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Engaging Clinician Leadership to Adopt Healthcare Technology – Breakaway Thinking

Posted on April 15, 2015 I Written By

The following is a guest blog post by Carrie Yasemin Paykoc, Senior Instructional Designer / Research Analyst at The Breakaway Group (A Xerox Company). Check out all of the blog posts in the Breakaway Thinking series.
Carrie Yasemin Paykoc

In many healthcare organizations, IT leaders are given the ultimate responsibility of implementing and adopting electronic health records (EHRs) and other health information technology (HIT) because the build and installation fall within their responsibility. While their technical skills and experience are necessary to select, install and maintain the HIT system, clinician leadership should ultimately own the use of the system.

Ownership of the system requires commitment to establish best practice workflows and system parameters that clinicians follow and evolve over time. The risk is that the technology won’t be used to its fullest potential and could even pose potential harm when used incorrectly or without knowledge of how information is entered, accessed, and used by other providers. In a recent alert from the Joint Commission, 23 percent of all reported HIT-related events were due to poor design and data associated with clinical content. Ensuring nurses, physicians, pharmacists, and other clinical staff are involved in decisions about how the system will be used will help alleviate these issues and ensure proper system use.

Over the years, The Breakaway Group’s research has shown that clinician leadership must be highly engaged to effectively adopt new EHRs and HIT systems. In fact, it is the most important predictor of successful EHR adoption. While clinician leader engagement may appear straightforward, competing priorities make it difficult to maintain the degree of engagement required after a new EHR system goes live.

For example, clinician leadership may see fewer patients or put certain responsibilities on hold until the system is implemented. In reality, responsibilities associated with the HIT system must shift and evolve among all stakeholders throughout the adoption journey. After go-live, clinician leadership involvement shifts from decisions around clinical applications and best practice workflows to decisions around upgrades, optimization of the system, and identifying workarounds. Both pre- and post-go-live responsibilities take time and need to align with the overall responsibilities for each role within the healthcare organization.

Involvement of clinician leadership early on in the adoption journey helps create a culture that embraces change and instills a sense of ownership to all levels in the organization. This cultural shift is not easy and requires the right mix of calculated planning and visionary leadership that must resonate with clinicians. A recent article published by The New York Times, describes the paradox of clinicians resisting new EHRs and creating “technology that physicians suddenly can’t live without.” On one hand this technology is causing resistance among clinicians to the point of reverting to paper, while on the other, this technology is helping mitigate countless medical errors and waste. Clinician leadership must engage to address both sentiments and create a culture conducive to change. With the rate of technological advances, a cultural status quo will not suffice.

Naturally clinicians are data scientists and lifelong learners. Show them data and provide them a comfortable learning environment to get up to speed quickly. Then they can help review the data and identify areas for improvement. For example, clinicians can query orders associated with quality outcomes such as electronic orders for flu vaccinations and determine if the rate ordered aligns with internal quality metrics. If the rate is below the agreed upon threshold, clinician leaders can focus efforts on systematically improving the rate ordered.

The longer clinician leadership involvement is delayed, the more likely resistance will fester and organizational culture will be at risk. Adopting technology, especially technology associated with government requirements, is painful and simply takes time. The difference is whether clinician leadership is involved early in the decision making process. If you do not want your clinician reverting to paper charts and/or throwing laptops and mobile devices out of sheer frustration, give clinicians the time and resources to fully engage in the adoption journey.

Xerox is a sponsor of the Breakaway Thinking series of blog posts.

Healthcare Applies Innovation from Other Industries for Big Impact – Breakaway Thinking

Posted on March 18, 2015 I Written By

The following is a guest blog post by Jennifer Bergeron, Learning and Development Manager at The Breakaway Group (A Xerox Company). Check out all of the blog posts in the Breakaway Thinking series.
Jennifer Bergeron

Healthcare is applying innovations from other industries to make advancements in the study of disease, surgery, and research. If you’re fascinated by new ways to use everyday tools and at the same time make life easier, also known as lifehacks, you can appreciate the same concept in healthcare.

3D imaging, cellphone camera technology, and sonograms like those used in underwater navigation are all being used in healthcare. Let’s begin with a look at cellphone technology and one way it is being applied to healthcare.

