I hesitated to write about technology because it may already seem dated by the time of publication. The ground is shifting quickly as hospitals come to grips with the worst economic conditions in a generation. Workforce shortages and other COVID pandemic fallout continue to plague us.
But then I realized that this is the perfect time. There is no better audience than the Chief Medical Officers (CMOs) of hospitals, the physician leaders who are the ones setting the strategy and tackling the healthcare system challenges we face.
CMOs understand well why Chief Medical Information Officers (CMIOs) and Chief Healthcare Information Officers (CHIOs), who have spent 7–12 years training to become physicians, might choose to cut back on what they worked so hard to achieve: caring for patients face to face.
Why would anyone give up immediate gratification and job satisfaction to attend meetings and spend more time in front of the computer screen? Ultimately, like those who agree to become CMOs, it’s because we believe we can help more patients, families, and colleagues by undertaking a different role than most of us envisioned while in medical school.
We believe we can help our fellow physicians and other clinicians help far more patients by turning data into information and equipping our colleagues with the best decision support and other tools and technology.
I found a key piece of information in our recently installed ambulatory electronic medical record (EMR) while caring for a patient in my first month of emergency medicine fellowship — even while our ED still used paper. The ability to know what congenital heart surgery a patient had completely changed my management and decision-making.
It clicked for me: Having the right information at the right time at the bedside could spell the difference between life and death.
Technology Can be Transformative
Perhaps COVID made this plainer, but it’s easy and popular to hate EMR systems. Much of the ire is well-deserved; numerous clicks and busy screens overwhelm us. What people may not realize, however, is that they do exactly what they were designed to do.
EMRs were created to help with billing and coding and supply the documentation to meet regulatory needs. The designers paid secondary importance to the needs of clinicians. What physicians and other clinicians needed was important, but billing, compliance, and regulatory leaders’ needs took the front seat.
With so many cooks in the kitchen, it’s no wonder the “recipe” got out of hand and the actual product isn’t what any clinician would order. However, significant progress has been made in recent years, with iterative feedback, significant developmental resources, and more attention to usability. Ironically, improvements are hindered because of the user base that has learned to navigate legacy systems with workarounds and sheer muscle memory.
Also holding great promise are recent changes by the federal government in relaxing the onerous documentation rules that required the 10-point review of systems. Gone too are the innumerable click boxes that existed solely to insulate against rejected or downgraded claims. One of the salutary aspects of EMR industry consolidation is that EMR vendors can devote more resources to optimize clinician functionality. Happily, they have done so by soliciting physician input.
All around the country, during the height of the COVID pandemic, we saw how helpful technology could be: the abrupt shift to telemedicine; the use of data analytics to drive medical decision-making; the use of computerized decision support to help equip physicians with the latest rapidly evolving medical knowledge; and patient portals to enable communication and self-service.
We’re now entering an age where advanced analytics (often hyped as “artificial intelligence”) and complex computerized clinical decision support are accelerating and will make an incredible difference. Computers can churn through vast amounts of chart data far faster than a physician can, potentially surfacing recommendations for order sets or pathways, or spotting missed follow-ups and other opportunities to improve care.
Automation of refills and health maintenance reminders and follow-up are extant, freeing up clinicians to focus on pathology. Doctors will soon be able to consult colleagues across the country, allowing them to compare notes and share information.
Sepsis and other clinical alerts are getting better each day and will continue to do so as we amass enough data and experience to refine them. They will become coal mine canaries and not just causes of alert fatigue.
Including patient phenotypic information, genomics, social determinants of health, etc., in treatment plans will soon be the standard of care—something impossible to deliver without EMRs integrated with terabytes of information at the physician’s fingertips and by the patient’s bedside.
The EMR/EHR is Not the Enemy
We take for granted now that we no longer have to hunt for film x-rays and CT scans, fight over the same paper chart (if it can even be found), squint to decipher a colleague’s illegible handwriting, or hunt for prescription pads to discharge a patient.
It’s easy to throw slings and arrows at EMRs that seemingly force so many clicks to meet billing and regulatory requirements. As noted above, they do so only because we required them to. But taking the long view, it is remarkable to see how far we’ve come since the American Recovery and Reinvestment Act of 2009, which included the HITECH Act that encouraged adoption of EMRs and “Meaningful Use.”
Where would we be if we didn’t have electronic systems in place to enable telemedicine visits, asynchronous consults, tracking of vaccinations, and the ability to build in complex clinical decision support for COVID treatments and the diagnosis and treatment of such clinical puzzles as multisystem inflammatory syndrome in children (MIS-C)? Even today, what would we do if we didn’t have so much of the healthcare data digitized to measure length of stay, adherence to protocols, track supply chain needs, and calculate our cost of care so we can improve our quality and outcomes?
EMRs are critical to helping us meet the financial pressures that hospitals face across the nation. Even the frequent drug shortages are problems that we are better equipped to face because we have digitized our healthcare systems.
