PPACA and American Recovery and Reinvestment Act Bring New Challenges and Opportunities

How to achieve C-suite EHR value realization

If you're in the C-suite, you may wonder, "Am I getting a return from all that money spent on an electronic health record or just getting more headaches?" Chances are, whether you're leading a large provider network, an independent hospital or in the midst of a merger, you're in the thick of it, dealing with the next "IT rollout" or rushing to meet a compliance requirement. You may feel like you just filled a pothole and another is down the street, at least if you're in Chicago after this winter. Sometimes it's hard to know if you are focusing on the right things to get the most value. To better assess potential IT investments, consider the challenges that face nearly all IT implementation efforts, as well as a few strategies to ease them.

What are the challenges?
A few areas of focus are worth attention: It may be no surprise that people, process and culture are on the list of any technology-based investment.

People. Central to value creation, in all HIT initiatives, are people. It's not unusual there are challenges. The situation today is difficult with more mergers and acquisitions and continuous shifts in the regulatory environment. Great demands are placed across the whole organization, and people are very overworked. Some argue IT organizations have it particularly bad. New systems are challenging, and with high labor turnover, support can be problematic.

We also see specific technical talent shortages. In programming areas, such as Java, .Net or Cerner, programmers can be difficult to come by, often needing to be hired as consultants. Costs will continue to increase as hospitals compete in the same markets for IT talent. With the increasing focus on telemedicine and mobility applications, (estimated to reach $38 billion in hardware/services alone in 10 years) the problem will get worse for a while. CIOs should keep a sharp eye on staffing and know the risks of a key programming and support staffing turnover. If they lose key talent, work load shifts, and deadlines can go out the window. The small-to-midsize hospitals with smaller staffs? They have it the worst. Thus, we need to place a lens on alternative process, organization and sustainability strategies.  

Process. Healthcare providers need strong process to implement new IT solutions and realize value. The best system incorporate ongoing performance improvement and innovation to achieve optimal value. When new systems rollout, change management and training are essential. This is a discipline sometimes underrepresented in hospitals. However, the need is real to accelerating clinical transformation. Who wants transformation to be about a medical staff and doctors begrudgingly forced into a new process and unable to innovate new ways to make it simpler or better?

Unfortunately, many physicians feel, that on balance, more is being taken away than being given in the early stages of any IT transformation. Why is this so hard? With continuous rollouts, staff become overwhelmed. You need to dedicate resources to "clinical transformation," focusing on ways to optimize and then innovate. You want the given EHR system to positively impact patient care and user satisfaction. Several studies have validated underperforming post live adoption and training is often central to issue.1

Culture. Support of people is most critical to achieving the value around the EHR technology platform you have committed to. Consider how leadership organizes and governs the effort. Do you have a single transformation and innovation leader? Does he/she report to a C-suite executive and is he/she empowered? Can he/she inspire breakthrough ideation, improve compliance and build a continuous improvement culture? Does your organization tend to measure and manage in silos? What are the incentives like? As you examine issues of alignment, goals, incentives and measurement, you may find opportunities not realized previously.

Let's consider a few…

Opportunities and action
What can you do today to best assure your team is improving value?  

Set up a transformation group. The C-suite should consider setting up a real innovation and transformation group, appointing a leader whose role is to assure HIT and EMR initiatives are looked at from an enterprise value perspective. This is more than informatics, or IT or process engineering. Great transformation teams set very clear strategies and engage across groups to assure investment and execution strategies are moving the business. For example, a leader may challenge her team's innovation with specific goals around enterprise value creation, risk reduction and quality: "Identify the top 5 correlates, across the network, for our 10 most impactful codes, which produce highest probability of lowering readmissions by 20 percent over the next two years." The analysis can yield models to enable decision options for executives. Operational plans for managing care and optimized investments can come from the process, reducing risk and improving care. While the team is looking at correlates over a several year horizon, they will also focus on continuous improvement. Core regulatory and compliance needs are obviously top on the list. Thus, it may be useful for a transformation group to look at two categories of value improvement:

  • Regulatory requirements, such as core measures, and
  • New delivery models, such as accountable care organizations and bundled payments.

In the latter case, consider measures that correlate with reduced readmissions or other metrics that reinforce proper coding that best assure maximum payments under CMS' Value-Based Purchasing program. Over time, cross functional teams can build competency and leverage data and analytics to take EHR to another level.

Empower your people to design process and organizational sourcing strategies. Leading CIOs become champions for bold value creation by transforming process and resource allocation. Some leaders are turning to a broader mix of sourcing initiatives. In IT, there are tradeoffs between internal IT applications development and support versus outsourced strategies. However, as technologies are changing fast, CIOs don't want to be caught without a sustainable approach. Some level of outsourcing may make sense to shift risk and provide predictability. The right partnerships can help the hospital move from the investment mode to accelerating value. In practice this may involve:

  • Investigating a blend of partnerships that augment the CIO's core teams, offer contractually lower platform costs and ensure predictability through service-level agreements. For example, a CIO might have her EHR vendor install a cloud-based platform. At the same time, she implements a managed services contract with a near shore provider to manage the day-to-day of the back office operations, including all domain and configuration management and clinical and compliance reporting. This improves sustainability, making certain core EHR support is working, through peaks and valleys, at predictable cost and performance levels.

  • Leveraging flexible multi-sourcing partnerships can augment and extend development teams. As many hospitals struggle with talent, having contracted teams, trained in Cerner, Epic or whatever the hospital's platform of choice is, can dramatically lower risk and cost. These people can operate outside of the region of the hospital, pool resources and be on site in short order. This gives the CIO's team control and assures resources for timely delivery of applications for the medical staff, saving the bottom line from cost overruns.

  • Align people and process with your measurable goals and incentives. Research supports how proper alignment can improve innovation and continuous improvement. Small things, like training, can make a big difference. Cross- functional teams are another organizational approach found to be best accelerate change and adoption. For example, in one hospital a team proposed a mobility and biometrics applications for their CPOE system. It made it easier to sign in, adoption was improved and substantial dollars in value were created. Institutions going through major change should consider use of specialized change management experts with deep experience in enterprise resource planning or healthcare IT transformations. They can help build process, improve workflow and align your governance.

David Dobkin, MBA, MSc, can be reached at david.dobkin@4thsource.com.

Special thanks to Contributor Brian Ralston, MD, CMIO Tenet Healthcare

1 ACA David Kaelber, MD, PhD, Peter Greco, MD, and Randall D Cebul, MD (2005). "Evaluation of a Commercial Electronic Medical Record (EMR) by Primary Care Physicians 5 Years after Implementation". AMIA Annual Symposium Proceedings 2005: 1002. PMC 1560716. Sameer Kumar and Krista Aldrich (2010). "Overcoming barriers to electronic medical record (EMR) implementation in the US healthcare system: A comparative study". Health Informatics Journal. doi:10.1177/1460458210380523.

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