At CHI Franciscan Health, an integrated health system based in Tacoma, Wash., that encompasses nine acute-care hospitals and 600 employed physicians in about 60 clinic locations (among a total medical staff of around 2,000), Dean Field, M.D., vice president for informatics and operations, and the organization’s de facto CMIO (no one at the organization carries that precise title), has been leading a variety of change initiatives there. He has been in his current position for four years, with one year under his current title. Prior to that, he had served as the health system’s medical director of ambulatory informatics on the outpatient side, and medical director of clinical informatics, on the inpatient side. Field practiced as a family physician for over 20 years.
Following his participation on a discussion panel entitled “Analytics: Integration, Standards, and Workflow,” which was presented Aug. 18 during the Health IT Summit in Seattle, Field spoke not long afterwards with HCI Editor-in-Chief Mark Hagland, about advances being made at CHI Franciscan Health. Below are excerpts from that interview.
Tell us about some of the clinical informatics work you and your colleagues have been doing at CHI Franciscan.
What we’ve done at CHI here in Tacoma is that we look at the EHR [electronic health record] as the leverage to create change, whether using it as a tool to promote consistency and practice transformation across our clinics, or with regard to how we can use it for population health management across our system. The advantage we have is that we’re a fairly large system in a concentrated area. We have nine hospitals in five counties; so it’s fairly compact.
Dean Field, M.D.
Even though you have the title “vice president for informatics and operations,” you are in effect the CMIO at CHI Franciscan, correct?
Yes, essentially. CHI nationally, we’re a very large organization, and locally, no one has CMIOs; we have application-based CMIOs. We have a CMIO responsible for Epic for four states. I’m responsible in the local market.
And how long have you been with CHI Franciscan altogether?
For 15 years. For 10 years prior to that, I was with Samaritan Health, now called Banner Health, in Phoenix.
How would you describe your organization’s journey around clinical informatics, clinical transformation, and population health?
Like many organizations, we’re an organization that’s been growing by affiliation. And you’re bringing together hospitals and medical clinics that had their own direction, their own way of doing things. So developing an electronic platform created that burning platform to really transform the organization, so that we could create more consistency, and more standards in how we did things. Historically, how physicians documented in their EHR didn’t really impact others, but now it’s clear to everyone that ordering, documentation, sharing clinical data, all of those needed to be standardized. And CPOE [computerized physician order entry] and order sets and reporting and structure of documentation, those were areas we began to focus on. Now, two or three years into the journey, we’re beginning to focus more on workflow and assignment of work, and more at the bedside level.
What are the challenges you’ve been dealing with, the obstacles, as you begin to address the mechanics of clinical workflow?
Everybody is doing what works for them. And that means that anytime you’re looking to change workflow, there’s a transition trauma, and whatever changes you make have to add some value. Because whatever a person or care team are doing, is a process that they believe is working for them. And you’re disrupting their workflow, and when you disrupt their workflow they become impatient, and they might be embarrassed in front of patients or peers, so you really have to have a good reason for making any changes.
Right now, we’re in the midst of working through our documentations standards, and we’re trying to come at that work from two angles. First, we want to make sure we tell the appropriate clinical story; we want to have good warm handoffs; we want to have some standardization around styling and vocabulary. So if we say a patient has stage-two kidney disease, for example, we want to make sure anyone touching that patient will understand what that means. And clear documentation improves case mix index, improves CDI and reimbursement, but none of those things add value for the physician per se, so we want to make sure that there’s a compelling reason for the physicians to go through that transition.
Second, the other part of that journey is that there is a real realization that our patients, our customers, are expecting more transparency. Cleveland Clinic is doing it, and Providence Health has announced it’s doing it this year, and we want to go to open notes and documentation transparency, but first, you need a style guide; and the sooner you work on the foundation of the not structure and the architecture—a patient doesn’t want to see a cardiologist from the organization, and see five different styles of notes.
EHRs are making the inconsistency of physician documentation patterns clearer, correct?