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December 2007 Volume 31 No. 11

On Self-Governance and Epic, too

"If absolute power corrupts absolutely", does absolute powerlessness make you pure? — Adlai Stevenson

Let’s hope not, because the results are in on the recent bylaws balloting, and the good news is that we have, by a large margin, ratified an elected chief of staff, who will also represent the Medical Staff on the SHC Board of Directors as a full voting member. [See Vote]. These are the most significant changes in medical staff governance in our history, and they put us in a much better position to influence decisions regarding the issues that matter most to us: that is, anything having to do with the quality of care our patients receive here (including those Hospital functions which support the efforts of the physicians caring for those patients).

This has been a major goal, but now that the fundamental governance changes have been accomplished, it’s time to actually govern. And that’s the somewhat less good news: more elections. We have another set of bylaws revisions coming up, as well as the election for Chief of Staff.

The first elected Chief of Staff will be a critical choice, as the first term will go a long way toward defining the actual scope of the office and the nature of the “medical staff voice” in hospital governance. (If you’re interested, step forward.) Please vote, and please consider your vote carefully.

In my view, it is crucial that the first elected Chief be someone who, while able to work productively with other medical center leaders, has both the will and the ability to express the medical staff’s perspective — even on those (uncommon) occasions when it may differ significantly from the positions of those other leaders. (This unfortunately has been an issue in our recent history.) Remember, Hospital and School of Medicine leaders have a great deal of power and influence in this medical center, and rightly so. But the Medical Staff Organization is the one place where the democratic voice of bedside clinicians should be paramount, and it is vital that we establish this as an independent voice.

And Epic, too

You may not have asked for it, and given our history with the original CPOE (computerized physician order entry), Carecast, and other IT installations, you may quite reasonably fear and loathe it, but Epic is coming nevertheless. This decision was made long ago, but while I share many of the concerns I’ve heard from medical staff members, I do think it was the right decision. Regardless, at this point we simply must join together to make this work.

Success is not a given — many EHR (electronic health record) implementations have tanked — but failure would be a real disaster for this institution. Here is why I think the decision was correct, why I think Epic should turn out better than our previous IT experiences, and a few things we can all do to improve the implementation process:

First, EHRs are coming worldwide, and resistance is truly futile. Virtually all of the major quality organizations are strongly in favor, governments are mandating them, and large businesses and medical payors are pushing hard. The only question, in my view, is the timing. Couldn’t we wait a while and let others work out the bugs with this thing? But the truth is that we’re not really an early adopter — many large healthcare institutions are already using EHRs and most of the rest are planning their own installations. The technology isn’t perfect yet by any means, but neither is it a beta version.

The status quo isn’t so pretty either. If there are any of you out there who will miss Carecast, please raise your hands... I thought not. Right now we have a god-awful amalgam of multiple IT systems that can’t talk to each other and sometimes work to fragment, rather than integrate, our care processes. So another good reason it was decided not to wait was that we couldn’t really tolerate the current system any longer.

What about the choice of Epic vs. other systems? Here I must defer to the selection process, which was long and thorough, informed by appropriate input from the Medical Staff, and resulted in a virtually unanimous decision to go with Epic. In fact, many of those who did the research refused to even name a second choice, since they were so impressed by Epic.

Skeptics should keep an open mind; we may find that we actually like using an EHR! In October, I visited Swedish Hospital in Seattle, along with Kevin Tabb and a few medical staff leaders, to see what we might learn about their recent Epic installation. [See related discussion]. As our colleague Topher Sharp points out, our Seattle colleagues noted some difficulties and frustrations, but the overall feeling there was quite positive, and none of the clinicians or nurses we spoke with would prefer going back to the old system.

So why should the Epic implementation work better than our previous IT experiences? There’s no guarantee, of course, but the main difference is a huge investment in a high quality system and adequate preparation. We are implementing what is widely acknowledged as a “high end” EHR system. We have a large team that has been working for some time on preparation — examining and revising clinical processes and flows, getting continual input from those who will be using the system, training “super-users,” working on hospital IT interfaces, and so on. If this implementation has its problems (and of course it will), it’s not for lack of effort.

What can we do to improve our chances of a successful implementation? First, please be as proactive as possible in signing up for training and completing the internet portion. If you haven’t signed up by the time you read this, please drop everything and sign up right now! Go to: http://sumlms.stanford med.org/sumtotal. If you have any problems, use the available support. [See Epic Q&A for details]

Most importantly, please be patient. There are always going to be snags, hitches and minor disasters in a project of this magnitude. Productivity will suffer in the short run. I can pretty much guarantee that every clinician in the hospital is likely to be extremely frustrated with some aspect of this transformation at some point along the way. If we can avoid, or at least delay, the tendency to extrapolate from each individual crisis to the conclusion that the whole system is doomed to failure, we may with good faith on everyone’s part be able to get through this. I assure you that Kevin Tabb, our physician chief medical information officer, and his team will do their best to address any problems and issues which arise. And I will continue to advocate for the medical staff, in part by encouraging maximal investment in support personnel who are easily reached, prompt, reliable and pleasant.

As always, if you have any suggestions, concerns, or comments, I am available at bbohman@stanfordmed.org; Stanford pager 10166, and office (650) 323-0617. Don’t hesitate to contact me.