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Nursing Management:
doi: 10.1097/01.NUMA.0000387094.26058.81
Department: Information Technology

Clinical leaders and the adoption of health IT

Sugrue, Mark D. RN-BC

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Mark D. Sugrue is the chair of the Health Information Management Systems Society Nursing Informatics Task Force and co-chair of the Massachusetts Organization of Nurse Executives Information Technology subcommittee.

Enter the word "leadership" into any online search engine and you'll likely find a plethora of information. Scholars have argued the precise definition for centuries and the debate continues in modern day management discussions. What's clear and universally agreed upon, however, is that the best leaders are those who inspire others toward a common goal. In healthcare, leadership offers many faces: from the physician who provides primary care and leads a practice of patients toward health, to the nurse at the bedside who leads a patient and family through a crisis, to the frontline managers in hospitals, practices, and clinics or the CEO leading an entire health system to achieve its mission. Patients, too, are often overlooked leaders who take accountability for their care and inspire friends, family, and the community to better health and wellness. Leaders in healthcare are making a difference everyday and are the ones who'll be responsible for shepherding the much-needed transformation of the U.S. healthcare system.

Although the vision of our future healthcare system is still evolving, experts generally agree that health information technology (IT) will play a significant role in the nation's reformed health delivery system. The American Recovery and Reinvestment Act (ARRA) includes $19 billion to be used as incentives for those healthcare providers who adopt technology and demonstrate its value through measures defined by regulatory agencies.

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Meaningful use requirements

What have become known as the meaningful use requirements will establish specific criteria by which providers can attain the incentive funding and demonstrate that they've not only purchased and implemented technology, but have also adopted technology in such a way as to support the following national goals:

* improve quality, safety, and efficiency

* engage patients and families

* improve care coordination

* improve population and public health

* ensure privacy and security protections.

Although these goals are associated with funding for technology adoption, it's important for all leaders to remember that technology alone won't lead the nation to achieve these goals. Health IT experts remind clinical leaders often that technology is nothing more than an enabling tool. The clinicians, patients, and others who use the tool and the processes that the technology enables are more important than the software, hardware, and networks that make up health information systems.

Achieving the national goals defined as part of ARRA will require the commitment, expertise, and resolve of clinical leaders from across the healthcare delivery spectrum as we collectively undergo this historic change. Clinical leaders will need to adopt a clinical transformation framework and rapidly develop base informatics and IT competencies to effectively lead teams, manage change, make decisions, and inspire others toward these common goals while simultaneously meeting the day-to-day needs of their organizations. Clinical transformation provides the framework for aligning clinical processes, organizational behavior, and emerging technologies to improve care delivery and overall organizational performance. Unlike traditional software implementations, clinical transformation considers core clinical processes first. Effective alignment of process, people, and technology using a clinical transformation framework can provide organizations with a competitive advantage while promoting quality care delivery and ensuring sustainable and measurable change.

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Clinical transformation process

Clinical leaders must be particularly engaged and prepared to provide direction during the following critical stages of clinical transformation:

* Visioning and planning. You should be involved from the very early stages of clinical transformation. Developing a patient-centered vision that recognizes the value of technology will require input from those leaders who provide care.

* Process redesign. It's likely that existing processes will need to be transformed and redesigned to embrace an evidence-based, best practice care delivery model. You must first and foremost advocate for process over technology. Redesigning a process solely to fit within the confines of a technology solution may result in harm. Ensure that any redesign of the care delivery model is implemented because it's the best way to deliver care. If the technology doesn't support the best care delivery process, you should advocate for new technology. Process changes should focus on reducing redundancy, eliminating waste, and increasing efficiency.

* System building, testing, and training. Every system comes with tables and parameters that need to be defined. For example, clinical protocols and decision support criteria must first be built into the system to provide evidence–based clinical decision support. You must be authoritative and ensure that this critical element of system design isn't dictated by nonclinicians or outsourced to external parties. Testing of systems, particularly point-of-care systems, is also critical. To ensure patient safety, you must be assured that all system testing follows a best practice methodology and puts forth the same or greater rigor than that which is currently applied to testing of new drugs or medical devices. Many healthcare organizations lack the competency and discipline to perform system testing effectively. Although you may not directly perform testing, you should be leading, overseeing, and approving all testing activities related to clinical systems.

