CPOE UnivErsity

Dan Morgenstern, MD, MBA

Principal

Computer Sciences Corporation

Physician Roles in CPOEMedical Staff Member Roles

A CSC Clinical Excellence Service Offering

IntroductionWhy Physicians?Medical Staff Roles in CPOE

The Physician Advisory CommitteeOther Medical Staff Member Roles

Questions, Comments, Discussion

Agenda

3

Who am I?

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Who am I?

• Dan Morgenstern, MD, MBA– MD, Albert Einstein College of Medicine

• 25 years of practice:» Private solo as well as group» Academic – US, Israel» Cardiac, thoracic, vascular, trauma and general surgery,

wound care– “Recipient” of a failed Hospital Clinical Information System

Installation - twice– MBA, Auburn University-Montgomery Al

• Major course of study: Information Systems– Left practice in 2003 – result of the malpractice crisis– Health Care Consulting since September, 2003

• Clinical Transformation• Workflow Process Analysis and Redesign• Clinical Master Plan Development• Medical and Clinical Staff Education• Clinical Issues Resolution, Implementation Support (go-live)• Vendor Selection Assistance• Clinical Content Development• Physician/Clinician Adoption

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Who are you?

• Name

• Practice specialty

• Institution

• Role in your institution’s CPOE project

• How did a nice guy/gal like you end up in a place like this?

• Your goals for this session

IntroductionWhy Physicians?Medical Staff Roles in CPOE

The Physician Advisory CommitteeOther Medical Staff Member Roles

Questions, Comments, Discussion

Agenda

7

Why Physicians?

• Society has conferred unique ethical and medico-legal privileges on doctors based on their training and expertise, allowing them to care for patients

• In the course of such care, doctors generate virtually all – Patient-care related activities

• Medications• Treatments• Procedures

– Variable costs– Healthcare-derived income in hospitals as well as outside profit

centers (rehab, mental health etc)

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Why Physicians?

• Such enormous leverage is brought to bear on individual patients through the “writing” of physicians’ orders in medical records which contain– Documented thought-process involved in patient care– Requested diagnostic and therapeutic instructions (orders)– The resultant values– And still more instructions based on previous results

• Others may also generate “orders”

However, the overwhelming preponderance of such order writing rests with medical staff.

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Why Physicians?

• EMR together with CPOE represent – Electronic version of time-honored patient chart– Areas where doctors conduct the majority of their “hospital

patient-care business.”

• Very large majority of “hospital patient-care business” transacted in the EMR and CPOE – will be under purview of physicians

• It is this duality of the EMR and CPOE that makes the physician so crucial to the success of a Clinical Information System implementation

• The medical staff is the preponderant end-user of CPOE and directly influences other end-users’ utilization of the overall system

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Why Physicians?

• Simply put, physicians’ pivotal role in healthcare make them the “make or break” constituency as far as Clinical Information Systems Projects are concerned.

• They must be involved in all aspects of the project.

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Where are we vis a vis others?

http://www.himssanalytics.org/stagesGraph.html

IntroductionWhy Physicians?Medical Staff Roles in CPOE

The Physician Advisory CommitteeOther Medical Staff Member Roles

Questions, Comments, Discussion

Agenda

13

Medical Staff Roles in CPOE

• Remember this?

• Simply put, physicians’ pivotal role in healthcare make them the “make or break” constituency as far as Clinical Information Systems Projects are concerned.

• They must be involved in all aspects of the project.

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Medical Staff Roles in CPOE

• Corollary of “They must be involved in all aspects of the project” is that they must be involved in all aspects of the project

• Right of criticism of end-product should be purchased with coin of the realm – participation

• CPOE is NOT an IT project, it is a clinical one– Physicians must participate in all aspects of

• Scope and requirements definition» What do we want, need it to do and where?

• Design» How will it look, feel, and work?

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Medical Staff Roles in CPOE

• CPOE is NOT an IT project, it is a clinical one– Physicians must participate in all aspects of

• Testing and validation» Does it do what we wanted?

• Training» What do we teach, how, when, where and to whom?

• Go-live» When do we flip the switch, where, how and who will

help support us?

