For Robert Slepin, health information technology has never been an end in its own right, but rather a tool that can be used to improve individual and population health. In this interview, Slepin discusses his organization’s goal of getting its hospitals and physician network on Epic in 2012, best practices for disengaging with vendors, how disease management can help improve patient outcomes, and why ICD-10 should be postponed. He also talks about the importance of transparency within an organization, how to effectively delegate tasks, and why it’s okay to say, ‘I don’t know.’
Chapter 3
- Clinician order entry and data granularity
- ICD-10 “There are undesirable effects of asking people to do so much at one time”
- The benefits of being a PMP
- Leadership — “We must be able to trust and delegate to our teams”
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What they’re used to is dictating a narrative, and that for most physicians is the most important part of the record—the story where they can read a paragraph and very quickly get a picture of what is really meaningful, timely, and relevant that they need to know about this patient right now.
The most important thing is to engage and involve the physicians in your organization in the decisions about the design of the system—how this is all going to work for them, the templates, what the rules and policies are going to be.
While the intentions of those who are regulating and legislating these requirements are obviously good, and eventually we want to do all these things, there are undesirable effects and consequences of asking the industry to do so much at one time.
It’s hard enough for us to get accurate, timely clinical documentation today. And it’s going to be challenging as we migrate our clinicians to the electronic medical record and teach them how to use that to do clinical documentation effectively and efficiently.
It’s important that you identify what kind of skills you need for project management in your organization. I think that every single employee in an IT organization must have some basic awareness and skills in project management—even the people in the helpdesk.
Guerra: When we talk about doing disease management and population health and quality reporting, the data that you’re going to pull out in the reports is only as good as the data that goes in, and that takes us to the frontline clinicians. This will sort of dovetail into a conversation about ICD-10. But the idea of the actual physician or nurse interfacing with the system and the granularity of the data that you are asking them to input—the more granular, the better the data and the better the reporting, but the less pleasant it is for them.
How do you balance that? We talked about natural language processing, we talked about importance of the physician narrative versus checkboxes and dropdowns that physician don’t love—they’re used to being able to dictate a note and they’re done as opposed to sitting and sorting through hundreds of checkboxes. So what are your thoughts around striking that balance between getting good date and overburdening the clinicians?
Slepin: That’s a great question. I think that is a major challenge that all of us face today. We need to manage that trade-off carefully and effectively, and so we need both. The physicians have a need to tell the story about the patient with today’s technology. What they’re used to is dictating a narrative, and that for most physicians is the most important part of the record—the story where they can read a paragraph and very quickly get a picture of what is really meaningful, timely, and relevant that they need to know about this patient right now to be able to best take care of them. Not that other information isn’t important, but we need to be able to preserve that story. And I think for a lot of folks, that means allowing dictation to still be allowed for that kind of narrative. Or it could be a matter of teaching the physician how to use the checkboxes and the text entry. Epic really has really done a good job of providing flexibility with the tools to be able to check the boxes, but when you check the boxes, you actually build a narrative and then a physician can look at the narrative. And it may be just perfectly fine or you can insert your cursor in there and change a word or add some words, either with a keyboard or voice input technology, so you can get the best of both.
I think it’s possible today to get the best of both if you want to do that, but it is a challenge to provide the training and support of the physicians. I think maybe the most important thing is to engage and involve the physicians in your organization in the decisions about the design of the system—how this is all going to work for them, the templates, what the rules and policies are going to be. And if you do that, you’ll be able to optimize the technology to be able to manage that trade-off so that you get efficiency but you also get very effective information to support the care process.
After all, what’s most important is the patient and ensuring that this information and the clinical documentation supports high quality care, safe care—we can’t lose sight of that. So if there’s a conflict, we need to make sure that we are preserving what’s best for the patient. I think if you keep those principles in mind and look at the best practices and look at what’s available from your vendor system, then I think you’ll make some good decisions.
Guerra: I mentioned DC1O even though it could be thought of as a coding issue, it still needs enhanced documentation upfront by the nurses and physicians. So that’s a burden for everyone—for the CIOs, one of the huge projects that are coming together with people gravitating towards ACOs, Meaningful Use, and ICD-10. And the AMA just came out and said they are going to actively and energetically oppose the deadline that’s currently in place. But I believe CMS has already indicated that it’s going to stand firm, so I guess we can’t hope or assume that it will be postponed. You have that down as one of your specialties—ICD-10 and HIPAA’s 5010. Tell me your thoughts around ICD-10—what it’s going to take and whether you think it should be postponed or whether you think it will be postponed.
