The Power of Plugged-In Physicians

Hospital and health system senior executives are continually searching for ways to engage their physician staff. Some are doing it through an employment strategy. Some are creating a variety of economic incentives for physicians to help them achieve the goal of fewer readmissions, meet quality targets, and agree on treatment protocols that fit evidence on cost and quality. They're working to educate physicians on the downstream effects of their decisions on the entire organization.

Those are all valid and important initiatives to attempt in an industry hungry for transparency, cost control, and better quality. But to hear many CEOs speak, it's a tricky business to encourage physician engagement, and they search for the right combination of incentives to get the job done. They fail at their career peril.

I have found that most execs have trouble defining what exactly physician engagement or alignment really looks like.

Here's an idea: try to make it simple. By that I mean look for ways to empower physicians to change their own work patterns to make them more efficient both in time and cost. If you can engender that kind of work environment, the rest has a way of sorting itself out. The majority of successful physician engagement initiatives I've seen seem to share one quality: the absence of micromanagement. The executives are there to articulate goals, get the physicians the tools they say they need to accomplish those goals, and get out of the way.

One good example I recently discovered was through a conversation with Greg Tipsword, the healthcare provider practice lead for West Monroe Partners in Chicago. I interviewed Greg for a story in an upcoming issue of HealthLeaders magazine about identifying—and using—the right data to help make life- and cash-saving interventions. He tipped me off to the work of two physician engineers (my term, not theirs) at Mayo Clinic in Rochester, Minn.

Executives are looking to increase the value of healthcare delivery, Tipsword says, meaning delivering a good outcome at a sustainable cost.

And you can't figure out costs and cut down on unnecessary work without efficient flow and tracking of patient data across the various enterprises that make up the agglomeration of healthcare services in a modern health system.

"There's data everywhere, and people everywhere are trying to make sense of it, but they're doing so in their own little world," he says. "They're not working toward a common enterprise goal."

Those fragmented data fiefdoms, as any executive knows, have an insidious role in high costs, unnecessary care, and poor quality. I use the word insidious because their influence is not immediately apparent because of outcome lag. Perhaps the problem seems so big, ingrained, and unmanageable that most executives don't know where to start to address it.

At Mayo, the best place to try to build the information stream was the emergency room.

Vernon Smith, MD, with some help from Tipsword and the Mayo Clinic's Center for Innovation, developed a system of sharing data that is powerful in its simplicity. Smith, who has self-described passion for computing and medicine, is one of the chief architects behind the system of 21-inch TV monitors at St. Mary's Hospital, a 1,265-bed hospital that is part of the Mayo system. The monitors aggregate a huge amount of data on patients currently in the hospital. Though developed in the ED, the system is now used throughout St. Mary's units and is being introduced at Mayo facilities elsewhere.

Called the "YES Board" (see the attached image) it contains a mind-boggling amount of information. Colorful icons tell a variety of caregivers the current state of individual patients. The best part: most of the data has been requested directly by physicians and nurses so that they know what has gone on with their patient since arrival, and they know it at a glance.

"There must be hundreds of data sources to pull data from any one point in time," Smith says. "The way we're handling that is by pulling all the data into one spot, and packaging it in such a way that the providers can see the information immediately."

It was not an overnight solution, by any stretch.

Around 2007, when Mayo first deployed the software that powers the monitors, all it monitored was the number of patients in the waiting area and which patients were in each room, says Andy Boggust, MD, who worked in partnership with Smith to expand the system's capabilities.

Neither was particularly enthusiastic about the new system to begin with. "We didn't have all the other clinical data," Boggust says. Smith adds a parallel about technology: "As I look back on all the times I've been told we're going to upgrade our EMR, I have never looked forward to it. It usually meant more work on my part not just as an IT person but as a clinician. The feeling was that it would make my life more difficult."

But a funny thing happened with the YES Board: Physicians started asking for more information.

"We were finding each person knew what they were waiting for [to move a patient to the next step in treatment], but nobody else did," says Smith. "We would come back around and find the patient still there and find that some step got missed. Now we make that very obvious to everyone."

The YES Board, with all its icons reminiscent of cave drawings, makes patient information transparent, and effectively allows team members in the ER, and now elsewhere in the hospital, to back-check each other.

"These [care] processes are becoming so complex, with so many people involved, it's really important that you make sure all the players are aware of what's going on as quick as you can," says Boggust. "If someone's waiting for someone else to complete a step and we make the patient spend an extra hour in the department, it doesn't affect the care, but it does affect the bottom line because that's an hour of bed time."

That's the out-of-the-silo thinking that most executives are trying to encourage among their clinical staff.

Ok, so the YES Board is beautiful in its simplicity, allows multiple caregivers to access data that was once trapped in silos, and makes for more efficient patient care—but many systems can do that in theory. What works in practice is that suggestions for addition of data are acted upon by Smith, and they're acted upon quickly. Physicians, nurses, and other care team members tread a path to his office when they discover another piece of data that might be helpful to see on the monitors.

"Far be it from me to tell them they don't need it or ask why they want it. My job is to figure out how to get it on there," says Smith. "They actually see the product of what they asked for. What so often happens with many of these systems is that whatever change you want to make was unlikely to be done, but even if it was, it would be on a glacially paced timeframe."

Slowness breeds apathy, or worse, workarounds.

"What happens to end-users is they stop asking for things because it's pointless. It's not going to change. Their whole attitude changes from 'How can I make it better' to 'How can I work around it,'" Smith says. "Systems bypassed can turn into really bad outcomes later."

The fastest he's acted on information requests is 10 minutes, although Smith acknowledges that it took several months to get the right combination of real-time data to indicate whether a patient is in danger of sepsis.

"One thing we're taking advantage of is that since we are computer engineers, we know what it takes to pull that data. Others don't. To them it's some sort of black magic," Smith says. "Meanwhile, what really helps is when you walk in and can show them, 'Here it is. I did this last night.'"

As different as the YES Board is from five years ago, says Smith, "it won't look this way next week," because the data physicians request is constantly being tweaked to make it better, more intuitive, and more quickly processed.

"As much data as you see on here," says Smith, "I've never seen a request to remove data."

And I've never heard a better argument for asking your physicians what they need to achieve the organization's goals, making sure they have the tools and expertise to get it, and then getting out of the way.