Since its formation back in 1999, Banner Health has made a name for itself by increasing the clinical standardization of its EHR technology to support clinical improvements.
As a result of its push toward value-based care and population, the health system comprising 29 hospitals and spanning 7 states has worked to mirror its high levels of clinical standardization on the inpatient side in its ambulatory sites. As the organization's CMIO William Holland, MD, puts it, the plan was to take that hospital EHR success and "move it across the system."
According to Holland, extending that level of clinical standardization to Banner's ambulatory facilities required a great deal of planning and a significant level of physician engagement. The Cerner shop now has both its inpatient and outpatient providers operating on highly standardized EHR systems, supporting the health system's efforts to transition to a population health management company.
In this one-on-one interview with EHRIntelligence.com, Banner's CMIO shares the lessons learned from implementing a single ambulatory EHR platform and working with physicians from various specialties to ensure a successful EHR adoption.
EHRIntelligence.com: What sets Banner Health apart as far as its use of EHR and health IT is concerned?
William Holland: The secret sauce at Banner is driving clinical improvement through clinical standardization. Everything is modeled around that, which means that when we put order sets or decision support into our electronic health record system we put in the same thing at every hospital, at clinic across the system. We function very much like one hospital or clinic with a bunch of locations.
About six years ago, we started aggressively increasing our ambulatory footprint both through organic and inorganic growth. A lot of that was primary-care based but many were specialists who practiced in our facilities and were also now employed by Banner in an ambulatory space as well. And then a few years ago, we became one of the first Pioneer ACOs and started beginning to take on risk. We started to see ourselves transitioning from initially an acute hospital system that was moving into an integrated care delivery system (ambulatory, acute, and post-acute) into a population health management company that was taking on risks for populations and doing the best we could do to have high-quality outcomes at a reasonable cost and drive a high-quality consumer experience.
EHRIntelligence.com: What challenges did undertaking an ambulatory EHR implementation across Banner Health's ambulatory settings reveal?
WH: One of the gaps we saw that we had about three years ago was that we had different EHR platforms, different plumbing, between the inpatient space and outpatient space. In the inpatient space, highly standardized and successful single approach to doing things across all our hospitals. In the ambulatory space, we had a few EHR platforms, but we weren't able to drive that integrated care experience at the level we were looking for and we didn't have same level of decision support tools. We started having a lot of conversations about what it would take to move to a more integrated platform in the ambulatory space, to start converting those clinics over and put us in an even better position to manage the health of populations.
EHRIntelligence.com: What did you come to realize about the role of physician engagement in the process of implementing an ambulatory EHR technology?
WH: The first one starts at a very high level from an alignment standpoint. You have to find a way to implement these things such that providers don't feel you're doing this to them — that they're the ones leading the change. We are a large health system. Historically, we have done some things really well and some things we've learned from. One that we learned first and foremost is that we needed to have some physicians from the medical group themselves as the visible face out in front leading this.
We typically at a board level have a handful of strategic initiatives across the system. These are pretty high-profile things like how we're doing financially, employee retention, and clinical performance. One of the strategic initiatives we had for last year and in to this year was around the implementation, the number of providers converted over. As one of the leads for that strategic initiative who is responsible for reporting to senior leadership and board on how we're performing on this was one of the CMOs from the medical group. He became a very visible face of this for the medical group — that they were the ones leading and driving this — which meant that the importance of this conversion got transferred throughout all the different leadership structure within the medical group. Very symbolic, very important. That started to bring in a lot of other leaders, both frontline and above, from within the medical group to be engaged. It created a different engagement model than what you'd traditionally see there.
The other piece is we needed to assess how ready different folks were for this change. Change management at most organizations typically is an email that goes out at some point that says, "Hey, by the way this in happening…" It's really more about making them aware. We wanted to have a very different model for change management. We brought in couple of our talent and organizational effectiveness people who specialize in driving complex change in our organization — not always technology based.
There are a lot of different models you can use — they happen to use the ADKAR — but surveying people initially, during the change, and after the change to understand how aware were they, what was their desire level, did they need more knowledge, did it need to be reinforced, etc. And then bringing together coalition of folks who are all in that same area around the change to prepare them to drive that.
EHRIntelligence.com: Is there such a thing as too much physician engagement?
WH: We certainly brought physicians in to be a part of understanding what we were rolling out and to influence some of the design considerations. With the first wave, I was overzealous in bringing physicians in. So we brought them in really early — we had only maybe built out 20-30 percent of what it was going to look like. And lesson learned? Bring them in when you have 80 or 90 percent built out and allow them to help you tweak it. We adjusted that as we went forward with some of the subsequent waves and it was a much better way of going about things. It brought them in at the right level of engagement to help do some of those design pieces.
But also we wanted to very heavily standardize. Once we had a design model for internal medicine, for instance, that was the model. We might adjust it and influence it, but that would become the model for everyone. We didn't customize differently from one clinic to the next, just by specialty where it was appropriate.
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Image Credit: Banner Health