John Maher: Hi. I'm John Maher. I'm here today with Janice McDonald, vice president of Community Hospital Advisors, which is a consulting firm dedicated to helping hospitals effectively install Paragon.
Janice is a physical therapist by training, and she became a community hospital chief information officer before coming to work for CHA. Today, we're talking about physician adoption in the McKesson Paragon Project. Welcome, Janice.
Janice McDonald: Hi, John.
John: Janice, we've previously talked about nurses and training nurses on the McKesson Paragon system. How do you get the doctors on board?
Janice: It's a really good question. It's become a really vital part of the McKesson Paragon Project and all IT projects with all of the government regulation changes in meaningful use, and all the things that are going on now. There's been a lot of burden placed on physicians for electronic order placement, electronic documentation. Again, we're changing their world, just like we're changing the world of all the caregivers out there.
We ended talking about training for nursing, which brought this subject up a while ago. I said this about the nurses. The physicians have to be engaged early. They need to understand what's going to change for them.
We need to understand that we don't just have doctors. We have emergency room doctors. We have hospitalists. We have internal medicine doctors. We have surgeons. We have doctors that are employed by our hospital doctors, that are just on staff at our hospital and private physician offices.
There's not just one audience here. It's a really broad range of physicians, and we have to meet their needs. In a sense, the doctors are both service providers to the hospital, but they're a major customer, too.
We have to make sure that we're engaging them early, because everything starts with the doctor. The doctor admits the patient to the hospital. The doctor writes the orders. Without the doctor, that patient is not at that hospital, and not getting care. If it's broken from the beginning, we're in big trouble.
John: Certain doctors, like emergency room physicians, they're at the hospital all the time. They're doing 24-hour shifts. Do they have an easier time adapting to a new system like this, because they get a chance to practice it more?
Janice: They may have an easier time with the learning curve, once you get things in, but honestly, the emergency room is one of the most challenging environments to try and get electronic ordering, electronic processing and everything in place, just because it is such a high-pressure dynamic. Everything's trauma. Everything's urgent. Everything's under pressure.
Very honestly, a lot of emergency room doctors are used to...one of the current practices is basically, almost all of their orders are verbal. They give verbal orders. Somebody else writes them down. Somebody else puts them into the computer. They're focused on the patient, and they sign everything later.
That is a workflow that's really having to change for emergency room doctors. There's requirements now. They're having to get into the computer right at the point of care, place the orders themselves, because the technology has changed, and now we have the clinical systems are actually giving alerts and guidance to the physicians as they go. They're giving them feedback. "You don't want to do that medication. The patient's allergic to that medication. Consider that they are also on this, this, and this."
There's all this clinical information, and it's now a two-way path, so again, the practice has changed so it really does compel the physician to be interactive with the computer so that they can get the benefit of all the information that's been accumulated on that patient. That's the power of the record, and if the physician's not interactive with it from the point of care, again, we've lost the benefit of all those allergies, all those home medications that somebody else documented.
All these things that have been accumulated on this patient, we've now got this feedback. We're changing the way it used to be done. It's just a big challenge to tell somebody, "Stop and do it differently." Specifically, emergency room physicians who, in a trauma situation, certainly they're not going to stop and go over to the computer. Some of those things won't change, but in day-to-day care, it's still hard to change the patterns of the way they do things.
We are being successful in emergency rooms, putting this whole workflow together with physicians being able to have pre-built order sets that work based on what's coming through the door, whether it's chest pain or stroke or whatever, because they know, and the care is actually very routine. That's the thing. You work with these docs, and you look over what they do, and you find that it's actually, they have the ways that they approach things, and it's pretty consistent from patient to patient. We can work with that, once we sit down with the docs and understand that. Again, engaging them early.
You're right, the emergency room is the one place where there's always a doctor in the emergency room, 24/7, but it's just as challenging with the surgeons and the way they provide care, the hospitalists and inpatient care. That's where we really have to look at how each of these different physician specialists, and what type of patients are they seeing, what's their demand for information, where is their information going to go, what information do they need back from the system immediately to help enhance the care they're providing from the patients.
John: How do you go about the training for doctors? Do you break them up into groups by what needs they have and then go about the training that way?
Janice: Actually, typically we start with...in a sense there's a few things that have to be created specifically for the physicians in the system. One of the McKesson Paragon products...there's a web portal called the "Physician WebStation," and that's where they go in and see the information. The web station isn't built, it's just the feed of all the information.
Then, physicians use basically two major things. They use what are called 'Order Sets' to do CPOE, which is Computerized Physician Order Entry, and a McKesson Paragon tool called, "Phys-Doc," or Physician Documentation, which is a way of doing electronic progress notes, histories and physicals, things like that. Those are the two parts of the system that really have to be built and customized to the needs of the specialty.
An intake note by an emergency room physician is not going to be the same as an intake note by a surgeon about to do surgery, or by an OB-GYN physician about to admit a mom into labor. So, again, depending, you really want to customize this to orders that they're going to place on the patients.