Slepin: Sure. Well, I left my crystal ball at home this morning, so my forecasting capability is a little off. I have no idea whether or not it will be postponed. Do I want it to be postponed? I think that would be great. I think that the amount of work that we have in the healthcare industry today to achieve the goals of healthcare reform is overwhelming for most of us. And while the intentions of those who are regulating and legislating these requirements are obviously good, and eventually we want to do all these things, there are undesirable effects and consequences of asking the industry to do so much at one time.
I think the change burden here is enormous, certainly for IT, but more importantly for the people at frontline—the physicians, nurses, and others that are delivering care. So I would certainly vote for the delay in ICD-10. That’s the last thing I would want to do coming off working on getting Epic in. I do not see how that is going to add value to improving safety, quality care, and efficiency in the short run. I think there are a lot more other things that we could be doing to move the needle other than ICD-10 in the next several years. Down the road, could ICD-10 be helpful? I understand there’s a case for it, and perhaps it could offer a lot of benefits, but right now I would say no.
We have a lot of work to do, like everybody for ICD-10. I think the biggest thing most people talk about is the training and the change management, and that will be the biggest thing for us as well. And we’re going from 14,000 diagnosis codes under ICD-9 to 69,000 codes under ICD-10. For procedure codes, we’re going from 38,000 to over 71,000. That’s huge. It’s hard enough for us to get accurate, timely clinical documentation today. And it’s going to be challenging as we migrate our clinicians to the electronic medical record and teach them how to use that to do clinical documentation effectively and efficiently.
And then to that and then a year later say, ‘Oh by the way, now we’re going to redo this and we’re going to change all this for ICD-10, and we’re going to train you or train you again,’ and you’ve got a whole other set of things to think about, it’s a lot. The good news for us is that because we’re implementing Epic, a lot of the IT challenges associated with ICD-10 will be met through the version of Epic that we’re implementing. That doesn’t mean we won’t have any IT work; we will. We’re going to have to upgrade or replace a number of other systems, and we’ll need to do testing and interface changes and so on. So there’s a lot of work ahead.
Guerra: So you are a PMP—a project management professional. I’ve spoken to many CIOs and they say project management expertise could be the most important thing that CIOs bring to the table, and it’s being called o now like never before. Would you really that sentiment?
Slepin: I think that project management is a core competency for an IT organization, because at least half of what we do is create value through projects, and it should be a core competency and skill set of a CIO. I don’t believe that every CIO needs to be a project management professional I certainly would put it as one of the top 10 if not top five skills for a CIO. I wouldn’t say that it’s number one; I would say leadership would be number one.
Guerra: I spoke to one CIO who said that because of the workload, he had passed off some projects to some people who worked for him, and it turns out he wishes he’d sent them for project management training. He may have given them some projects which were a little too big a little too soon. Do you see any type of that dynamic where you are entrusting your staff with projects and you have to make sure they are ready to deal with all the moving parts that they call for?
Slepin: Well Anthony, welcome to my world. I live this every day, as does every CIO, right? Because we really can’t do much ourselves—the work is being done by our teams, and we’re the leader of the team. We must be able to trust and delegate to our teams the work that’s required to plan and execute projects that are high-risk, and in some cases take a long time and a lot of money, and there’s a lot of value on the line. So it’s a big deal and we’re doing it every day with obviously the electronic health record being the biggest one today for most people.
But there are many, many other projects that we’re working on. We were talking earlier about how project management competency is core to IT, so it’s important that you identify what kind of skills you need for project management in your organization. I think that every single employee in an IT organization must have some basic awareness and skills in project management—even the people in the helpdesk. And in fact, one of the first things I did when I started at Lincoln was we put the entire IT staff through basic project management training that we did in-house with the help of an outside consultant. I believe it was a two-hour core course, just to get the fundamental awareness. That was for everybody. And then for the people that were team leads or project managers—whether or not they have the title—or who are actively involved on projects like business analysts, for example, we did a longer course with them; a two-day course. I believe it was a total of six to eight hours for that segment, along with some follow-up coaching.
We’re planning to continue to invest more in project management training. We’re going to identify those individuals that are most active in project management, and we’ll and probably put them in a two- or three-day project management 101 boot camp. We’ve also developed a project management methodology, again in collaboration with an outside consulting firm. And so we’ll continue to invest in project management and developing that competency. It’s something that we’ll keep working on and getting better at.
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