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In 2011 and early 2012, the Fort Drum Regional Health Planning Organization led a region-wide project to create Patient-Centered Medical Homes in primary care practices throughout Jefferson, Lewis and southern St. Lawrence counties in Northern New York. The project also involved implementing or optimizing EHRs at 37 practices, and setting up a Health Information Exchange, allowing providers to exchange patient information across the provider continuum.
The clinical aim of the project was to improve care management and coordination for patients suffering from Chronic Obstructive Pulmonary Disease (COPD) in an area experiencing nearly twice the expected hospitalization and mortality rates from the disease. The project was funded by a New York State Healthcare Efficiency and Affordability Law for New Yorkers Phase 10 (HEAL-NY-10) grant.
Our experience with leading a successful community-based HIT initiative holds useful lessons for other organizations attempting similar projects. In this article, we will focus on governance strategies that can help ensure a successful project.
Our governance model
At the top level of our organization, we have the FDRHPO board of directors, made up of executives from our seven member hospitals, plus leaders from county public health departments, EMS and behavioral health.
Within the FDRHPO, the North Country Health Information Partnership (N-CHIP) was created to represent all stakeholders participating in the grant project.
Below the board of directors is the N-CHIP Provider Executive Committee, which includes about 20 physicians. The makeup and activities of the PEC changed slightly with each phase of the HEAL-NY-10 project.
During the first phase, the PEC included representatives from our participating private practices and hospital clinics, including primary care and pulmonology, allergy and radiology, the three specialties that deal with COPD patients. The PEC met monthly and was actively engaged with implementing the goals of the project.
Three PEC subcommittees existed during this phase: the PCMH Subcommittee; the Financial Subcommittee; and the Clinical Guidelines and Outcomes Subcommittee. The PCMH Subcommittee focused on workflow changes necessary to achieving Patient Centered Medical Home certification and standardizing that process as much as possible. The Financial Subcommittee oversaw the allocation of contingency funds for the project. The Clinical Guidelines and Outcomes Subcommittee aimed to standardize best practices for chronic disease management, to drive consistent and predictable clinical outcomes.
During the second phase of the HEAL-NY-10 project, with PCMH certification achieved and the focus of the project moving to the Health Information Exchange, the PEC grew to incorporate representatives from additional practices in cardiology, orthopedics and pediatrics. The PCMH Subcommittee was disbanded. The Clinical Guidelines and Outcomes Subcommittee evolved into the HIE Clinical Subcommittee, with a focus on gathering and reporting clinical quality measures through the HIE.
The third and current phase of the project is the sustainment phase. During this final phase, the PEC grew again, adding additional practices and community members. It transitioned out of a grant- and disease-specific focus to a community representation model. It reduced the frequency of its meetings, from monthly to quarterly, and took on a more advisory role. Work is now mostly done through the subcommittees. A temporary Sustainment Subcommittee was added to determine what the community needed from N-CHIP going forward to support the infrastructure and processes put in place during earlier phases of the HEAL-NY-10 project.
In the future, a Community Liaison or Oversight Subcommittee may be added to ensure responsiveness to the needs of the medical community going forward.
Clinical leadership: why it’s crucial
The grant required a clinical steering committee. But we also knew from the beginning that in order to be successful, we needed to approach the governance structure from a provider perspective. We wanted to have providers involved from the ground up in designing how the new HIT systems would be implemented to ensure the systems would be useful, affordable and supportive in this very challenging, rural Health Provider Shortage Area (HPSA).
I had worked on another HIT project within a single hospital, and during that project, the administrative and technical staff developed the new system, then handed it off to the frontline providers, who then had to live with what they’d been given. There was much pushback and refinement after the fact. It was a disaster; doctors felt they hadn’t been involved in the process; the technical and administrative staff felt the doctors could never make up their minds. This backwards system of implementation drove a perpetual cycle of dissatisfaction on both sides.
This taught me the importance of including clinicians from the ground up in any project that affects their workflow and potentially the quality of patient care. Clinicians need to be – and feel – invested in the project, and guide an implementation that best supports their care goals. This will ensure that the HIT project does what it’s meant to do: support superior health care.
More principles of good governance
Having clinicians driving the process is the number one principle for a successful project. But there are other important characteristics of a well-governed HIT project. Here are several good rules of thumb:
Set up a governance structure early.