They are specific to the patient in front of them, and again, depending on what other care is being provided, they're going to place a different set of orders. Before you can even think about training, you do have to figure out right what are all of our different specialties that we're going to address. Usually we put together a committee of physicians, early on in the project so that they can work in an advisory role.
You're not going to ask your physicians to sit down and build screens or order sets, but they need to be reviewing the sets that you're building for them, early and often so that when we come to training down the line, there's been physician input all along, and we're not delivering a cookie cutter standard order set. We've actually thought about the OB-GYN workflow, the orthopedic surgeon workflow, the ED physician workflow, the hospitalist.
We've taken the staff that they used to use on paper or on their old system, and we've shaped it so that it works very smoothly in this new world. So that hopefully the physician training is much more about just the look and feel of the screens they have to touch than that we've changed everything in terms of what their ordering practices were, or how their documentation was structured.
John: We've talked before about the go-live, when the system gets put into place, do you find that the doctors have an easy time after all of this training when you do hit that go-live date?
Janice: I've been at go-lives where it went really well, and in go-lives where it went really horribly. Really, we saw that was based on how the training was done ahead of time. The medical staff is often very resistant to...and I understand this. You can't pull doctors away from patient care for four hours of training, eight hours of training. I've worked with a few hospitals who actually successfully did that. They had incredibly strong medical directors who were engaged and did the training themselves, I think I saw that at one hospital.
Usually you need to do the physician training in small pieces, but if you...the other things run back a little bit because it worked really well. If you can do a doctor-to-doctor training it's the most effective. Whenever we've worked at a hospital where we found physicians who were supported by the hospital financially or just engaged and excited about the project and willing to give some of their committee time, or other work time they would give to the hospital to do this. When physicians trained each other...just so much more successful, they just understood each other, and the training went really well.
Short of that, if you can do repeated training with physicians because they'll usually only be available to you for an hour or two hours max. Again, make that training very workflow-based. Let's run through a patient, let's practice, let's pretend we've got this patient in front of you. The mechanics are easy, you can show people screenshots, you can give them materials to take away, you can give them little power points that they can do on their own time.
Physicians really again...they want to feel confident, they don't want to look at all like they don't know what they're doing. You really have to give them the opportunity to practice in small doses, to come back and get support. I find that...more as we talked about nursing training it's highly structured, it's 16 hours, it's pulled out of patient care. We run through workflows.
It's really a different push with the physicians. It tends to be repeat, "Let's start with this. Let's start with this," and you build on it until you get them confidently going through OK. It's really a little bit more one-on-one, one-on-three. Big groups of physicians in a classroom is just not a recipe for success, as far as I've experienced. [laughs]
John: Right, because they're going to learn from the hands-on experience of getting into the system, and, "Let's try this on a patient and see how it goes," and then ask questions from there and learn from it.
Janice: Yep, and that tends to be...You've got it. They really just want to jump in and get their hands on it and try it. What I've found, overall, is the doctors are really, really excited to do that. They want to do that. They don't want to sit down in a classroom and be talked at for four hours. They want to get their hands on the system and start practicing what they're going to be doing.
We've been successful in structuring training that was in small pieces, that gave them take-aways, an hour at a time, started early, and kept them right up until the time of go-live. Then just having a lot of what we call "at the elbow" support.
If a doctor is working on the in stress, we want somebody right at their elbow. We don't want them on the phone waiting for a help desk line when they're trying to put in an order on a patient. At go-live, we like to really provide a lot of support, just circulating for those doctors, making sure they're not getting stuck, and they're not getting stuck on little things.
When they get stuck on a little thing, they get frustrated.They walk away, and then you've got to kind of dig back out of that hole, so we really like to make sure. It's like frequent hits, right up until the time of go-live, and then during go-live, we don't leave them alone. We almost follow them around [laughs] and make sure that they're really well supported. That tends to work really well.
The doctors just want to provide good care for their patients. They don't want to be stuck with technical glitches. They don't want to be feeling their way around. Most of them, if given the opportunity, are very, very willing to take the time, as long as we're respectful of their schedule and their needs, and not trying to force them into, again, sort of a didactic, "You've got to sit in a classroom for four to eight hours." It doesn't work for them. It's just too difficult in their day-to-day workflow.
Yeah, we've been successful that way, and it's a different approach than you take for your other employees. Physicians are not your average employees. As I said, everything starts with them, so if we have a strong, well-trained group of docs that have done peer-to-peer training, and they get it, it just makes go-live so much more successful and so much easier.
John: All right, great. Well, Janice MacDonald, thank you very much for speaking with me today.
Janice: OK. Thanks a lot, John.
John: For more information, you can visit the Community Hospital Advisors website at commhospital.com. That's C-O-M-M-hospital.com, or call 888-811-4687.
Photo credit: Yuya Tamai / Foter / CC BY