Training is one of the most important and often overlooked elements of clinical transformation efforts. Practice models need to be reviewed and modified in the context of the new technology. Training staff members on the new practice and supporting technologies is time consuming, expensive, and difficult. You should recognize the impact of training, plan for it during the budgeting process, and provide unwavering support for it throughout the transformation.

* Go-live and support. Many leaders think of clinical transformation as a project or initiative, with a defined beginning and end. However, clinical transformation is an ongoing program that needs to be embedded in the culture and spirit of the organization. Technology is dynamic and changes over time. The meaningful use requirements, as part of the ARRA funding, call for changes and updates to technology every 24 months to achieve the next level of funding. Although you need to celebrate the achievement of milestones, you must also demonstrate ongoing commitment, support, and resolve. Managing the significant change during clinical transformation is your greatest challenge. Your change management skills and competencies will be tested at each turn. You'll need to keep some very basic and fundamental change management principles in mind. These principles include:

need for change. There's often resistance and skepticism toward change. You must engage colleagues, employees, patients and families, board members, and other stakeholders, providing reasons and rationale for the change. Answering the question "What does this mean to me?" for each stakeholder group is vital.

shared vision. The leadership team must coalesce and develop a shared vision for the future state of the organization. This future state must be defined within the context of the organization's overall mission and rooted in its history and culture. To be effective, the vision must employ a strategy that recognizes technology is an enabling tool to support people and processes.

leadership commitment. As with any initiative, but particularly with those involving technology, you must demonstrate commitment and resolve. Although best practices are still emerging, it's clear that technology adoption can be difficult for any individual or organization. You must establish a governance model that's aligned with patient care and IT strategic plans. Roles should be clearly defined and individuals should be held accountable for their actions. This includes the establishment of a governance model that defines roles, promotes accountability, empowers leaders, and supports the organization's unique culture and environment.

employee involvement. Employees and other stakeholders should be involved from the beginning. This translates to early involvement during the system selection or technology acquisition process for those organizations purchasing commercially available technology solutions or in the design process for those who choose custom development. You must recognize that the "it takes a village" adage applies to clinical transformation. Make sure you have a good handle on the unique culture and effective communications channels of the entire organization and employ strategies that account for this uniqueness.

integrated organizational changes. In an effort to manage change, many organizations attempt to adopt technology in smaller, more bite-size pieces. This can be an effective strategy; however, it can lead to an implementation that's declared a success for one area but a disaster for another if not managed appropriately. Consider the implementation of an ED information system that satisfies the needs of the ED workflow but fails to meet the workflow needs for those patients who require transfer to inpatient care. Leaders at all levels need to ensure that, first and foremost, they think about process and secondly that they think outside departmental silos. This is often challenging for even the most experienced leaders.

An organizational culture that promotes process and empowers departmental leaders to think outside of their area of expertise is a prerequisite for clinical transformation. Additionally, leaders must be provided the tools to allow for integrated organization changes. For example, a common project management approach and methodology, with standardized status reporting, common rules of engagement, uniform system testing principles and guidelines, and a shared repository of issues is a good first step to promote integration between various teams.

* Performance measures. You must be vigilant in ensuring that alignment exists between clinical outcomes, quality measures, and organizational values. Technology solutions shouldn't be implemented without clearly defined goals and outcomes. As in clinical practice, measurement of baseline metrics is essential. Sustainable change can only be secured if measures are defined from the beginning, monitored throughout, and reported after the adoption of technology.

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Preparing for the future of health IT

The future of our healthcare system is unclear. As politicians and others continue to debate the best model for our country, frontline clinical leaders will need to begin to embrace change and prepare their organizations for what's coming. Clinical leaders will undoubtedly play a vital role in the reformation and transformation of care delivery as we know it. Those leaders who understand the ideas and principles of clinical transformation and change management will be best positioned to lead us into a 21st-century, world-class health delivery system of which we can all be proud.

© 2010 by Lippincott Williams & Wilkins, Inc.

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