End of day 4 of and EHR go live. Are we getting punchy? No, this is a real sushi roll from a real restaurant here in Pueblo.
How can we not order Monkey Brains from the menu?
A pretty good day overall. Our physician informatics team is doing the rounds on 6 floors of the hospital, about 8 physical buildings and about 30 clinics. Here we are ‘debriefing’ over beers.
The vast majority of the clinics are doing really well, physicians and providers learning the note writer tools, order sets, pre-op process, secure chat communications, inbasket messaging, 2 factor authentication for controlled substance prescribing, and dragon speech recognition. And, seeing patients (and in one case, treating a mass casualty from a freeway pileup!).
We are so impressed with the dedication of the clinicians and the hospital and clinic staff.
Makes me think of that song from Fiddler on the Roof:
Instead we would sing it ‘Dis-RUP-tion, Dis-RUP-tion!’
Oh, that’s a uke song candidate you say? Hmm.
Musings about tech adoption
During a major go live like this, we see all sorts of interesting things. For example, we actually experience and can see the bell curve of technology adoption exhibited among clinicians.
Some clinicians are flexible, see the EHR as a new set of tools, and appreciate our help as we suggest best practices using the new tools. Within 2-3 days they are discovering innovations and pushing themselves to see ‘what this new thing can do.’
These are early adopters and digital natives. They need no ‘push’ from the informatics team, instead sometimes we judiciously apply the brakes on their wild flights of ideas. ‘Why don’t we survive this go live first before investing in your proposed next set of tools.’
Some clinicians are circumspect. Although they come in all age groups, most are older, less comfortable with computers and smartphones, think of EHRs as glorified paper charts, but valiantly spend time to learn, adapt, and willingly accept help and advice as they find their way in a new land. They are willing to consider that this might be better than the old paper process.
These are digital immigrants with open minds, and the largest group in the middle of the bell curve. Establishing trust and nudging are the best informatics tools. ‘Hey, good to see you again. How is it going? How can I help? Can I suggest trying another new thing today?’ Or, expressed as a haiku:
Come, see what I learned!
No, not that trick, but this trick.
It’s tricky but cool.
Some clinicians are doubting Thomases. They’ve heard that Epic is coming and have looked for jobs elsewhere, surprised to learn there are no new positions open that don’t also require EHR use. They are often senior clinicians with deep expertise, have established practices, large patient panels, finely tuned paper-based workflows honed over years. They are used to generating high volume and providing high quality care, and now everything has changed.
For these clinicians, their clinical expertise and years of experience are drowned under the heavy mantle of technology inexperience. They may perceive a loss of respect, a loss of autonomy, a loss of mastery. These are digital immigrants who were forced to relocate to this unfamiliar and hostile land, and wish to return to a home that no longer exists.
It behooves us in informatics to be humble and remember their value, their deep history and their expertise.
Some clinicians are super early adopters: ‘Hey, I want a bluetooth speech recognition mic to go with my mobile tablet.’ ‘Show me your predictive algorithms for sepsis and how we are going to do surveillance.’ ‘I hear there is a way that the EHR can write your whole note for you.’
In the other direction, conversations can boil over into emotion and outbursts at staff, at colleagues, and at our informatics and IT teams. I’m told that a clinician did throw a trash bin in frustration this week.
However, we are proud to say that our primary metric is ‘Days since last chair-throwing’ and that is an unbroken streak of 2500 days, back to 2014, since a trash bin is clearly not a chair.
Hence my cryptic quote from yesterday, as we philosophically debriefed our team over beers:
The bell curve is made up of the entire bell curve.
Every medical staff has members in all these groups, including the extremes.
Choose your own adventure!
Want to try out the CMIO / physician informatics role during a go live? Here are some challenging questions. How would YOU respond? Answer honestly before reading our approach.
Q: SO. What’s allowed as a Verbal Order? (meaning, I intend to use YOUR computer system as little as possible)
A: Actually, UCHealth policy is “verbal orders only in clinically urgent situations, or when the clinician is scrubbed in, or in transit and unable to enter their own orders.” However, the EHR only reflects your hospital’s medical staff policy. Let’s work with your leadership to clarify this.
Q: That “F2” key doesn’t work right in the note. It doesn’t even go where it is supposed to.
A: Let’s sit down and you can show me what you mean
Q: Why do I have to cosign all these orders and notes that my resident/fellow wrote? I trust them. Can’t I just “shift-click” and get rid of all of them?
A: Sounds great that you trust your team and that you’ve developed a great team workflow. At this time, the system does insist you glance at the work as your signing them one at a time. If there are standard protocols or policies that allow clinical colleagues to do their work, let’s develop them, document them, and we might be able to eliminate these co-sign tasks.
Q: I haven’t seen a thing that is quicker in this new system compared to our existing system. It is an expensive waste of time.
A: I’m sorry to hear this. However, you are only in the first week of a major go live and disruption in your work. Nothing is the same. The tools are flexible, and I’m convinced that our team and your team can work together to build new workflows to match or exceed your previous methods. It usually takes 1-2 months to fine tune your team’s new process.
Empathy. Trust. Respect.
Regardless of my artificially applied categories, there is a universal approach to clinician adoption of technology. We treat everyone with empathy and respect, honesty and transparency. We tell them why. We tell them where we are going, that the technology-empowered medical team performs better than the unassisted medical team. We open a dialogue, build trust, set behavior boundaries (when it comes up), and get through the transition together.
When we do this right, every clinician we work with will look back and say, ‘I can’t believe we used to do this any other way.’
CMIO’s take? Our ideal: no physician left behind.