UCLA researchers developed a lens-free microscope that, through a series of steps, allows tissue samples to be formed into a 3D image using a microchip that is the same type found in your cellphone camera. The image shows contrast so the researcher can see tissue depth. This lens-free microscope also offers a broader, clearer view than conventional microscopes. The result is that “the pathologist’s diagnosis using the lens-free microscopic images proved accurate 99% of the time”, according to a recent study.   In order to apply this same concept to disease, imagine that a researcher could isolate a section of diseased tissue, remove it from its environment, color code the tissue to easily spot abnormalities, and have the ability to study it from all angles. reminds us that lasers, used in missile defense, in the world’s fastest camera (which takes 6.1 million pictures per second), in entertainment devices such as Blu-ray players, and in grocery check-out lines, are also used in surgery and diagnoses. Lasers can decrease the diagnosis time and cause less disruption to a patient’s comfort. Zero-dilation Scanning Laser Opthmalogy (cSLO), a new imaging technique, can diagnose a patient with diabetic retinopathy, which causes progressive damage to the retina, in as little as 3 minutes.

Technology is not only impacting the patient experience, but how caregivers are brought up to speed on new technologies. In fact, the founder of The Breakaway Group based the company’s electronic health record (EHR) learning concept on flight simulation. Flight simulators train pilots how to maneuver in extreme circumstances, situations that would be difficult to create in real life. At The Breakaway Group, we use simulation technology to increase adoption of EHRs by training providers, nurses, and healthcare professionals.

Speed to proficiency, one of four key adoption elements of The Breakaway Method, provides learners with real-life situations in a safe environment.  Learners can quickly experience many different circumstances, fail, and learn to complete tasks correctly, all without affecting patient outcomes. In addition, The Breakaway Group can cut classroom time in half on average by using simulations.

Healthcare is reaching into other industries to become more efficient and effective. Whenever information is shared and innovations are repurposed to make a process better, we all benefit.

Xerox is a sponsor of the Breakaway Thinking series of blog posts. The Breakaway Group is a leader in EHR and Health IT training.

The Future of Electronic Health Records in the US: Lessons Learned from the UK – Breakaway Thinking

Posted on December 17, 2014 I Written By

The following is a guest blog post by Carrie Yasemin Paykoc, Senior Instructional Designer / Research Analyst at The Breakaway Group (A Xerox Company). Check out all of the blog posts in the Breakaway Thinking series.
Carrie Yasemin Paykoc
With 2014 coming to a close, there is a natural tendency to reflect on the accomplishments of the year. We gauge our annual successes through comparison with expected outcomes, industry standards, and satisfaction with the work done. To continue momentum and improve outcomes in the coming years we look for fresh ideas. For example, healthcare organizations can compare their efforts with similar types of organizations both locally and abroad. In the United States, looking beyond our existing borders toward the international community can provide valuable insight. Many other nations such as the UK, are further down the path of providing national healthcare and adopting electronic health records. In fact, the National Health Service (NHS) of UK has started plans to allow access of  Electronic Health Records (EHR) on Smartphones through approved health apps. Although healthcare industry standards appear to be in constant flux, these valuable international lessons can help local healthcare leaders develop strategies for 2015 and beyond.

By the year 2024, the Office of the National Coordinator (ONC) aims to improve population health through the interoperable exchange of health information, and the utilization of research and evidence-based medicine. These bold and inspiring goals are outlined in their 10 Year Vision to Achieve Interoperable Health IT Infrastructure, also known as ONC’s interoperability road map. This document provides initial guidance on how the US will lay the foundation for EHR adoption and interoperable Healthcare Information Technology (HIT) systems. ONC has also issued the Federal Health IT Strategic Plan 2015-2020. This strategy aims to improve national interoperability, patient engagement, and expansion of IT into long-term care and mental health. Achieving these audacious goals seems quite challenging but a necessary step in improving population health.

