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?
You’ve absolutely identified what the issue is. And that’s changed over the years; the younger physicians, people who have come out of medical school recently, are more used to collaborating with other physicians and with other clinicians on the team, not so much anymore as lone wolves making all the decisions alone. Physicians are very competitive; you can use that in this context. And one of the things that’s been found to be very useful is to show people how they’ve been performing compared to their peers. And if you show somebody that they’re an outlier and not doing as well as their colleagues along some measure, in the end, those things have generally found to be very effective. So you can use that competitive nature to help move people forward in these areas.
Is it harder to create cultural change among specialists than among primary care physicians?
I think the specialists tend to view themselves as being in an almost unique environment. My patients are different form anyone else, my practice is different from anyone else’s. Many specialists have that attitude, but in many cases, they are also the most data-driven and evidence-driven, and if you can show them good data and evidence, they’ll come around. And there are some fundamental human factors—if you can get someone to think that it’s their idea, they’ll be far more enthusiastic about it.
How difficult is it to move everyone towards standardized practices? Many years ago, physicians in practice really did practice as though they were lone wolves for the most part.
In a lot of areas, it hasn’t been that difficult; but there have been certain areas where it has been. The physicians have to feel they’re creating the process, and they’re buying into it. When I said, identify stakeholders and experts-this goes to your Geisinger story—you have to identify the physicians whom other physicians will listen to—and that’s not always people in official roles like department chair; it’s natural leaders. And ultimately, this is a retail exercise. For every one of these clinical scenarios, whether pregnancy testing, managing diabetes, whatever it might be, you’ve just got to get down in the dirt, and get into discussions with all the key stakeholders in that area, and work out what you’re going to do. You can’t do it wholesale. But if you have enough of those retail discussions, it changes the culture. I’m not just going to close the door to the exam room.
How optimistic or pessimistic are you in terms of the shift taking place in U.S. healthcare system overall, in terms of moving towards mapping out processes and moving into continuous clinical performance improvement?
I’m actually fairly optimistic. I’ve seen things change a lot. I graduated from medical school in 1985, and I remember the first time in the early 1990s when someone came into a committee meeting and talked about W. Edwards Deming, and I was one of those who thought he was nuts. He was right; he was just ahead of his time. So I’ve seen things change where that sort of thinking was completely rejected; now, the thinking is accepted; how we apply it on a daily basis still has a ways to go. But people are more accepting in terms of thinking about how to apply this to best practices.
Do you have any advice or thoughts to share with CIOs and CMIOs in patient care organizations?
I think that the environment has gotten a lot more favorable in terms physicians being more receptive to working on a team, working as part of a system, and in essence, getting used to the idea that you’re not just alone in a room doing whatever you want. I think that physicians are more receptive to seeing that you can use evidence and data to follow it to best practices.
I think there is a perception on the part of a lot of physicians—and whether this is reality or not depends on the institution—but there’s a perception that a lot of the information technology isn’t really there to serve them and to serve patients, but that they’re there to serve the technology. And there is some truth to that in some places. It would be good for CIOs and CMIOs to be aware of that and to recognize that to the extent that that perception is based in reality, to try to do something about that. I think a lot of physicians do have some pretty good points about technology not serving them at the moment.
Do you think that EHRs are going to get better overall, in the coming months and years?
That’s a loaded question. I think they will. I think the real question is going to be, will progress be just little incremental steps, or will there be a transformational leap that makes things a lot easier? I think a couple of ways we’re hampered—the interface; keyboard-mouse-point-and-click is probably not the most efficient interface. Also, EHRs tend to be one-size-fits-all across different specialties. What I need as an anesthesiologist is very different from what a PCP needs in a clinic, from what an emergency physician needs in the ED, etc.—we almost need different front ends, and maybe even different back ends. So there’s room for improvement.
Is there anything you’d like to add?
This might be preaching to the choir, but I’d make the pitch that there’s a crucial role for people with informatics skill sets, who are clinicians first, and understand the clinical world, but have enough of an understanding of the IT that they can translate and interpret between clinicians and IT.
I’ve often said that clinical informaticists are almost like UN interpreters, when they sit in meetings with pure clinician leaders and with pure IT leaders. Would you agree?
Yes, I absolutely would; that’s a very good analogy.