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A Team Approach

August 1, 2007
by Suresh Gunasekaran
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Rather than being the responsibility of one individual, EMR governance takes a village

Suresh Gunasekaran

Suresh Gunasekaran


his article is the second in a series detailing the journey to implement an electronic medical record (EMR) at UT Southwestern Medical Center University Hospitals in Dallas. The first article appeared in the July edition of HCI.

At UT Southwestern University Hospitals, we are continuing EMR planning activities as we go through the process of contract finalization. We are focused on the staffing of our internal IT and operational teams. Recruitment work is under way on all fronts: information systems, nursing as well as pharmacy. Most notably, we are recruiting for a dynamic clinical IT manager to lead our EMR initiative (no one is immune to untimely resignations).

During this planning period, we are establishing a new governance structure to drive the development of an effective EMR system and associated care model that will meet the objectives sset forth when we began this project. Much in the industry has been written about effective governance models for information technology; we've taken some of the advice, but we've decided to forge our own path as well.

Traditional approaches lacking

Most traditional IT governance models are designed with a primary focus on making a decision, and making a decision that will stick.

The model usually has two layers (there can be more, but they follow this general pattern). One layer is an interdisciplinary team with operational knowledge that will make most of the system and process recommendations for the project. There is a layer above this group that includes the most important people that will referee the lower group when they can't make a decision, and will serve as an enforcer if decisions aren't adhered to.

The appeal of this model is not surprising, given the most common frustration of any CIO is usually, "If the operational folks would just make up their mind, I could get the job done." There are also numerous horror stories from around the industry of EMR projects running off-track as clinicians either took too long to make system design decisions or constantly revisited decisions causing significant cost and time overruns.

As a matter of fact, we've used the traditional model at UT Southwestern for many years, but there have been some major drawbacks:

  1. Primary Focus is On Communication. Usually the IT department spends the most time presenting what work is being done and what work is upcoming. This leaves most non-IT members of the committee with the feeling that IT is driving most of the decisions.

  2. IT and the Vendor Drive the Agenda. The committee agenda is driven by the needs of the IT build alone. There is typically a portion of the agenda devoted to decisions that the IT team needs to move forward on the implementation. Unfortunately, this leaves the governance group feeling disjointed as they have input into certain things and not input into others. The group is not clear on what they really are "in charge of."

  3. No Roadmap. There is typically no roadmap of the beginning, middle and end of the project with key responsibilities of the committee at all junctures. There is always reporting on progress of the project plan, but rarely is there a shared understanding of where we are and what we need to get completed to go-live with the project.

The path ahead

In an attempt to avoid these traditional pitfalls, we are forging a new trail in the area of IT governance at UT Southwestern. Our governance committee structures will stay the same. However, we will change the mission of each of the governance groups and charter each group much differently than we have in the past. We will also run these committees much differently. Major changes include:

  1. Make the Entire Operational Group the EMR Experts. We will provide an orientation to the committee members on the EMR implementation plan so that the entire group understands the steps involved in implementation. This orientation will be focused at the appropriate level of detail so that non-IT leaders can understand the major steps involved.

  2. Divide the Project Plan Into Pieces and Give Oversight Responsibility to Individual Committee Members. We are driving committee accountability by making every major section of the project plan accountable to a non-IT leader (in partnership with IT) so that they may drive the decision making and performance monitoring for their portion of the project plan. They will also be expected to report status as necessary in committee meetings.

  3. The Agenda Is Driven By the Whole Committee. Every other steering committee is dominated by status presentations by different committee members. The updates will largely focus on discussion items related to work in progress. Alternating steering committees will be driven by our clinical quality team that will present best practices in EMR usage and care models to keep the group focused on developing the best possible design.

  4. The Executive Committee Will be Focused on Change Management and Financial Management. The executive committee will be focused on monitoring and guiding the major clinical and operational changes driven by the project. They will assist in championing key initiatives and assist in removing organizational change barriers. The group will also be educated on the major cost components of the project so that they have an understanding of financial commitment at any given time relative to project progress.

EMR governance is more than oversight of the IT department's implementation of EMR software. Implemented appropriately, the governance groups become the fulcrum for innovation, and home to the change agents. Building consensus and making timely decisions remain important, but we believe we can bring the organization together around the necessary decisions through this new model. We believe that through this model the village can actually raise the child and not just watch her grow up.

Suresh Gunasekaran is assistant vice president and CIO, University Hospitals & Clinics, UT Southwestern Medical Center, Dallas

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