Change Management for Health IT: Preparing for your Next Challenge

Preparing for your Next Challenge

Krystyna Hommen BSc MBA – President and CEO, Excelleris Technologies Laurie Poole BScN MHSA – Vice President, Telemedicine Solutions, OTN Dr. Jeremy Theal MD FRCPC – CMIO, North York General Hospital

“…a strategic and systematic approach that supports people and their organizations in the successful transition and adoption of electronic health solutions. The outcomes of effective change

management include solution adoption by user and the realization of benefits.”

- Canada Health Infoway Pan-Canadian Change Management Network, 2011

Why is it needed?

“Resistance to change is not some inviolable law of nature;

resistance to change occurs because individuals do not see the benefit of changing, or a high likelihood of being able to do so successfully.”

Catchment area: > 400,000

Three Sites:

General, Branson, Seniors’ Health Beds: 418 acute care

192 long-term care

Volume per year:

113,000 ED visits 29,500 inpatient cases

1.

Organizational Goals, Vision, Commitment, Readiness

2.

Select Leaders and Clinician Champions

3.

Identify and Mitigate Barriers to Change

4.

Communicate, Educate and Engage:

•

Share the Vision, Goals and Plan

•

Involve and Engage Clinicians

•

Build Positive Anticipation pre- go live

5.

Support Conversion: ensure CPOE is “the new normal”

What is eCare?

+

Standardization on Evidence-Based Care

+

Safe Prescribing and Medication Administration

+

Clinical Decision Support (Rules, Alerts)

A new era in patient care

using EMR technology

•

Computerized Provider Order Entry (CPOE)

•

Evidence-Based Order Sets & Clinical Workflows

•

Closed-Loop Medication Administration

•

eMAR, Medication Reconciliation, Depart Process

•

Advanced Clinical Decision Support

Goals of the eCare Project

•

Implement advanced electronic medical record technology

to improve patient outcomes:

 Quality and safety of patient care

•

Embrace culture of evidence-based care, best practices

 Make it “easy to do the right thing”

 Build evidence into clinical workflow

•

SHARED VISION = “by clinicians, for clinicians”

 100% clinician adoption

Clinician Champions

•

Roles:

– Representation from each major scope of practice (MD, nursing, pharmacy, allied health)

•

Responsibilities:

– Practice alongside peers and have their respect

– Create shared vision for project success

– Have paid, protected time for the project

– Have accountability to the success of the project

– Be local to each implementation site

– Work in partnership with clinicians,

Selecting Clinician Champions

Effect of Peer Influence amongst clinicians:

• Clinicians (particularly MD’s) value autonomy

• Changes perceived as imposed are not well adopted

• Changes suggested/demonstrated by peers more frequently adopted

Essential to identify at every institution:

• Technophiles: innovators and early adopters • Opinion leaders: with high peer influence

Peer Influence HIGH

Peer Influence LOW

Affinity to IT HIGH _CLINICIAN

CHAMPIONS

SuperUsers

Affinity to IT LOW _STRONGEST

RESISTORS

Intensify Training

3 main project foci:

• Medication Integration

• CPOE/Order Sets

and Physicians

• Interprofessional Integration

Each focus led by:

• Clinician Champion

• Executive Sponsor

Foci integrated by:

• Steering Committee

• Core Committee

Clinician Adoption of IT: Supply/Demand

Traditional implementation approach focuses only on supply: “Build it and they will come”

“Up to 30% (of CPOE implementations) fail”

National Health Information Network Co-ordinator David Brailer, Washington Post, 2005



adoption is NOT guaranteed!

For advanced systems – must focus on demand:

Technology readiness and adoption needs of diverse user groups

Supply Demand

• Development of innovations and technologies to enable efficiency and quality in healthcare

• Deployment of innovations – depth (complexity) and breadth

• Determining readiness of

technology infrastructure and users • Attracting users and fostering

Understanding Your Users: Physicians

Doctors are motivated by:

• Independence and autonomy (imposed change will fail) • Efficiency (save time)

• Quality of patient care (often feel they give top quality already) • Evidence – need hard proof that change is warranted

• Peers – based on respect, shared experience, training models • Respect/Ego – want respect of peers, don’t want to “lose face” • Competition – show them they’re falling behind the leaders

of the pack, this will drive change faster

Engaging Physicians

Physician Input



Iterative Design



Buy-In:

•

Led by Physician Champions (peer-based autonomy):

•

Design of system components

•

Review of order set evidence and content

Order Sets are not “Cookbook Medicine”!

