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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?
4
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
5
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)
8
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.
9
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
10
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.
11
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.
14
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?
15
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
16
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
17
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
18
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
21
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
22
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
23
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
24
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
25
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
26
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
27
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
28
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
29
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
30
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
31
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
32
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
33
Sample End User DeviceConsiderations
Global Messaging Tools
Physician PortalHome and Office
Portable Order Entry Devices
Results Reviewing and Order Entry
Easy Log OnRapid Access
34
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
37
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
38
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
39
Physician CPOE Training
40
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
41
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
42
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
43
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