Don’t get to governance halfway through a project. The earlier you get a structure in place, the better – this will help participants to feel like they came in on the ground floor. People won’t have to readjust their expectations midway through the process.
Your chairperson needs to be well-respected as a clinician.
This might sound obvious, but often it is doctors who are well-respected as administrators, rather than for patient care, who nominate themselves for such roles. And great clinicians will likely shrink from such obligations. Nevertheless, the great doctor is the one you want leading the steering committee, not the great administrator. You want the project to reflect concern for great clinical outcomes, and you need all your providers on board to do this. This is best accomplished with someone at the helm who commands respect for his or her clinical wisdom.
This person should be identified and recruited within the physician community. And the medical community should also be the ones to speak with that great administrator, who perhaps feels slighted when he or she isn’t chosen for this leadership role.
Similarly, the provider steering committee should be as much as possible self-selected, not chosen by the project manager, to ensure the greatest investment and engagement by participants.
A little conflict is a good thing.
If everything goes exceptionally smoothly, watch out. This could be a sign that you have too many like-minded people involved in the project. A bit of conflict, a little messiness, are good things, signs that you have included people with different opinions and constituencies. This means the project as a whole will better represent common clinical objectives throughout the medical community.
You need a committee charter that is very simple, and establishes ground rules for participation.
The charter should make clear that absenteeism at a certain level will result in being kicked off the committee. It should also make clear how decisions are made – will a majority vote suffice, or would the group rather strive for consensus? In our case, majority voting was the rule, but we never invoked it – we always functioned by consensus.
Different circumstances merit different governance structures
A distinctive feature of our medical environment in New York’s north country is our collaborative, non-competitive nature. For providers practicing here, the work is not about money primarily; if that was their main goal, they would likely be practicing elsewhere. Rather, our providers want to be an integral part of their community and practice in a way that satisfies their goals as clinicians. Because we are a Health Provider Shortage Area, there isn’t competition for patients; the concern is, rather, how to provide good care in a very busy environment to the patients a practice already has. This atmosphere has allowed us to be more relaxed in some of our policies because of our natural stability and centric orientation. For example, when the pace of the project put stress on the providers and their practices, they were naturally able to come together and share best practices without fear of relinquishing competitive advantages.
In a more urban environment, with competition high, different incentives are going to affect how the governing clinical committee functions. The time ratio between figuring out what to do and actually doing it is going to be different. In a rural Health Provider Shortage Area, our providers often agreed about what needed to be done, so we spent more time on implementation. In a competitive environment, you are more likely to spend a lot of time identifying shared goals. You will need to be much more aware of different agendas and conflicts of interest. You will need to put in place control measures that establish trust – for example, strict guidelines governing conflict of interest. We were fortunate enough to have significant levels of trust among providers when we began our project; in an urban setting, policies will need to be implemented that can establish a basic level of trust so that competing providers can work together cooperatively.
Finally, in a more competitive setting, because your time ratio is inverted (determining what to do and actually doing it), the key is to start small and get the committee to actually accomplish something. Physicians like to get things done; they like to fix things. If they’re not fixing things, their attention will dissolve, they will disengage. So start small and get something done; this is how you demonstrate that the committee can indeed accomplish larger goals, and practice working together. Beginning with a smaller project to get the committee functioning successfully will help ensure your grander ideas see the light of day.
To sum up: clinical leadership is crucial to the successful governance of any community-wide HIT initiative. It is important to begin at the beginning, by establishing a solid governance structure before the real work of the project starts. Other keys to good governance include: encouraging the medical community to identify and recruit a well-respected clinician to head the governing committee; understanding that a little conflict is a good thing and helps the project to incorporate diverse goals and constituencies; and establishing a committee charter that sets clear, simple rules for participation. Finally, your project governance should reflect your medical environment. Competitive environments need policies that establish trust and encourage collaboration between practices that may otherwise be business competitors.
At the culmination of this project, we created an in-depth guide for those pursuing a community-based quality initiative. Feel free to use this resource in your own community: Building Community-Based Chronic Disease Interventions: A Handbook. (While this material is under copyright protection, it can be freely distributed in its original form, with credit given to the Fort Drum Regional Health Planning Organization. Distributors are prohibited from charging for its use.)