•

Important message to address perceived



autonomy

•

MD makes decisions based on individual patient characteristics

•

Order set simply provides evidence-based “guardrails” while

•

Inpatient management of diabetes and hyperglycemia:

– CPOE order sets for diabetes care

– 25% LOS reduction for diabetic inpatients,

with improved glucose control

Single hospital study, Schnipper, JL. J Hosp Med 2009; 4(1): 16-27

•

Sepsis – CPOE order set:

• Length of stay reduced by 6.3 days (p=0.02) • 15.5% absolute mortality reduction (p<0.01)

Single hospital study, Thiel SW et al. Crit Care Med 2009 37(3):819-24

•

41-hospital study in Texas – CPOE and CDS:

• 21% reduction in death from pneumonia, $538 saved/patient

Amarasingham R et al. Arch Intern Med 2009 169(2):108-14

Evidence-Based Care: The Gaps

1)

Belief Gap:

2)

Capacity Gap:

– Finish medical school and residency knowing everything – Read and retain 2 articles every single night

– At the end of 1 year:

3) Temporal Gap:

– Average of 17 years for evidence to reach the bedside

200 MB capacity 6,000 articles/day 300,000 RCT’s

GAP

1,225 years behind

Training and Support

•

Training:

•

Multiple modalities for different practitioners/learning styles

•

Computer-based training, classroom-style, simulation lab

•

Carrots for physicians: CME, scheduling flexibility

•

Audit, reinforce and repeat (drop-in, roamers, tips, portal)

•

Support:

•

Peer-to-peer where possible (clinician SuperUsers)

•

Dedicated 24x7 support command center, for 4 weeks

•

Centralized feedback system

•

Change/improvement request triage with prompt response

\

In-Hospital Death Rates Down

Across Greater Toronto Area

• Annual CIHI Report demonstrated that

preventable in-hospital deaths were reduced

• NYGH – top performer in Greater Toronto

and second best in all of Canada

• CEO Tim Rutledge: “health information

technology has hard-wired quality and safety into the hospital”

Study: CPOE and Evidence-Based Order Sets

Retrospective chart review:

• All patients discharged with a main diagnosis of Pneumonia or COPD • Population #1: Pre-CPOE (Jan-Sep 2010) n = 520

• Population #2: Post-CPOE (Jan-Sep 2011) n = 511 • Groups similar in age, gender distribution

• Corrections: “Probability of Death”, critical care admission

Primary Hypothesis:

• Use of CPOE is associated with reduction in adjusted mortality, 30-day readmission, length of stay vs traditional paper processes

Secondary Hypothesis:

• Use of CPOE with a matching evidence-based admission order set is

associated with reduction in adjusted mortality, 30-day readmission, length of stay vs use of any order set

Study Results

Outcome Odds

Ratio

Confidence

Interval p-value

Death adj for Probability of Death

and CrCU Admission 0.55 0.36 – 0.83 0.005

•

Primary Hypothesis (CPOE vs Paper)

•

Secondary Hypothesis (evidence-based OS selection)

Order Set Outcome Odds

Ratio

Confidence

Interval p-value

Diagnosis-appropriate

Death adj for Probability of

Death and CrCU Admission 0.44 0.21 – 0.90 0.024

Close to diagnosis Death adj for Probability of

Death and CrCU Admission 1.82 0.78 – 4.23 0.16

Any order set Death

Study Results: Subgroup Analysis – Order Set Use

Paper Orders CPOE (eCare) Percentage of patients for

whom a

diagnosis-appropriate order set was used

Pneumonia 26.05% Pneumonia 60.43%

COPD 0.0% COPD 45.1%

Percentage of patients for whom any admission

order set was used

.

Pneumonia 37.90% Pneumonia 97.54%

for Canadian CPOE development resources

• CPOE Implementation guide (>500 pages)

• Searchable library of evidence-based order sets

•Medicine, Surgery, Critical Care, Paediatrics, Maternal-Newborn •Coming soon: Long Term Care, Mental Health

• Multi-publisher sharing model

•Each contributing organization shares content at no cost,

• Change Management and Physician Adoption

• Project Planning and Project Management

• Order Catalogue Creation

• Electronic Order Set Development • Electronic Medication

Management

• Clinical Decision Support • Integrating Workflow • Technical Implementation • Training • Go Live • Maintenance • Downtime

BY THE NUMBERS

42

5

353

652+600

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Join today at:

http://www.cpoe-toolkit.ca

For more information, please contact: Jeremy Theal MD FRCPC

Chief Medical Information Officer Email: [email protected]