• Obviously a plethora of– Roles and jobs for physicians to fill– Tasks for physicians to accomplish

• Remember ! – If you don’t, someone far less qualified, knowledgeable and interested will

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Medical Staff Roles in CPOE

• Participate in Physician Advisory Committee (PAC)– Leadership body– Member Attributes

• Enthusiastic about technology in medicine• Respected in the medical community• Leader - recognized or in the making

• Become Super-User– Need is for many, not just a few– Attributes

• Enthusiastic about EMR/CPOE technology• Willing to learn• Does not need to be a geek

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Medical Staff Roles in CPOE

• Act as Subject Matter Expert– Attributes

• Knowledgeable in area of medical practice • Clinically up to date

• Become Physician Trainer– Likes and wants to teach

• Other roles– System validators and testers– Various workgroups, sub-committee posts

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Medical Staff Roles in CPOE

REMEMBER!

You get what you pay for

Physicians need to be compensated for their time

I’m at yur survisto make thingz betr

IntroductionWhy Physicians?Medical Staff Roles in CPOE

The Physician Advisory CommitteeOther Medical Staff Member Roles

Questions, Comments, Discussion

Agenda

20

The PAC (Phys. Adv. Comm.)

• Physician Advisory Committee– AKA Physician Steering Committee, Physician Advisory Group

etc– Sample Table of Organization

Executive Sponsor Steering Committee

Medicine

Work Group

Medicine Sub-SpecialtyWork Groups

Surgery

Work Group

Surgery Sub-SpecialtyWork Groups

Pediatrics

Work Group

SupportSpecialties

Work Group

OtherProvider

Work Group

CMO or Physician Sponsor/Champion

Physician and Clinician Advisory Committee

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The PAC (Phys. Adv. Comm.)

• Physician Advisory Committee– Highest ranking clinical committee– Reports to executives– Serves as final arbiter of all clinical conflicts related to

project that cannot be resolved by other mechanisms – Has direct liaison to highest ranking IT and

operational committees– Owns the CPOE project on behalf of the medical staff– Is reflective and representative of the medical staff

• Balance of specialties, practice types and patterns, computer literacy etc

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PAC Tasks

• Make medical staff policy recommendations and decisions

• Communicate to the medical staff

• Oversee the development, validation, approval and maintenance of project clinical content

• Oversee, decide and implement project clinical policy issues

• Map or sign-off on physician workflow analysis

• Review and sign-off on future state

• Serve as liaison with other project work groups

• Delegate and coordinate tasks to physician subgroups

• Direct physician engagement and adoption of change

• Support Physician Champion

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PAC Tasks

• Make medical staff policy recommendations and decisions concerning– System design– Implementation approach– Work-arounds if necessary– Definition of - and sign-off on - physician requirements– End-user device strategy– Question of “mandatory” usage– User certification– Security/Privacy/Access– Definition of Legal Medical Record– Electronic Signature– Common Medical Vocabulary– Chart Completion

• In general, represent all physician interests in the CPOE project

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PAC Tasks

• Communicate to the medical staff– Methods

• Office staff channels• Dedicated project website• E-mail• Focus groups• Grand Rounds• Social events

– Messages• Communicate concerns and issues through appropriate

channels• Communicate with physician audiences in collaboration with

executive champions• Present positive image of system and benefits to colleagues• Act as liaisons between physician community and CPOE

Project Team

• Newsletters• Surveys • Videos• CDs• Webcasting• Internal broadcasting

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PAC Tasks

• Oversee the development, validation, approval and maintenance of project clinical content– Order sets– Documentation tools– Flow-sheets– Best practices library– Problem lists– Clinical Decision Support– Monitor facility physician utilization statistics

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PAC Tasks

• Oversee, decide and implement project clinical policy issues– Clinical rules– Decision regarding “mandatory” usage– User certification– Security/Privacy/Access– Definition of Legal Medical Record– Electronic Signature– Common Medical Vocabulary– Chart Completion– Usage and handling of

• Verbal and telephone orders• Co-signatures

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PAC Tasks

• Map or sign-off on physician workflow analysis– Conduct workflow interviews– Validate workflows with direct process observation– Validate workflows with process owners– Diagram workflows in Visio or other standard tool– Assemble workflows into care continuum format– Identify and categorize workflow defects

• Review and sign-off on future state– Participate in future state design sessions– Analyze current state defects for future state repair or

elimination– Validate all future state scenarios for clinical

• Relevance• Applicability

• Efficiency• Quality

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PAC Tasks

• Serve as liaison with other project work groups– Coordinate with quality improvement and other committees or

groups such as Pharmacy and Therapeutics Committee– IT and operational groups– Clinician (nursing) groups– Other working groups, official and ad hoc– All clinical project work groups, official and un-official should

have physician representation• Representation at all but the most technical groups also

desirable

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PAC Tasks

• Delegate and coordinate tasks to physician subgroups– Assist with pilots and rollout of system at facility– Monitor physician training at facility

