Sunday, August 9, 2009

Is medical culture ready for EMR and healthcare change?

I've written about the "tribal culture" of medicine a few times on Twitter, and it seems to resonate with people who work clinically, so I thought I'd write a few thoughts about the cultural shift needed for successful EMR implementation.

When people first try to understand the challenges involved with EMR implementation, they commonly reach for common life experiences which they imagine might be similar : Like, for example, installing software on your computer at home or at work.

The problem is that if you use this as your conceptual model for EMR implementation, you will make one of the most common mistakes : Thinking, "'s like installing software on your computer."

Problems that arise from this conceptual model :

Mistake 1 : The belief that "training" is an instruction book or training class that teaches you to "use the software"
Mistake 2 : The belief that "support" is a help line to answer questions.
Mistake 3 : The focus on "the software" as being an experience at the computer.

Okay, so I'm not being fair in saying that these are really mistakes, since they are certainly useful in starting to understand the enormity of the issue. But if that's where your understanding ends, then you make the bigger mistake of not seeing the bigger picture at work.

"It's not just the software, folks..."

The point I wanted to convey tonight is that "going electronic" is a major cultural shift in healthcare.

1. It means you need to take a hard look at some well-held beliefs, and prepare to readjust them.
2. It means you need to examine your workflows and prepare to resort them.
3. It means you need to build new managerial structures to deal with the culture shift and navigate the tremendous amount of information you will uncover along the way.

So now, the challenge becomes : In addition to buying the software and arranging for starting training and continued support, how do we manage change in a culture that is so fiercely tribal?

So here are my thoughts of useful cultural features to help prepare your office / hospital for this shift :

1. When discussing management or IT : Lose the formal titles of "Doctor" or "Nurse" or "Administrator" or "Pharmacist". (I personally cringe if people use my formal "Dr." title, since I really believe that use of the title reinforces the "us-vs-them" mindset. It's much easier to build a team when everyone feels they're in the same tribe.

2. Take a hard look at the culture your front-line employees live in. Are they nervous to try new things? How do your front-line managers handle their mistakes? If the environment feels too punitive, you will suffer from people not trying the software, and from people not sharing the problems-everyone-should-learn-from.

3. Invest in your employee's skills. There are front-line employees who understand the operations of their department very well, and are interested in being more involved in managerial decision-making. Rather than a the older top-down approach of decisions coming from the top, consider bringing some front-line staff to the top, and let them be responsible for the outcomes.

4. Prepare for new sources of data on clinical functioning. One of the benefits of going to an EMR is that you will suddenly be able to sort through large amounts of data quickly. Things that took hours of chart review in the past now become a quick Excel spreadsheet. Make sure you plan for staff who can help you tap that information and sort through it in a meaningful way. Then develop plans for how to deal with the information you'll obtain.

5. Realize that good teaching is much harder than it looks. It's helpful to talk to anyone who has worked in the educational field about how complicated good education is. (Ask a teacher what the difference between "education" and "good education" is.) You will need to commit to the training and support of a large amount of employees - Are you prepared for that challenge? What resources do you have for this, and when are they available? People will eventually be able to blossom on their own, but generally training will get your employees to a 100-level understanding of your EMR - Eventually, you'll want to bring them up to a 400-level understanding, and that takes resources.

6. Set realistic expectations. It's a simple fact : Some people are impatient. If you have too many of these people, you will have a hard time meeting their expectations early on, and you risk losing confidence and buy-in of your clinical thought leaders. If you focus on setting realistic expectations early on, you'll help avoid the problems that can result from these people.

Sorry it's not a nice list of five things... So it's six. I'm sure I'll think of more in the future.

Thanks for the feedback on the last posts! I look forward to sharing some more insider CMIO tips in the future! :)


Rich Berning, MD said...

Please write a post about your thoughts on the "Medical Tribe". I missed your comments on Twitter, and would like to hear your insights about the medical tribal culture.

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