Tuesday, April 12, 2011

Are physician informaticists cost-effective?

Another common question you get asked in informatics, especially as a physician is, "Do we really have to pay a physician to do this work?"

This is certainly a valid question - In times when budgets are tight, it's important to question why an organization is paying a physician to do informatics work.

I'm going to present the case about why I think a physician informaticist is cost-effective.

I. BACKGROUND : HOW TO MAKE A CHANGE

The first thing you need to know, to understand the argument, is "How do I make a change?"

To answer this, I'd like to break down the roles you played when you sent your last email - After all, the purpose of all email is to help make some sort of change (either "to own a book from Amazon" or "to inquire about renting a house") :

1. Owner
2. Builder
3. Tester
4. Approver
5. Publisher
6. Monitor

"What's that?", you say? Yes, you actually did all of these roles.

1. Owner - You subconsciously decided, "I need to send an email" and "I will be responsible for what I write" and "I will follow-up on the success of the email."
2. Builder - Based on your decisions, you started to draft an email
3. Tester - You decided to proofread the email before you sent it, to see if it met your quality standards.
4. Approver - After proofreading, you decided "This email is good enough to use!"
5. Publisher - You published the email by clicking "SEND".
6. Monitor - You waited for a response and checked your return emails to see if your email was successful. If needed, you might go back to Step #1.

To make a change in a clinical setting, you basically have to do the same steps, but since you're doing it for someone else, there is a crucial extra step you will need :

1. Owner - Person who owns the tool
2. Builder/Informaticist - Person who designs the tool with the Clinical IT Analyst
3. Tester - Person who tests the tool to "make sure it works as designed" before approval.
4. Approver - Usually a committee who examines the purpose, and the testing data, and approves the tool for use
5. Publisher - Person who publishes the tool for use in the clinical setting (EMR or Printshop)
6. Educator/Implementor - Person who trains clinical staff on the tool - Educates them about how it's published (where to find it), and how to use it.
7. Monitor - Person who monitors the success of the tool after it's implemented, and troubleshoots any problems

And finally, to get to the full list of responsibilities required for designing / testing / implementing clinical tools in the electronic era - there are two last players we will need :

  1. Clinical workflows are notoriously difficult to analyze, and so it's helpful to have a Subject Matter Expert, who answers detailed questions about clinical operations and evidence-based practices.
  2. Clinical IT systems are very complicated (much more so than sending an email), and so we will need a Clinical IT Analyst to know the programming needed to build these clinical tools, together with the Informaticist. (This role was not needed in the "paper world".)

So this brings us to the final roles that need to be filled to make a successful change in the technologically-advanced clinical setting :


1. Owner - Person who owns the tool
2. Builder/Informaticist - Person who analyzes the workflows and develops standardized tools in conjunction with the Clinical IT Analyst
3. Clinical IT Analyst - Person who develops standardized tools in the EMR in conjunction with the Clinical Informaticist
4. Subject Matter Expert - Person who is responsible for knowing the details of the workflows and being able to cite evidence-based practices
5. Tester - Person who tests the tool to "make sure it works as designed" before approval
6. Approver - Person/committee who reviews the purpose of the tool and testing data and approves the tool for use
7. Publisher - Person who publishes the tool, after approval, for use by your clinical staff
8. Educator/Implementor - Person who trains clinical staff on the tool - Educates them about how it's published (where to find it), and how to use it
9. Monitor - Person who monitors the success of the tool after it's implemented, and troubleshoots any problems.

II. IF YOU HAVE A NON-PHYSICIAN INFORMATICIST :

If your institution has an informaticist who is not a physician, you might have the roles filled as such - Take, for example, the implementation of an order set for your Hospitalist group :

1. Owner = Hospitalist Director
2. Builder/Informaticist = Your non-physician Informaticist who works with your Clinical IT Analyst to build draft of tools
3. Clinical IT Analyst = Person who works with the Informaticist to build draft of tools
4. Subject Matter Expert = Hospitalist Director
5. Tester = Informaticist + Hospitalist Director
6. Approver = (Your order set committee)
7. Publisher = Your Clinical IT Analyst (who publishes the draft by moving it from TEST to PROD environment)
8. Educator/Implementor = Hospitalist Director
9. Monitor = Hospitalist Director

This is a perfectly acceptable setup, but your Hospitalist Director may not have time to fill all of those roles successfully :

  1. Ownership - Deciding this does not take long, but...
  2. Subject Matter Expert - This can take many meetings to help explain the clincal workflows and evidence-based practices - And depending on how much your director works clinically, he/she may have trouble answering detailed workflow questions.
  3. Tester - This can take many hours reviewing tools and workflows and making sure they meet standards for approval - Again, depending on how much your director works clinically, he/she may not be helpful in testing the tool.
  4. Educator/Implementor - This can take many hours explaining to staff how to use the tool and where to find it (especially if it's a new tool or something complex)
  5. Monitor - This can take many hours to review the effectiveness of the tool - Are the hospitalists using it? Are they using it successfully?
And in a modern medical practice, the changes are coming fast and furious - Every time QA, or an insurer, or a regulatory body say "Jump this high or you won't get paid" - You will need someone to update/maintain all of those tools :
  • All of the hospitalist order sets will need constant maintenance
  • All of the hospitalist documentation will need constant maintenance (forms, notes, checklists, flowsheets, etc.)
  • All of the fancy tools will need constant maintenance (clinical pathways, protocols, etc.)
Every time the FDA makes a change - You will need to maintain all of these tools.