• Direct physician engagement and adoption of change – Act as coaches to physician super-users – Become physician super-users– Identify and address areas of resistance – Act as change agents and represent the interest of the

physician community as respected leaders

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PAC Tasks

• Support the Physician Champion– He/she represents the physician face and owner of the project– Is tasked with the following (inter alia)

• Communication» Liaison between physician community and

Executive/Project Team• Education of physicians as well as executives/project team• Advocacy for physician community• Coordination of all physician-related activities for the

project

• Does not need to be a “one-man show”

• PAC members in conjunction with the champion should assume and assist in these duties

• Y’all sink or swim together

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Sample PAC Deliverables (I)

• PAC Charter

• PAC and Champion Interviews and Summary

• Collection and Review of Order Sets & Clinical Pathways

• Order Set Inventory Summary

• PAC Work and Resource Allocation Plan

• PAC Agendas

• PAC Discussion Decks

• PAC Issues Management List

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Sample PAC Deliverables (II)

• PAC Status Reports

• Conflict Check of Nursing Guidelines and Physician Order Sets Summary

• Physician Communication Strategy Document and Written Content

• Physician Training Plan

• Physician Communication Materials

• Physician Training Materials

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Sample End User DeviceConsiderations

Global Messaging Tools

Physician PortalHome and Office

Portable Order Entry Devices

Results Reviewing and Order Entry

Easy Log OnRapid Access

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Sample PAC Project Plan

• Sample Plan in Microsoft Project Format– Tasks– Roles– Dates– Gantt Chart

IntroductionWhy Physicians?Medical Staff Roles in CPOE

The Physician Advisory CommitteeOther Medical Staff Member Roles

Questions, Comments, Discussion

Agenda

36

Other Physician Roles

• Develop physician training materials and requirements

• Develop expertise as physician super-users

• Act as Subject Matter Experts (SME’s)

• System validation and testing

• Participate in various workgroups

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Other Physician Roles

• Develop physician training requirements, tools and materials, timetables– Clinical scenarios for training

• Generic as well as specialty-oriented• Can also be used for system testing

– Training materials for physicians• Clinically appropriate• Generationally appropriate (personal experience)

» Stickers, smiley faces, chocolate kisses – of dubious motivational value

• Venue appropriate» Classroom materials » Tutorial materials» Online materials

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Other Physician Roles

• Develop physician training requirements, tools and materials, timetables– Physician expectations and requirements

• What do we really need to know to be competent users of the system?

– Certification materials• Quizzes, tests, requirements

– “Train the trainers” in physician-appropriate methods, needs, requirements

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Physician CPOE Training

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Other Physician Roles

• Develop expertise as physician super-users– Need is for many, not just a few– Attributes

• Enthusiastic about CPOE technology• Willing to learn• Does not need to be a geek

– Attend vendor supplied super-user classes– Disseminate knowledge gained to physician community– Perform final clinical validation of system design

• Workflow• Screen look and feel

– Act as physician go-live support

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Other Physician Roles

• Act as Subject Matter experts (SME’s)– Attributes

• Knowledgeable in area of medical practice • Clinically up to date

– Clinical content development• Orders• Flow charts• Other content

– Workflow analysis and validation– Screen design and layout– Problem and “bug” prioritization

• Testing phase• Go-live phase

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Other Physician Roles

• System validation and testing– Test the system design before putting into “production”– Validate design assumptions– Ensure that future state design really supports clinical

workflow– Look for bugs– Look for missing pieces– Look for poor design that impedes rather than enhances

physician workflow– Try to break it– Methods

• Closed chart replication• Clinical scenario development and usage

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Other Physician Roles

• Physician workgroups charged with a variety of EMR and CPOE tasks– Develop content– Office of project communication– Map or sign-off on physician workflow analysis

• Report to the Physician Advisory Committee

• May be standing committees– P&T– Departmental committees

• May be ad hoc for the CPOE implementation– Various SME subgroups

• Specialty order sets• “Flow-sheet workgroup”

– Task specific subgroups

– Develop go-live plan

IntroductionWhy Physicians?Medical Staff Roles in CPOE

The Physician Advisory CommitteeOther Medical Staff Member Roles

Questions, Comments, Discussion

Agenda

46

Questions, Comments, Discussion