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Perspectives

The Buck Stops Here

How a no-holds-barred approach to standardization transformed IU Health.

Dr. Seung Park, Senior Vice President and Chief Health Information Officer, Indiana University Health

9/19/2018

People experience value in different ways.

In a hospital setting, each member of the care team and each member of the C-suite are driven by a different set of values. While each of these values tends to be largely congruent with each other, there is no singular definition — and that's where, according to Dr. Seung Park, the senior vice president and chief health information officer (CHIO) at Indiana University Health (IU Health), most people get it wrong.

In 2017, IU Health ranked near the bottom on performance metrics compared to other systems on Cerner's platform. Just one year later, it ranks near the average. How was such a transformation achieved? If you ask Park, he'll tell you: You speak to each and every value presented by the collective members of your organization and execute — with boldness and compassion — on true end-user needs, not on the end-user wants that are represented as needs.

"There are ways to make sure that the spirit of those values — as long as they are good values — are honored," he said. "We have done exactly that in an environment where we're increasing our experiments, service lines and the volume of patients who are being seen."

A turnaround for better performance

IU Health, formerly known as Clarian Health Partners, is a nonprofit health care system with a 14-year history as a Cerner client. It's also Indiana's largest health care system, with 18 facilities and almost 33,000 employees.

When Park joined IU Health in May 2017, he recognized what the organization's pain points were.

"The reasons for our low performance ranking were obvious," he said. "If there was something that could be customized, we had done it."

According to Park, at IU Health thanks to an overly customized electronic health record (EHR), the numbers weren't reflecting the type of performance he needed to see. The average transaction response time (ATRT) was a maximum of 0.72 seconds, and the percentage of transactions greater than five seconds — the most accurate physician satisfaction indicator — peaked at 1.7 percent, when the national average is 0.5 percent. IU Health also had 10 times more alerts than the national average, according to Park.

"We immediately instituted a moratorium on any EHR modifications that were not emergency changes," said Park. "That was a huge cultural shift for IU Health."

Today, the percentage of transactions less than or equal to two seconds sits at 95 percent (up from last year's 89 percent). Transactions greater than five seconds are at the national average. All these changes and more have come as a result of the organization's decision to stringently adopt Cerner Model Experience in every aspect of the EHR. This meant developing the governance structure and tools necessary to succeed with such a strategy.

"As the CHIO, it is my responsibility to make sure our system is designed well," Park said.

A model culture

How did Park do it? He sums it up this way:

"To customize the build for one person slows it down for everybody else, and we will do what is best for everyone, not just a handful of individuals."

Park found that IU Health had completely customized the standard inpatient nursing solution. One of his earliest interventions was to revert to Cerner Model Experience for the solution, which promoted efficiency, driving the ATRT from 2.39 seconds to 0.40 seconds. When his team removed 90 percent of all the alerts that had ever existed in IU Health's system by volume and by raw number, they watched as the performance of the Discern Expert® timer went from a maximum of 0.30 seconds to 0.19 seconds. This change cut down the average transaction time of the system, allowing it to run faster. He then led a repeat of these efforts with the organization's Emergency Department solution. After a year of relentless iteration, the system build is either at or close to the national average on all performance metrics.

In his determination to modernize IU Health and update the technology clinicians were using, Park applied for and received funding from IU Health to adopt a build of the newest technologies Cerner had to offer. This meant replacing some platforms that clinicians had been familiar with. Park's conversion strategy has been to get physicians in a room through a Lean-organized event: He resists customizing the EHR for them and instead teaches them to use the new tools in the most efficient way possible, and he watches their adoption over time.

"We went from a system in which change control was impossible," Park said. "There were multiple committees, each of which had veto power over one another, but were very permissive. It was a system where physicians could call the help desk and get a change put into the EHR. We went to a system of very strict governance."

IU Health divides the governance of its system into three branches: clinical governance of clinicals (CC), with the chief medical officer at the top; technical governance of technical (TT), reporting to the chief information officer; and technical governance of clinicals or clinical governance of technical (TC), with the CHIO overseeing.

Park thinks of these governing bodies as parallel to the three basic things needed to operate a car. CC is the driver: It provides the direction, requirements and clinical content derived from the requirements, but does not do design or builds. TT is the engine: It handles implementation, information security and infrastructure. It is not over the requirements, the vision or design. TC is the transmission, and it is responsible for two things: design and education.

"If you don't have the driver, the car isn't going anywhere — you're driverless," Park said. "If you don't have an engine, your car isn't going anywhere, because it's powerless. If you don't have a transmission, then your clinicians are going to complain, but their signals aren't going to get through to the engine in a way the engine understands."

Formerly, IU Health had seven different councils. It could take months for a decision to be made on a suggested enhancement. This resulted in a lengthy queue that could mean a year's wait before the enhancement could be implemented.

Now, they have a single point of failure called the CHIO Council. Physicians can submit requests for specific functionality, but more often than not, the preference for strict adherence to supplier standards is maintained. This culture of standardization has set a new tone for IU Health.

"Ours is a culture of no, not a culture of yes," said Park. "That's the most important thing we did, because that has stuck."

From worst to not worst

How does Park's culture of IT governance translate to increased physician satisfaction with the EHR?

"You have to relentlessly show up," Park said passionately. "Always be in the trenches with your people, with the physicians. If you're a C-anything-O, you stay in the trenches and you figure it out. You evangelize standards, and you have courage about your convictions. If you don't, no one else will, and your EHR will suffer for it."

Since beginning the transformation process, IU Health's physician engagement scores have risen significantly. Physician satisfaction has risen, and the amount of time physicians spend documenting in the system has dropped, on average, to between two and five minutes, allowing more time for patient interaction. Physician adoption of Dynamic DocumentationTM has risen from 7 percent to 33 percent in the space of a single year. Physician burnout has dropped by over 10 percent (as measured on the Mayo Clinic Physician Burnout Index). The last time IU Health took a system upgrade, instead of having 20 to 30 open critical issues, they had five.

In early 2018, IU Health acquired and took live onto its EHR a small critical access hospital called Jay Hospital. There, Cerner Model standards were in place from the beginning — and today, Jay Hospital claims IU Health's most satisfied physicians.

"That is the capstone of this story," Park said. "This is not a story of from 'good' to'great' because we were never good. This is a story of 'worst' to 'not worst.' And I think people need"to hear that it is not impossible to go from customized to not customized, because if IU Health can do it, then anyone can do it."

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