The person who originally coined the phrase ‘change is never easy’ could very well have worked with physicians. For myriad reasons, from a desire to keep patients safe to fear of the unknown, they can be a difficult audience when you want to introduce new technologies and workflows. But for leadership at UCHealth, the long-term plan to become more transparent and squash the traditional pockets of secrecy was worth the fight.
Recently, healthsystemCIO spoke with Steve Hess, CIO, and CT Lin, MD, CMIO, about how they’ve been able to move the needle. As we learned, it starts with having the right infrastructure and governance in place, having the patience and persistence needed to convince users to get on board, and having a “world-class team of physician informaticists.”
Join Hess and Lin for their presentation, “Is This the End of Secrecy in Healthcare?” on Monday, Nov. 4 at 4 p.m. at the CHIME19 Fall CIO Forum.
Gamble: UCHealth is doing a lot of innovating things, especially when it comes to creating a more robust user experience, both for patients and providers, and enabling a level of transparency we don’t see in many organizations. Even going back to the early 2000s, the organization was ahead of the curve in doing things like offering auto-release test results. Was this met with resistance at first?
Lin: We’ve always had an interest in transparency, and that includes our leadership as well. But as most organizations will discover, clinicians have traditions about how we should care for patients. There’s always been a strong belief that medical information is private and should stay with the doctor, because it would take too much effort to explain to patients. We always have to overcome this bias that medical information is too complicated.
That’s been set upside-down since the onset of the internet and we’re still struggling with it today. We’ve worked very hard to set up structures and governance and have conversations that push forward the thinking that we can trust patients with their own information.
Sometimes in order to be innovative we have to look outside healthcare, because there aren’t a lot of examples. We’ve looked at Wikipedia, Travelocity, eTrade, and other examples where having customers participate makes things better for everyone.
Gamble: Do you think some of the hesitancy stems from concerns that giving patients access to information is too risky?
Lin: That’s a reason we often hear: ‘This is healthcare; it’s different. You can’t possibly expect patients to understand doctors’ progress notes. It’s too complicated.’ In fact, I remember going from meeting to meeting to speak with doctors about releasing text results. I made the mistake of asking which results they wanted released, and the answer was none of them, because they’re all too complicated.
‘How about cholesterol tests?’ ‘No, the cholesterol guidelines are very complicated. There’s 30 pages of reading.’ We learned that we weren’t going to get their permission, and so we said, ‘Okay, we’re going to try it at a pilot site and see what happens.’ And that’s how we started on this path.
Hess: The physician informaticist’s role in all of this is so important, because we’re trying to take that provider-patient relationship to the next level. But with technology comes uncertainty and fear, and so that change management piece and that governance piece is critical. We need to tell them, ‘It’s going to be okay. We’ll go live, we’ll review the data, and we’ll look at any issues.’ It’s such an important part of this.
For the most part, all of our different implementations of patient transparency initiatives have been relatively successful. We haven’t had a lot of complaints or additional clarifying questions asked of the doctors. Patients are so much smarter than we give them credit for.
There were issues where along the way where a result was released appropriately, according to our rules, but was released prior to the clinician having a conversation with a patient. We’ve had those type of one-off issues where there were results with a specific test. The knee-jerk reaction is to say, ‘Let’s revisit all the rules,’ and so we’ve had to step back, take a breath, and say, ‘Let’s work through this. It’s one result out of millions. Let’s improve our processes so that the conversation can occur before results are the released.’
It hasn’t been perfect, but it’s been really well-received by patients, and so we just have to constantly have the fortitude to work through the challenges. That’s where we really rely on CT and his team.
Gamble: How did you work pass the initial hurdles and build confidence among physicians?
Lin: We approached it with data and testing sites. At the time — and this was in 2003 — we were doing our OpenNotes projects in the clinics. And so we sat down with a group of physicians at a cardiology practice and showed them the proposal where doctors’ notes were shared with patients. Of the seven physicians, three said they already carbon-copy patients on referral letters. The other four said, ‘This is a terrible idea. But it looks like you’re going to do a rigorous, measured study. So by the end of the year, you’ll know precisely how bad an idea this is.’
But eventually, everyone agreed to proceed, because we were going to measure it carefully, and we were willing to make changes to the process if something wasn’t working. That really got us over the hump.
At the end of that year, we published the study through the SPPARO Project, and we were able to say that 100 patients in the system did not create a lot of work. It was five more minutes of work per week for nurses to answer phone calls. But that five minutes would evaporate by the end of the year, because people got it. They understand the reason they’re not seeing notes in time it because it takes several days for the transcription to return. But in general, releasing test results and OpenNotes to patients turned out to be, as one colleague called it, a ‘nothing burger,’ because the anticipated fear doesn’t materialize.
It’s important to point out that these were significantly ill patients seeing cardiologists; these weren’t the ‘worried-well’ patients. These were patients with real diseases benefiting from this transparency. And we were able to measure the data, publish it, and use it as a starting point for conversations with the rest of the organization.