Data is Not Information
One of the wonderful things about having electronic medical records is that we have accumulated a vast cosmos of data. We only need to make sense of it all. Digitization of data has been successful, but often overlooked is that data by itself is not information. A byproduct of having so many cooks in the kitchen is the data is often very dirty. Notes are copied and pasted or copied forward so that they reach 10–12 pages in length, under the presumption by most physicians that “the longer the note, the better” for billing (and increasing the case mix indices).
Doctors jaded by the many click boxes for physical exams and review systems and other “hoops” for billing have learned not to take their notes seriously—at least not as seriously as when they were handwritten and the only means to memorialize diagnoses, therapies, and orders.
Today, we have a generation of younger doctors who have never handwritten an H&P, progress note, or even prescription. Trainees may not even know what a succinct and well-written physician note looks like.
Much time and effort are needed to clean and curate EMR data for accurate use and AI. This calls for a physician who understands informatics as well as clinical medicine. That physician must also possess the passion and vision to devise the analytics for the CMO.
Technology Alone Isn’t the Answer
It’s easy to think technology can solve everything by itself, but technology needs to be paired with people. And those people need to be open to change. There also need to be supporting processes that allow adoption and improvements.
The experienced CMO (and CMIO) knows that technology often is only a small part of the process; user workflows need to be changed, adapted, or even blown up to take full advantage of new innovative technologies. That is the only way to improve patient care. Critical to success are early adopters willing to change their habits and adopt new workflows to improve care. When others see their peers getting good results, they will be willing to follow suit.
Perhaps the biggest challenge today is that everyone is already stressed and overstretched; changing workflows and tools are not easy asks. Ironically, we usually need to impose upon them. A temporary sacrifice of time and an expenditure of effort are the tradeoffs for a workflow that can actually save them time and make patient care more efficient.
Don’t Sweat the Small Stuff—but Sweat the Small Stuff
You can’t please everyone all the time, or even most of the time; even a modest upgrade to the EMR can be quite a challenge for a portion of your medical staff. Muscle memory is not to be underestimated, and moving a button even a few centimeters to one side can cause a lot of distress.
At the same time, you can’t hold up innovation and improvement of systems because you are afraid to change the status quo. Technology is the one field where change is constant. Sometimes to the front-line physicians it feels like it’s just change for the sake of change. However, well-designed upgrades typically impose modest inconveniences while setting the stage for more dramatic improvements and new functionality that will ultimately make your physicians more efficient.
One way to help physicians is to regularly offer refresher and advanced training, ideally offering protected or compensated time to do so. If not possible, offering benefits like CME can go a long way so it is not viewed as wasted or sacrificial time.
Even then, the physicians who need the training and optimization opportunities the most are often the ones who are most reluctant to spend extra time. This is because they feel they already spend too much time in front of the computer. Where possible, “at the elbow support” staff can help with real-time training. These staff members are worth their weight in gold.
Partner With Technology and Informatics Colleagues (Whenever Possible)
It’s not realistic for a busy CMO to be the primary executive identifying technology solutions, or personally diving into EMR data. Keeping up with ever-changing and advancing technology trends and solutions can be a full-time job, and even for seasoned IT leaders it is challenging to sort through the sales noise and hype.
However, the CMO can highlight the clinical and operational challenges that require attention. The CMO also knows where data and analytics can be deployed to meet institutional and clinical priorities. Partnering with trusted colleagues such as a Chief Information Officer can be game-changing.
Appointing a physician leader adept in information technology and clinical medicine to serve as an IT medical director, chief innovation officer, or chief medical information officer will pay dividends. The right partner(s) can catalyze changes and focus resources on the right technology tools, and help with the design, buy-in, and implementation.
Depending on the size of your organization and resources available, partnering with a forward-thinking and collaborative CIO is the ideal dynamic. The CMO can best identify, articulate, and prioritize the clinical and operational challenges and problems that need to be tackled. The CIO can perform the landscape survey to determine the best possible tools and solutions. Together, the CMO and CIO can deeply evaluate potential solutions and ultimately select one.
The CMIO role came into being during the rush of activity to implement EMRs. CMIOs typically were chosen to be the EMR champions and cheerleaders to persuade skeptical colleagues. Hearing another physician extol the advantages of EMRs helped generate buy-in. CMIOs identified design problems or were given feedback that they then took back to IT analysts for improvement. Successful CMIOs have a good blend of EQ and IQ.
Over time, many CMIOs became responsible for training curriculums and resources. Others evolved to become CHIOs with oversight of analytics, clinical decision support, or large EMR application teams. Having a physician with an in-depth understanding of both the clinical and informatics worlds can be extremely helpful for CMOs.
It bears repeating: Data is not information. We need people who understand the source of the data, how to clean and curate it, and how to analyze it and make it meaningful. Digitization of medicine came much later than other fields. That is understandable as healthcare is more complex than finance or sports. A physician who understands how to make data information and the power it holds can ensure no time or effort is wasted on bad data.