EHR Adoption in UK
The US is not alone in their EHR adoption and interoperability goals. Many nations in our international community are years ahead of the US in terms of EHR implementation and utilization. Just across the Atlantic Ocean, the United Kingdom has already begun addressing opportunities and challenges with EHR adoption and interoperability. In their latest proposal the NHS has outlined their future vision for personalized health care in 2020. This proposal discusses the UK’s strategy for integrating HIT systems into a national system in a meaningful way. This language is quite similar to Meaningful Use and ONC’s interoperability roadmap in the United States. With such HIT parallels much could be learned from the UK as the US progresses toward interoperability.

The UK began their national EHR journey in the 1990s with incentivizing the implementation of EHR systems. Although approximately 96 percent of all general provider practices use EHRs in the UK, only a small percentage of practices have adopted their systems. Clinicians in the UK are slow to share records electronically with patients or with their nation’s central database, the Spine.

Collaborative Approach
In the NHS’s Five Year Forward View they attempt to address these issues and provide guidance on how health organization can achieve EHR adoption with constrained resources. One of the strongest themes in the address is the need for a collaborative approach. The EHRs in the UK were procured centrally as part of their initial national IT strategy. Despite the variety of HIT systems, this top-down approach caused some resentment among the local regions and clinics. So although these HIT systems are implemented, clinicians have been slow to adopt the systems to their full potential. (Sarah P Slight, et al. (2014). A qualitative study to identify the cost categories associated with electronic health record implementation in the UK. JAMIA, 21:e226-e231) To overcome this resistance, the NHS must follow their recommendations and work collaboratively with clinical leadership at the local level to empower technology adoption and ownership. Overcoming resistance to change takes time, especially on such a large national scale.

Standard Education Approach
Before the UK can achieve adoption and interoperability, standardization must occur. Variation in system use and associated quality outcomes can cause further issues. EHR selection was largely controlled by the government, whereas local regions and clinics took varied approaches to implementing and educating their staff. “Letting a thousand flowers bloom” is often the analogy used when referring to the UK’s initial EHR strategy. Each hospital and clinic had the autonomy of deciding on their own training strategy which consisted of one-on-one training, classroom training, mass training, or a combination of training methods. They struggled to back-fill positions to allow clinicians time to learn the new system. This process was also expensive. At one hospital £750 000 (over $1.1 million US) was spent to back-fill clinical staff at one hospital to allow for attendance to training sessions. This expensive and varied approach to training makes it difficult to ensure proficient system use, end-user knowledge and confidence, and consistent data entry. In the US we also must address issues of consistency in our training to increase end-user proficiency levels. Otherwise the data being entered and shared is of little value.

One way to ensure consistent training and education is to develop a role-based education plan that provides only the details that clinicians need to know to perform their workflow. This strategy is more cost-effective and quickly builds end-user knowledge and confidence. In turn, as end-user knowledge and confidence builds, end users are more likely to adopt new technologies. Additionally, as staff and systems change, plans must address how to re-engage and educate clinicians on the latest workflows and templates to ensure standardized data entry. If the goal is to connect and share health information (interoperability), clinicians must follow best-practice workflows in order to capture consistent data.  One way to bridge this gap is through standardized role-based education.

Whether in the US or UK, adopting HIT systems require a comprehensive IT strategy that includes engaged leadership, qualitative and quantitative metrics, education and training, and a commitment to sustain the overall effort.  Although the structure of health care systems in the US and UK are different, many lessons can be learned and shared about implementing and adopting HIT systems. The US can further research benefits and challenges associated with the Spine, UK’s central database as the country moves toward interoperability. Whereas the UK can learn from education and change management approaches utilized in US healthcare organizations with higher levels of EHR adoption. Regardless of the continent, improving population health by harnessing available technologies is the ultimate goal of health IT.  As 2015 and beyond approaches, collaborate with your stakeholders both locally and abroad to obtain fresh ideas and ensure your healthcare organization moves toward EHR adoption.

Xerox is a sponsor of the Breakaway Thinking series of blog posts.

Measuring Steps to Patient Empowerment – Breakaway Thinking

Posted on November 19, 2014 I Written By

The following is a guest blog post by Jennifer Bergeron, Learning and Development Manager at The Breakaway Group (A Xerox Company). Check out all of the blog posts in the Breakaway Thinking series.
Jennifer Bergeron

Trends and fads come and go. When they stick, it’s clear they address a consumer need, whether it’s a service, promise, or hope. Here at The Breakaway Group, A Xerox Company (TBG), we operate within a proven methodology that includes metrics, and it’s exciting to those of us who can’t get enough of good data. Most people find metrics interesting, especially when they understand how it relates to them, and the results are something they can control. Metrics are powerful.