It's a lot for a modern clinical director to manage.

III. ENTER THE PHYSICIAN INFORMATICIST (AKA "EMBEDDED INFORMATICIST" OR "CLINICAL JEDI")

The physician informaticist works with the Department Director to help save time and continously maintain the clinical tools for the department, to keep up with the myriad of evidence/regulatory/billing needs. By training a hospitalist physician in informatics practices, you can develop the following arrangement :

1. Owner = Hospitalist Director
2. Builder/Informaticist = Your physician informaticist
3. Clinical IT Analyst = Your person who works with the physician informaticist to build a draft of tools in TEST environment
4. Subject Matter Expert = Your physician informaticist
5. Tester = Your physician informaticist
6. Approver = Your (order set committee)
7. Publisher = Your Clinical IT Analyst
8. Educator/Implementor = Your physician informaticist
9. Monitor = Your physician informaticist

So in this way, your physician informaticist will play all of these roles :
  1. Builder/Informaticist
  2. Subject Matter Expert
  3. Tester
  4. Educator/Implementor
  5. Monitor
ANOTHER OPTION : 
You *could* ask your Hospitalist Director to fill these roles, but you will have to pay him/her the salary for this time - Which, as Hospitalist Director ($250k/year?) is probably higher than the physician informaticist ($200k/year?)

ANOTHER OPTION :
If you have a non-physician informaticist, you *could* divide the roles this way :
  1. Builder/Informaticist = Your non-physician informaticist
  2. Subject Matter Expert = Your hospitalist director
  3. Tester = Your hospitalist director
  4. Educator/Implementor = Your hospitalist director
  5. Monitor = Your hospitalist director
But again, this will mean :
  • Having to hire a non-physician informaticist (This could be $50k/year for maintenance.)
  • Having to pay your hospitalist director for the extra time it takes to fill all of those roles properly (Even at 0.1 FTE spent on that, that could be $25k/year for maintenance.)
The physician informaticist, by combining so many roles, saves a tremendous amount of time and money, and I believe you will have better maintained/updated/used tools.

By having a hospitalist trained in informatics, he/she can spend 0.8 FTE clinically, and 0.2 FTE on maintaining informatics for the hospitalist group and accomplish most of the maintenance very well, at a cost of about $40k/year for maintenance.

This then sets up the following structure :

1. Hospitalist Director = Makes all of the big decisions about "how things will be run"
2. Hospitalist Informaticist (aka "Physician Informaticist", "Embedded Informaticist", or my personal favorite, "Clinical Jedi") = Helps make Director's dreams a reality and worries about the details to implement them properly and quickly.

In this way, the Physician Informaticist becomes an essential tool of change. And because the tools are built by a hospitalist, buy-in problems are virtually eliminated.

So the next time QA says "Every hospitalist patient will need _________", the Hospitalist Director can work with his/her Hospitalist Informaticist, and relax knowing the details will be worked out, the tool will be rapidly changed, and the implementation will run smoothly.

IV. IN CONCLUSION
For all of these reasons, I believe the "Physician Informaticist" :
  • saves both time and money
  • improves change-management
  • improves departmental accountability (by having an expert in the department managing changes)
  • improves quality
  • improves reimbursements
... and so, I see this as a rapidly growing role in modern medicine, especially in hospitals who are going EMR or have gone EMR.

Would love to hear any thoughts/comments! Feel free to leave your experiences with physician informaticists!

5 comments:

Dirk Stanley, MD, MPH said...

Scot - Agreed, 100%. I know you've been fighting this struggle for a long time - Lots of us are tackling the issue just now. (I suspect this will go on in every hospital with an electronic medical record.)
Thanks for all of the good articles... :)

Dirk Stanley, MD, MPH said...

By the way, in your experience, do you think the term "Information Architect" helps? I feel like "Informaticist" just has too much trouble and controversy associated with it.

Scot M Silverstein MD said...

By the way, in your experience, do you think the term "Information Architect" helps?

It was an old term, so it clearly did not help!

I feel like "Informaticist" just has too much trouble and controversy associated with it.

The "controversy" is twofold:

1.It is a term that is poorly understood by many, largely due to misuse/overuse of the term (see #2 below!)

2. The term has been misappropriated by those seeking to protect their territory; as I wrote long ago.

I do not know of a better term, however.

Ultimately, thought, the problem with health IT leadership is not terminologal; it is political:

Firstly, physicians sticking up for what's best for patients. Secondly, sticking up for themselves.

Physician learned helplessness is all too real (see here).

S.

Scot M Silverstein MD said...

By the way, next time you get asked this question, simply appeal to authority:

"The HHS says so."

See "ONC Defines a Taxonomy of Robust Healthcare IT Leadership".

Then ask of the inquirer:

"Any more questions?"


S.

Dirk Stanley, MD, MPH said...

Scot - Sorry, I accidentally deleted your initial comment about 'I can't believe people are still asking these questions'... (Was scanning through my settings and accidentally pressed it on my iPhone)... Mea culpa, my apologies. :)