“Never waste a good crisis.”
This quote has been ascribed to various sources, but whoever said it was wise. Often, one can make significant progress in a short amount of time when the environment is unstable. Normal rules go out the door. Maybe this is because there’s an existential crisis and something had to be done to save the organization from doom. Perhaps a leader has exited and before the management vacuum is filled, a long dormant project is resurrected and quickly implemented under the radar. Whatever circumstances led to the crisis, enterprising folks often take advantage to get stuff done.
I once found myself with a mini-crisis on my hands, and I didn’t want to waste it. While I’ve taken a few liberties with some facts in order to protect the innocent (or guilty), you’ll get the gist of it. I was summoned to the C-suite to meet with the chief medical officer (CMO) and chief information officer (CIO). I was told that “we have a problem.” Apparently insurance company audits showed that some of our physicians weren’t completing required documentation in required ways in a required timeframe. Shock and horror ensued, naturally. “But… but… I’m sure we told them they needed to do this. Didn’t we? We did. I know we did.” Regardless of whether we did or didn’t, those crazy doctors were in trouble, and the hospital was in trouble along with them.
What could be done to rectify the situation? My natural inclination as a parent was to sit those physicians down and give them a stern talking-to. “Listen, doctors. You need to complete this documentation in the way I say, and in the time that I’m allowing. Or else! Do you hear me? I’m talking to you. Look at me!” This did not go over well with my executive audience. I considered trying to reason with them. “You fine group of physicians. Don’t you like following the rules like good health care providers should?” That one got me a hearty laugh, but still, a no go.
There was one more option, but I would never have thought of it. It was suggested that maybe, perchance, perhaps, possibly we could put a hard stop in the EHR so the doctor had to fill out the information. When I have my CMIO hat on, this option is almost not even worth discussing. I hate hard stops. They are the bane of my existence. Some folks want to invoke the nuclear option right away, so my default answer is no. We don’t do hard stops unless we’ve exhausted every other option.
I understand the appeal of hard stops. Doctor, at this point in the workflow, you can’t move forward until and unless you give us what we want — what we need. It’s just that what an administrator or a researcher or someone else might want/need may not directly correlate with what the physician or the patient wants/needs. Sometimes those things do overlap. If a doctor is ordering a medication, we need to know the dose, route, and frequency. Those are inherent parts of the medication order; without those data, there is no reason to move on. Those are great places for a hard stop.
But often, we either don’t have the technical ability to halt a workflow in a convenient place, or it’s just not a safe thing to do. My standard spiel is “I’m waiting on the keyboard company to give me the ability to apply a light electrical shock to the person typing, but even after they do, I’m not sure biomedical engineering at the hospital will approve.” While there are select areas of the EHR where it’s possible to stop a doctor in his/her tracks, should we? Let’s think about patient safety. Are those data fields so important that we essentially tell a physician that he/she can’t open a different patient’s chart, can’t order a medication or lab test, or can’t review patient progress or consultants’ notes? Typically the answer is no. But no isn’t always the answer.
We recently put a hard stop in a doctor’s workflow, but we made it minimally onerous by pre-populating the necessary field with the likely answer. This way, most of the time, the doctor simply has to check that the data we think is correct is, in actuality, correct. It won’t always be right, and sometimes the data won’t flow at all, so the physician will have to enter it manually. But overall, I think we are making it easy to do the right thing. This was one of those wins where IT and the medical staff should both be happy with the outcome!
As I was proudly showing my CMO the team’s handiwork, he looked at me with slight amazement. “Hey, I noticed that now that the physician has answered the mandatory fields, the EHR magically inserts that information into his/her note. That’s great stuff. Why don’t we do more of that?” My slightly sarcastic answer was, “Because most doctors weren’t filling in the fields before we made them hard stops. If our colleagues would just follow the workflow that we defined and trained, then we could do cool things like default in documentation and make super smart clinical decision support. But since the majority of docs didn’t follow our suggestions, I couldn’t trust that the automation would work.” That’s what I told him because he’s my boss. What I wanted to say was, “If you kids would listen and not argue with me about everything, we could have nice things. But with all the fighting and throwing and misbehavior, I won’t bring nice things into our house.”
The moral of the story: listen to your CMIO.
Craig Joseph, MD, is the Chief Medical Officer for Avaap, an EHR and ERP consulting firm. He is a pediatrician and physician informaticist with experience in both clinical practice and the use of the EHR to improve patient care and physician efficiency. Dr. Joseph also currently serves as the Interim CMIO at El Camino Hospital in Mountain View, California. This piece was originally posted on Avaap’s blog page.