To understand the power of data in shaping behaviors, consider the popularity of the self-monitoring fitness tracker or wearable technology. Even as their accuracy is scrutinized, sales in 2014 are predicted to land somewhere in the $14 billion range.1 Do mobile fitness trackers actually help people change their activity habits? Could doctors actually use the data to help their patients? Can companies be built on the concept of improving health with a wearable device? Not conclusively.2 Does a dedicated athlete need this kind of information? Some think not.3

So what is driving the growth of the fitness tracker market and what are these devices offering that creates millions of dedicated users? The answer is real-time data, personalized goals and feedback, and a sense of control; in other words, empowerment.

In the 70s and 80s, my grandparents spoke about their doctor as though he were infallible. They didn’t doubt, question, or even note what he prescribed, but took his advice and dealt with the outcomes. If healing didn’t progress as planned, my grandmother blamed herself, as though she’d failed him.

Jump ahead a few decades when more emphasis is being placed on collaboration. We expect our physicians to work with us, rather than dictate our treatment decisions.4 Section 3506 of the Affordable Care Act, the Program to Facilitate Shared Decision Making, states that the U.S. Department of Health and Human Services is “required to establish a program that develops, tests and disseminates certificated patient decision aids.”5 The intent is to provide patients and caregivers educational materials that will help improve communication about treatment options and decisions.6

Patient portals are important tools in helping to build this foundation of shared information. The portals house and track patient health data on web-based platforms, enabling patients and physicians to easily collaborate on the patient’s health management.7  Use of patient portals is a Meaningful Use Stage 2 objective.

The first measure of meeting this objective states that more than half the patients seen during a specified Electronic Health Record reporting period must have online access to their records. The second measure puts the spotlight on the patient and their use of that web-based information. MU Stage 2 requires that more than 5% of a provider’s patients must have viewed, downloaded, or transmitted their information to another provider in order for the provider to qualify for financial incentives from the Federal government.8

Empowered consumers want information immediately, whether it’s a restaurant review, number of steps taken in the last hour, how many calories they’ve burned, or their most recent checkup results. We like to weigh the input, make a decision, and then take action. Learning and information intake, no matter the topic, is expected to happen fast.

Metrics show us where we stand and how far we’ve come, which empowers us to keep going or make a change, and then measure again. We’re in an age of wanting to know but also wanting to know what to do next. The wearable device market has met a very real need of consumers. Whether or not fitness trackers make us healthier, whether or not our doctors know what to do with the information, or if this is information an athlete would really use, these devices can serve the purpose of putting many people in control of their own health, one measurable step at a time.

1 Harrop, D., Das, R., & Chansin G. (2014) . Wearable technology 2014-2024: Technologies, markets, forecasts. Retrieved from

2 Hixon, T. (2014) . Are health and fitness wearables running out of gas? Retrieved from

3 Real athletes don’t need wearable tech. (2014) . Retrieved from

4 Chen, P. (2012) . Afraid to speak up at the doctor’s office. Retrieved from

5 Informed Medical Decisions Foundation. (2011-2014) .  Affordable care act. Retrieved from

6 HealthcareITNews. (2014) . Patient pjortals. Retrieved from

7 Bajarin, T. (2014) . Where wearable health gadgets are headed. Retrieved from

8 (2014) . Patient ability to electronically view, download & transmit (VDT) health information. Retrieved from

Xerox is a sponsor of the Breakaway Thinking series of blog posts. The Breakaway Group is a leader in EHR and Health IT training.

8 Steps to Creating a Solid EHR Foundation – Breakaway Thinking

Posted on October 15, 2014 I Written By

The following is a guest blog post by Noelle Whang, Sr. Instructional Designer at The Breakaway Group (A Xerox Company). Check out all of the blog posts in the Breakaway Thinking series.
Noelle Whang
Implementing an electronic health record (EHR) is a huge undertaking, but the work after go live can be even more demanding. Mapping and redesigning workflows is an important aspect of EHR implementation and optimization that is often overlooked, especially after the application has been live for a while.  This seemingly simple but complex task involves diagraming and analyzing all current work processes and adjusting them to include use of a new EHR system or upgrade, or to be more effective with a current system.

