On Thursday, June 14, at the Health IT Summit in Minneapolis, sponsored by Healthcare Informatics, Karl Poterack, M.D., delivered a presentation on “The Role of Clinical Informatics in Practice and EHR Convergence.” Dr. Poterack, who is based at Mayo headquarters in Rochester, Minnesota, is a practicing anesthesiologist and the medical director of applied clinical informatics at the Mayo Clinic organization, based in the headquarters office of that patient care organization, in Rochester, Minnesota.
Following up on the presentation by Cris Ross, Mayo’s CIO, the day before, Dr. Poterack noted, speaking of the unified electronic health record currently being implemented at Mayo, that, “One of the things we were really doing with implementing a new EHR is using it as tool to drive workflow and practice innovation, and to get everybody on the same page to drive best practice. I’m an anesthesiologist and board-certified informatician. I still practice anesthesia,” he added.
“I’m going to identify some of the issues involved clinical practice and workflow convergence,” Poterack told his audience. “And I’ll connect those issues to core informatics content, and issues around EHR practice convergence.”
Going on, Poterack said, “We are an academic, physician-led, multispecialty group practice, non-profit. Once upon a time, we were almost unique in being an entity where the bottom line of the physician group practice was the same as the bottom line for the hospital. Once upon a time, that was almost a unique situation; now that’s not so unusual. And there is an extent to which it makes it a little bit easier to undertake some changes. It’s not easy to make change, but easier than it was,” he said. He noted the size of the Mayo organization, which encompasses 20 hospitals in five states, including three “destination medical centers,” in Rochester, Phoenix, and Jacksonville, as well as what is called the “Mayo Health System,” which encompasses six community hospitals, and 11 critical access hospitals. Altogether, the Mayo Clinic organization encompasses about 2,900 staffed beds, 76,000 employees, and 1.3 million clinic visits, 130,000 hospital admissions, and over $11 billion gross revenue every year.
With regard to how information technology can be used to help drive the standardization of clinical practice, Poterack provided his audience with a few examples. “For example,” he said, “there have been major differences in anesthesia practice between Minnesota and Arizona. In Arizona, if you were a pre-menopausal woman undergoing anesthesia, you routinely underwent a pregnancy test first, since the risk to a fetus is high. But that rarely happened in Rochester. The reality,” he said, “is that there were hundreds, maybe thousands, of examples like that, where the workflows and clinical practices were different. And we wanted to leverage our EHR to drive uniformity in practice.”
Further, he said, “We didn’t want geography to determine the care practices you experienced. And even though there is one Mayo culture, there are subcultures in Jacksonville and Phoenix; and that includes differences in resources. For example, Rochester has big residency programs. It would be unheard of for a physician in a Rochester to round on a big inpatient service all by him or herself. In Jacksonville and Phoenix, it’s very common. But in the health system, a physician doesn’t have that kind of help. So there are some real resource differences. And every time you consider a change, there’s, the ‘We couldn’t possibly do it that way’ response. And sometimes, that means, we don’t want to do it that way.”
Poterack cited two process “laws”: Hofstadter’s Law, which says that “It always takes longer than you expect, even when you take into account Hofstadter’s Law”; and Sayre’s Law, which says that, “In any dispute, the intensity of feeling is inversely proportional to the value of the issues at stake.” With regard to Sayre’s law, Poterack qualified his comment somewhat, saying that, “While we’ve had some very contentious debates over things that don’t matter, we’ve also had some contentious debates over things that did matter.”
The six core lessons learned, he said, are the following: “Identify the stakeholders and those with expertise; get them all in a room; be careful of the loudest voice in the room; look to science and best practices; have a set of principles to help you say ‘no’; keep your eyes on the prize—keep goals and limits in sight, and focus on timeline, scope, goals, and resources” in moving forward with any initiative. “You’ll have to say no to a lot of people,” he said. “So to the greatest extent possible, you’ve got to have a set of principles to guide you” in moving forward towards any broad goals.
Karl Poterack, M.D.
Following his presentation, Dr. Poterack sat down with Healthcare Informatics Editor-in-Chief Mark Hagland. Below are excerpts from that interview.
You’ve just shared great examples of some of the challenges around creating a unified clinical practice culture in the Mayo organization. Having covered healthcare for nearly three decades, I’ve seen a massive change in the physician culture in the U.S. overall. And one element in that change has been the shift away from ‘lone-wolf’ medical practice, and towards multidisciplinary team-based, transparent, accountable practice. How are your efforts fitting into that context?