiency as well as vendor suggestions surrounding key functionality that you may be missing. For shadowing, I recommend a checklist of what should be observed as well as some general questions for the providers. Queries for the providers should include the following. What do they find awkward to use? What are their pain points? What do they have difficulty finding? How are they doing with EHR messages (i.e. in basket) What functionality do they wish they had? Of note, when this was done at one organization—several requests were received for functionality that already existed but clearly, the users were not aware! Education tends to bring the biggest value in this optimization effort.
Build changes: I recommend developing a ‘menu’ of standard items that typically benefit from clean up. With input from other providers, the physician lead would then choose which configuration changes would benefit this specialty. Items to consider include the following: note templates, preference lists for items like the reason for visit, diagnosis, labs, imaging, referrals, and procedures. In addition, you will want to offer clean-up of current EHR build—or what has been dubbed ‘getting rid of stupid stuff’. Look for items in daily EHR use that are unnecessary, not functioning correctly, or ‘just plain stupid’. Also, identify opportunities for education.
Education format: A model of HOW the education occurs may vary by organization and may even vary within the organization (i.e. a large primary care specialty may benefit from a different style than a small subspecialty). Consider a traditional classroom setting, with sensitivity to physical distancing, led by a trainer or physician. If possible, have lots of additional resources in the classroom so there are people to support the providers ‘at the elbow’ during class. Consider ‘assigned seating’ – this can really make a classroom more productive. In the current climate, you probably also want to consider doing online classes in real-time with support personnel who can use ‘chat rooms’ to provide 1:1 help. Plan for additional time after class for practice, personalization, and clean up of charts and the in-basket in the production environment. Consider offering CME for the training. Put build changes in production in time for training events. Use the production environment with test patients for learners. Personalization of the software can be done as part of class so they are then available the next time they work.
You will want to be able to demonstrate an ROI, so I strongly recommend measuring before and after the intervention. Metrics to consider include:
- Homegrown pre/post survey
- Arch Collaborative survey before/after endeavor
- Time in EHR after hours on clinic days
- Time in EHR on non-clinic days
- Time spent on EHR messages or volume of message
Of note, different specialties use the EHR differently so some changes may be seen in different data points based on specialty.
Think Long Term – A Few Will Benefit Many
This is not a ‘one and done’ endeavor. You will want to think about how to maintain ongoing education, continuous improvement of EHR configuration, and selection of vendor-provided enhancements going forward. That is a natural outgrowth of this endeavor. We frequently see a ‘physician lead’ emerge out of these events who can be leveraged as the point person going forward. Planning the ongoing program is a discussion for a different day.
In addition, once you start these optimizations, sprints, or whatever you may call them and providers have positive experiences, you will likely start to see an improvement in the culture surrounding the EHR and IT. When providers hear that their input is being heard and an experience that helps them is coming their way, they will likely begin to feel more positively about the EHR and IT.
StarBridge Advisors has a strong team of very experienced CMIOs and CNIOs who are available to help as you plan this journey toward a better future. Contact us if you would like them to share their experiences and insights.