Workflow mapping and redesign should occur before implementation and regularly after go live to ensure end users truly adopt the EHR and organizational benefits are realized. Following these eight steps can ease the task of mapping workflows to identify any that should be adjusted to maximize optimization:

  1. Identify what workflows will need to be mapped in detail. “Understanding the full clinical context for health IT to the level of task, resources, and workflow is a necessary prerequisite for successful adoption of health IT,” according to a Perspectives in Health Information Management article. It’s helpful to first map out the entire patient care process at a high level, such as from registration to discharge in the inpatient setting and scheduling to check-out in the ambulatory setting. Documenting how business is performed at a high-level facilitates identifying the more granular tasks that need to be mapped in detail, such as scheduling a patient appointment or placing verbal orders.  It also helps in identifying all the roles involved in each workflow, as these can vary depending on the department or patient process.  For example, discharging a patient from Labor and Delivery may include roles, such as a lactation nurse and pediatrician, not found in other departments.  Remember to also consider departments or patient processes that are often overlooked, such as Materials Management and Respiratory Therapy. Other areas of concentration should be those with lower productivity or that relate to how the organization is going to determine return on investment.
  1. Identify teams to map out each process. After identifying what workflows need to be mapped, establish the team that will do the actual mapping. Usually, individuals who perform a particular workflow or those who are responsible for implementing any redesign changes are best suited to map workflows, as they have in-depth knowledge of the process. For example, select one registrar, one nurse and one physician to map out all workflows in the Emergency Department.
  1. Determine the process for mapping the workflows. Once the team has been identified, determine how information about workflows will be gathered, documented, and visually represented. The process for gathering information can be through interviews, observation, or meetings.  The information can be documented with tools such as Microsoft Word or Visio or simply on paper.  The data can be represented in formats such as a swim lane chart, a flow process chart or other process diagrams.   In my experience mapping out workflows, the most commonly used format is a swim lane chart created through Visio.  And remember: Internal staff will most likely need to be trained on how to gather the data and use the appropriate tools.
  1. Map the workflow as actually performed. After determining how information is gathered and documented, create the actual workflows diagrams.  Document all work as it is currently being performed, including any undesirable behavior such as workarounds or inconsistencies.  For a case study on how one organization created their workflow diagrams, see the following Journal of American Medical Information Association article.
  1. Analyze the workflow. Once the workflows are diagramed, begin the analysis. If a vendor has not been selected, use the diagrams to determine if a particular application fits the needs of your organization, with the caveat that it is neither feasible nor desirable to keep workflows exactly the same after an implementation.  If the application is already in place, the diagrams can be used to determine where problems are occurring, what the root cause is, and how to fix them.  The diagrams can also be used to determine where optimization or efficiencies may be gained.
  1. Document the new workflow. Once the analysis is complete and you have determined what workflows are currently not working for your organization, document the new and improved workflow.  It is a good idea to take the new workflows through a couple of use-case scenarios to ensure that the updates are not causing other problems or unintended consequences.
  1. Update or create policies and procedures. New or updated policies and procedures may be necessary to implement and support the new workflow. This can include determining consequences for any end users that do not adhere to the new workflows.  Note that this also requires thinking about how non-adherence will be identified, perhaps through routine application audits or quarterly in-department observation.
  1. Train staff. After all the hard lifting of creating the workflow diagrams, analyzing the processes and updating the workflows, the last step is to train end users on the new workflows, policies and procedures.  Remember to convey why the changes are occurring, and if possible, tie the reasons to big-ticket items such as increasing patient safety and satisfaction.

