John Glaser

Organizations increasingly are faced with the need to make significant investments in clinical information systems such as computerized provider order entry and electronic health records.

These investments often are seen as essential contributors to improving patient safety, operational efficiency, and the cost-effectiveness of patient care.

However, these investments are expensive and difficult to implement. In addition, for the investments to be effective, the medical staff has to be not only supportive of the undertaking but also active users of the systems.

An organization may find that its medical staff is hesitant to back these initiatives. Physicians may be concerned that these systems will add time to their already overburdened days, will embarrass them as they struggle to learn how to use these systems, and will capture data that will be used against them. Several recent examples have shown that such concerns can heighten and lead to outright resistance-a situation fatal to the implementation of these systems and possibly to the jobs of those who were system proponents.

Lessons Learned

What can the organization do to increase physician support for clinical information systems? Several lessons can be learned from organizations that have been successful in their CPOE and EHR efforts.

The overall working relationship must be good. Clinical information system discussions will not be the first time that administration and the medical staff will have had to work together. There will have been prior discussions about facilities, clinical service expansion, expense management, investments in medical technologies, and physician recruitment.

If these discussions have been plagued by mistrust, apathy, and accusations of incompetence, then the IT discussions will be similarly blessed. An overall lousy working relationship cannot be fixed by an IT discussion, and such a relationship will severely threaten a clinical information systems implementation. If the relationship is not good, then one should not be embarking on efforts to implement CPOE or an EHR. The risk of failure is too high.

The medical staff leadership must believe that these systems are necessary. The decision to pursue clinical information systems is significant for the medical staff. Capital and management attention will be diverted from other worthwhile projects. Physicians will have to change their workflow and behaviors. To agree to this undertaking, the medical staff leadership has to believe that these systems are necessary investments and be actively engaged in their implementation and use.

To obtain physician buy-in, medical staff leadership already should be tightly integrated into the organization's processes for developing strategies and providing high-level oversight of the progress of other major initiatives. Physicians should have real input into decisions and see that their perspectives and desires lead to action. It is in these forums that the decisions to pursue CPOE and the EHR will be made. And it is essential that the medical staff leadership view these decisions as the right decisions.

The medical staff leadership should not only understand the strategic rationale for these systems but also appreciate the nature and demands of implementation and the related organizational process changes necessary for the investment value to be realized. There are many ways to educate physicians (and other members of the leadership team) on these topics, including:

  • Inviting leaders from organizations that have implemented these systems to talk candidly about their experiences
  • Having the leadership team visit organizations that are using these systems to see the systems in use and learn about strategies for addressing the inevitable challenges
  • Asking the leadership team to attend conferences on clinical information systems and discuss what they have learned

The medical staff leadership involved in these activities must be the same leadership that participates in senior leadership forums and is highly respected by the medical staff. One should never view physicians who "like computers" as adequate surrogates for leadership. The outcome of these discussions will need to be a firm commitment from the medical staff leadership.

Also, one should not believe that commitment is obtained solely through presence in senior leadership forums and education sessions. Commit-ment can involve negotiation, horse trading, one-on-one meetings during dinner, and conversations on the golf course. Successful CEOs, COOs, and CFOs have developed an understanding of how to handle certain individuals and what methods are the most effective in certain situations. Their effectiveness with the medical staff has been learned through experience.

The medical staff leadership must understand its roles. During the activities that span the time from the beginning of system selection through the last stages of implementation, the medical staff leadership has several critical roles.

The senior leaders of the medical staff must be visible champions and supporters of the effort. This broad championship means that they express the importance of the undertaking in various forums and during meetings with the medical staff. They arrange time with hesitant colleagues to discuss concerns or issues. They attend meetings that discuss the new system and ensure that their colleagues attend necessary meetings.

The organization will need more than one physician champion. The physician community should see that its leadership is broadly supportive of this undertaking. Political problems can be created if the" knighting" of one physician as champion is construed as meaning that the other members of the medical staff leadership are simply spectators of this event.

However, it is appropriate to ask one member of the medical staff to devote a significant percentage of his or her time to working with IT staff and the organization during this process. Selecting one individual helps to make it clear who should serve as a medical staff point of contact for routine selection and implementation issues. The designated day-to-day champion should be a respected clinician who is not seen as a "computer geek." Moreover, this person must be given time to devote to the task, which may involve relieving the individual of other administrative duties and providing financial compensation for lost clinical income.

In addition to serving as champions, the medical staff leaders also will need to accurately convey to the administrative leadership the concerns being expressed by the physician community. They must be advocates for the physician community. They need to work with the administrative team to develop strategies for responding to concerns, fears, and anxieties.

Members of the medical staff will be asked to serve on committees and task forces that have been developed to support the selection and implementation. These task forces may need to develop the functional requirements for the clinical information systems, discuss implementation rollout sequence and timing, assist in designing screens and reports, review implementation support needs, and examine a variety of policies and procedures on topics such as verbal orders, password use, documentation, and approval of order sets. The contribution of the medical staff during these activities is essential.

Staff members who serve on these committees and task forces should be thoughtful and highly regarded clinicians. It also can be wise to ask medical staff who are often critical of the organization to be included in this undertaking.

Package appropriately. No one likes to sign up for an initiative that will go forward no matter how well it is working. None of us wants to be a passenger on a runaway train. Physicians should be assured that a careful, defined process is going to be taking place.

One way to provide this assurance is by structuring implementation in stages. Each phase should be followed by an assessment of the phase and a determination of what should be done differently in successive phases. Structuring implementation with phasing indicates that the organization will take stock and not mindlessly barrel ahead. It also means that, unless a phase is disastrous, the organization will go on to the next phase.

Listen, respond, and engage. The implementation of clinical information systems is a difficult undertaking that is certain to encounter pockets of turbulence. Medical and administrative leadership need to be candid about the difficulty and the turbulence. Messages should be delivered that acknowledge the effort required, the difficulty of process and behavior change, the inevitable IT bumps, and the imperfection of application designs.

Throughout selection and implementation of the system, formal and informal meetings will be needed to hear about problems, discuss potential solutions, and review progress. The leadership must have very good antennae for identifying concerns and work hard to address issues once they have been raised. At times, the leadership will need to go to meetings for the sole purpose of getting beaten up.

Reassure. The decision to pursue implementation of a clinical information system is no different than the decision to pursue any other major organizational undertaking that affects the lives and livelihood of the medical staff. Organizational members-medical staff included-are usually willing to support major system implementations if they know:

  • This needs to happen.
  • Leadership is committed.
  • Competent administrators will work hard to solve problems and address concerns.
  • The implementation is a partnership.
  • Their concerns will be listened to and addressed as much as possible.
  • The design and implementation of the solution or system is responsive to their ideas.

A Complex and Difficult Undertaking

The implementation of clinical information systems is complex and difficult. These implementations will be successful if the medical staff is committed and engaged; they will fail if the medical staff is not. Engaging the medical staff requires that they believe in the need for the system, their roles are clear, and the implementation is responsive to the issues they raise.


John Glaser, PhD, FHIMSS, is vice president and CIO, Partners HealthCare, Boston (jglaser@partners.org).

Publication Date: Saturday, October 01, 2005

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