Gamble: Last year, UCHealth took it several steps further, launching OurNotes, online scheduling, and a cost calculator. I’m sure it made a big difference having already laid the groundwork in previous years.
Hess: Exactly. First, the organizational strategy has four pillars to it. Two of those are experience and innovation, and so part of what we’ve tried to do is to create a world-class digital patient experience. We have a whole team devoted to our patient portal and our mobile app; we’re trying to push the envelope with transparency.
I don’t think any of this would have been possible if CT and the team didn’t lay the foundation years ago with results release. And then we went after OpenNotes, online scheduling and patient estimates. We also have radiology images being made available to patients and a whole host of other offerings.
With online scheduling, for example, we have a call center where patients can call in and schedule appointments. Not only is that an expensive proposition, but it’s not open 24/7. If I’m sick on a Sunday and want to schedule an appointment, I don’t want to wait until a call center is open. And so we’ve created the ability to go online and make appointment, both for primary care and specialties, and we’ve seen some great adoption. It was slow at first, but then it really ramped up, and we can do more with less in terms of scheduling FTEs.
Going back to CT’s point about looking outside of healthcare, with some of the things we’re doing, there is no blueprint. We’re creating blueprints. We looked at how easy it is to schedule a dinner reservation through OpenTable, and made it almost as easy to schedule a doctor appointment; it’s never going to be as easy, but we try to base our design on that concept. Everything we do is around bringing the patient and their families into the care process and making it easier to interact with physicians.
Gamble: For organizations that are looking to make transparency part of the culture, do you have any advice on how to move in that direction?
Hess: Having someone like CT on your team really helps. But I really do believe it starts at the top. During our session, we’ll show how everything we’re doing from an IT and innovation perspective cascades down from our organizational strategy. It has to be a priority driven by the CEO or a senior executive around patient experience or innovation or transparency, and not just a mandate from the state or federal government. You need to be willing to push the envelope, but it has to be driven from the top.
But if you don’t have a physician informatics team and a strong CMIO, it’s going to be really difficult. CT has more than 30 physician informaticists on his team; they really are that change agent. They’re out there connecting the dots and helping IT teams build solutions that work for patients and providers. They take a lot of those slings and arrows and convert them to positives. At the end of the day, healthcare is one patient and one provider at a time, and you need those individuals on your side.
I think it has to start at the top and cascade down, but also the physician and clinical informaticists who can manage these changes, one patient and one physician at a time.
The value of the team of informaticists I work with is that we are humble enough to be out there in the field with our front line clinicians asking what they think. How was that OpenNotes project? How was the OurNotes project? We’re in the midst of that now. The idea is to ask patients, what are the three questions you have for your doctor, and what has happened since last time? So that the patient actually co-authors the doctor’s progress notes. They’re not just reading it; they’re helping to write it.
This isn’t something you can just mandate. You have to have the vision to do it, and that requires a CMIO and an informatics team. You also have to shop it around and talk to clinicians. You have to talk through it and be willing to say if this doesn’t work, we’ll pivot. We’ll listen. We’ll pivot and do something that’s a win-win for both patients and clinicians. I think that closed loop where we say we’re committed to making this a success for everyone — that takes us over the finish line.
Gamble: It seems like an interesting dichotomy; in some ways you want to push physicians along, but you also have to be aware of the burden they face; they’re
Lin: We like to think of it more like a ‘nudge.’ If you really want to change the culture and change behaviors, it has to be done incrementally. You don’t come in one day and propose a massive change; you do it a little bit at a time. ‘Wouldn’t it be easier if we did this?’
As a matter of fact, we have a patient-centered family care council. We work with them constantly to say, ‘What do you think about this?’ instead of, ‘We’re going to mandate this.’ By doing that, we’re able to take the voice of the patient back to the clinicians and say, ‘Our patients are requesting test results.’ This way our patients have a voice, and we believe having all those voices at the table helps us move the culture forward.
Gamble: You seem to have very different personalities. Can that be challenging at times? And how are you able to leverage each other’s strengths to provide better leadership?
Hess: We’ve been together 10 years and have done some really cool stuff together. We mesh really well; our styles our different. We come from very different backgrounds and have very different skillsets and competencies. But we blend extremely well. He’s a master change implementor, and he allows me and the IT team to make sure the infrastructure and technology are built effectively to drive efficiency.
We’ve also created a world-class physician informatics team around C.T, and we’ve been able to justify the spend and the FTE allocation for those physician informaticists because we feel it’s imperative, but we’ve also been extremely successful. And so yes, our styles are different, but very complimentary. We feed off each other. If you don’t have a great relationship between the CIO and CMIO, the teams below you can get different directions and get confused.
We agree 95 percent of the time, but we also have the relationship where we can work through the other five percent, and so we’re able to provide a consistent direction and strategy to our team. I think that’s been part of our secret sauce.
Gamble: I’m sure. This has been great. I want to thoank you both so much for your time. UCHealth is doing some incredible work, and I look forward to hearing about it during your presentation. Thank you!