It’s easy to focus entirely on big tasks such as vendor selection and system configuration when implementing an EHR, but neglecting workflows can have serious negative impacts, including costly reconfigurations and operational inefficiencies.  It’s like building a house where each individual room is perfect, but the doors are all in the wrong place. With poor design you end up having to go through the closet to get to the kitchen, or even worse the foundation may begin to crack.  Similarly, with poorly designed EHR workflows, you can end up with duplicate documentation, activities that take more time than they should, and workarounds or shortcuts that can lead to negative consequences. Set your healthcare organization up for success and create a solid foundation by making workflow mapping and redesign a priority.

Xerox is a sponsor of the Breakaway Thinking series of blog posts. The Breakaway Group is a leader in EHR and Health IT training.

Work IT! Optimize Health Technology with EHR Adoption – Breakaway Thinking

Posted on August 20, 2014 I Written By

The following is a guest blog post by Carrie Yasemin Paykoc, Senior Instructional Designer / Research Analyst at The Breakaway Group (A Xerox Company). Check out all of the blog posts in the Breakaway Thinking series.
Investing in an electronic health record (EHR) is largely based on the decision to improve patient safety, align with clinical guidelines, enhance revenue cycle times, and capture government-based incentives. But without a proper EHR adoption plan in place, healthcare providers risk never optimizing their investment and achieving their intended goals.

Once an EHR is implemented, healthcare organizations must continue striving toward their goals to optimize their systems. Improving workflows, establishing best practices and increasing overall proficiency of end-users in this application are all components of optimization. Healthcare organizations that are able to maintain this level of focus will see improved clinical and financial outcomes.

This process isn’t easy and requires a commitment to the initial performance metrics that drove the healthcare organization to purchase the new system. Today, nearly half of all healthcare organizations use an EHR, but many struggle to ensure it provides clinical value across the organization. They carefully select and implement systems but fail to make the tool work as originally envisioned. Just because they bought a new EHR doesn’t mean it is serving their patients, providers, or bottom line.

A parallel comparison can be made with buying a high-end, a mobile exercise device to track aerobic and anaerobic steps. Individuals seeking a healthier lifestyle invest in these devices, hoping it will help them achieve their personal health goals. After making the initial investment and adapting daily habits to wear the device, one can begin to adopt the technology to achieve improved health goals. But realizing these goals takes work and commitment. If performance is not monitored, results can plateau and, in some cases, regress. This could result in a growing waist line for the person trying to lose weight, an ironic and unfortunate twist. For healthcare organizations, their growing waistline is unhealthy organizational performance, visible through increases in adverse drug events, recurrent admissions, revenue cycle times and government penalties, all symptoms of goal misalignment. The more healthcare organizations look away from their initial performance goals and utilize EHRs for data storage only, the more noticeable the symptoms become. Both individuals and healthcare organizations can benefit from the process of system optimization to make the tool work for the betterment of the individual or organization.

Extensive research has been conducted by The Breakaway Group (TBG), A Xerox Company, to identify elements that lead to optimization. TBG reports the key adoption elements exhibited by healthcare organizations that optimize their EHRs:

Engaged and Clinically Focused Leadership
Healthcare organizations must demonstrate engaged and clinically focused leadership. Clinical leaders must align their EHR by refining workflows, templates, utilization, and reporting to meet their organizations’ clinical and financial goals. The Chief Medical Information Officer (CMIO) is well suited for this venture.

Targeted Education and Communication
Healthcare organizations must provide targeted education and communication.  When system upgrades are released, organizations must effectively and efficiently educate end users to alleviate reductions in proficiency and productivity.

Comprehensive Metrics
Healthcare organizations must be able to use EHR data.  Organizations must move past the superficial use of an EHR and begin to analyze what is entered. The EHR is of little value, if the data is neither clinically valuable nor used.

Sustained Planning and Focus
Healthcare organizations must sustain planning and focus. Change occurs frequently in healthcare, so system optimization requires preparation, adjustment and real-time communication.

With these adoption elements, healthcare organizations can make their technology work as originally intended—to improve patient and financial outcomes. To overcome the EHR implementation plateau, they must focus on their original performance goals to truly optimize health information technology systems. This process isn’t easy. It requires endurance, but the payoff is worth it. It’s time to “Breakaway” from the status quo and work IT– by optimizing use of HIT systems!

Carrie Yasemin Paykoc
Xerox is a sponsor of the Breakaway Thinking series of blog posts.