Shifting from Fire Fighting to Fire Prevention

One of my favorite things about working in the healthcare technology industry is meeting other Clinical Informatics professionals who are working hard to keep healthcare running electronically. The work is hard, and the hours are long.

I recently had an informal meeting with a number of other Clinical Informatics professionals, and I wanted to share some thoughts about a great conversation we had as a group. It started with an informal discussion about the necessary ‘care and feeding’ of an EMR. But eventually, our informal talk progressed into a much more meaningful discussion: how can healthcare IT shift from ‘fire-fighting’ to ‘fire prevention’?

Across the industry, some of us are noticing that a number of people generally feel overwhelmed. Both inside and outside of Clinical IT, people are describing things like: 

• ‘I don’t feel like we can ever get enough done.’
• ‘It’s too hard to make decisions.’
• ‘I come in planning to do A, but then find out we have to do B.’
• ‘I just built this, but now it has to be changed again.’
• ‘Why doesn’t it just do what it’s supposed to?’

These statements are all symptoms of a larger problem: insufficient infrastructure to maintain your EMR. So what does it take to build a sufficient operational infrastructure?

Here’s a list I’ve put together:

1. Clinical/Administrative Governance – Strategy for how to make synchronous organizational decisions that align clinical, administrative, IT, and sometimes research/educational stakeholders.
2. Data Governance – Strategy for how to define and standardize important concepts and terminology across the organization, formally review/approve requests for information, and use data/information as a strategic asset.
3. Terminology Management Strategy – Determining how to manage and standardize terminology, concepts, and hierarchies in your organization.
4. Policy Management Strategy – How to draft, review, approve, modify, publish, and archive policy standards in your organization.
5. Document Management Strategy – How to create, modify, and archive EMR-related (clinical) and non-EMR-related (administrative) documents in your organization.
6. Project Intake Strategy – How to have a single point-of-entry to document and analyze project requests, with a preliminary project scope, risk evaluation, ROI, Total Cost of Ownership (TCO), and other important factors before
7. Project Prioritization Strategy – How to review, prioritize, and approve projects that have been analyzed during your project intake strategy (above).
8. Project Management Strategy – How to manage small, medium, and large projects with routine and urgent priorities.
9. Design, Build, and Testing Strategies – Designing, building, and testing workflows (prior to education, implementation, and support).
10. Change Management Strategy – How to make workflow improvements/enhancements without significant disruptions to clinical care.
11. Change Control Strategy – How to implement changes across both EMR-related and non-EMR-related environments, without disrupting other people/projects.
12. Educational Strategy – How to train clinical/administrative users of your EMR.
13. Communication Strategy – Communicating important items with clinical/administrative users of your EMR.
14. Application Support Strategy – How to provide elbow-to-elbow, help desk, and other application support for your users.
15. Content Management Strategy – Maintaining the clinical content configured in your EMR (e.g., How will you update your order sets? Make formulary/payor updates? Manage urgent regulatory or safety issues?)
16. Business Continuity Strategy – Maintaining clinical operations when your EMR is down for planned/unplanned down times.
17. Onboarding Strategy – How to document and share information related to new clinical and administrative users for your EMR. (Often tied together with your credentialing process.)
18. Off-boarding Strategy – How to document and share information related to clinical and administrative users who are leaving your organization.
19. Reporting/Analytics Strategy – Reporting and analyzing information from your EMR, for departmental, organizational, local, and regional purposes.
20. Patient Portal/Engagement Strategy – How to engage patients and release information to your patient portal.
21. Provider Engagement Strategy – Engaging clinical staff (Physicians, Nurses, Advanced Practice Providers, and other clinical staff) in workflow discussions and EMR-related projects.
22. Technology Procurement Strategy – Managing technology purchases (both hardware and software), to help ensure the implementation cost and total cost of ownership are both understood before purchase.
23. Practice Procurement Strategy – Procuring new practices (e.g. those that want to join your network), to convert over their data, terminology, and practices to meet the needs of your organization.

Of course, there are more.

These are all important parts of maintaining a healthy EMR, and many organizations already have a lot of these pieces in place, but they are usually not an area of intense focus until an organization becomes more mature with their understanding of technology. Unfortunately, until then, the environment can feel a bit chaotic and unstable. This is all part of the road from implementation, to stabilization, to optimization.

That’s why it is important to acknowledge that the CIO, CMIO, CNIO, clinical informatics, and health IT staff need to focus on more than just what’s inside the EMR. The processes and tools outside the EMR are just as important as the ones inside the EMR. If they don’t have influence over those tools and processes outside the EMR, they cannot align expectations with EMR configurations, and user satisfaction and productivity will drop.

As it’s often been said, clinical Informatics technically has nothing to do with technology. It is more about information architecture, the processes external to the EMR, and how they impact the configurations inside the medical record. The same work would apply in a hospital with a paper record — but, as we know, paper is more forgiving about workflow inconsistencies, so the need for an infrastructure is not as great. (Metaphorically, paper is like building with marshmallows, and EMRs are like building with bricks.)

So as a CMIO, about half of my work is managing expectations and configurations inside the EMR, and half of it is working on these sorts of external infrastructure enhancements.

Strategic Planning

If having this infrastructure in place helps prevent ’fire-fighting’ (E.g. Frustrated users, slow projects, unanticipated outcomes, workflow inconsistencies, rebuilds, etc.), then the simple strategic initiative needs to come from a gradual focus on fire prevention strategies (e.g. building this infrastructure).

It can be hard to do this when resources are tight, but it starts with strategic planning. Below is a sample strategy for building an EMR infrastructure:

• Next 6 months: Spend 4 hours a week on infrastructure enhancements (‘fire-prevention’ strategies).
• 6-12 months: Spend 8 hours a week on infrastructure enhancements (‘fire-prevention’ strategies).
• 12-18 months: Spend 12 hours a week on infrastructure enhancements (‘fire-prevention’ strategies).

Alternatively, if you have additional resources available, it could be helpful to have a separate team to focus only on developing infrastructure, so that your internal resources are not disrupted from the routine day-to-day activities needed to keep your system operational.

Either way, I believe fire prevention is always more cost-effective than fire-fighting, and will help you to better realize the potential benefits of your EMR. I hope this can serve as a guide for developing a strategy for stabilization and optimization. Remember, half of the work is inside your EMR, and half of it is outside.

This piece was written Dirk Stanley, MD, a board-certified hospitalist, informaticist, workflow designer, and CMIO, on his blog, CMIO Perspective. To follow him on Twitter, click here.