EMR GOVERNANCE: BUILDING A BUSINESS CASE IS JUST THE BEGINNING

Nothing is more important to the likelihood of an EMR implementation s success than good governance. Implementing an electronic medical record (EMR) system is a project that senior healthcare executives may attempt once or maybe twice in their careers. The success or failure of projects can have a profound effect on both healthcare organisations and their senior leaders. And nothing is more important to the likelihood of success than good governance. Seeking to promote broader understanding of EMR project governance, InterSystems facilitated a discussion, The role of senior leaders in IT governance, at the 2017 Australian Healthcare Week. Based on that discussion and presentations by other EMR project leaders, a wide variation in governance models was apparent. It is common for healthcare organisations to put forward a business case to secure funding for an EMR implementation, however long-term governance models that ensure business cases are actually tracked and realised are far less common. Australia is a relatively advanced market for EMR systems and tends to reflect global trends. It would be fair to say that the global healthcare industry is on a journey in which EMR governance models are still evolving. This does not mean that most aspects of EMR projects are not subject to proper governance. The governance of activities around EMR design and implementation are nearly always a priority, including project governance, risk management, clinical engagement, and clinical governance. Longer-term governance associated with the sustainability of EMR projects, however, appears to be less common. This includes the development of the EMR business case, benchmarking performance, and benefits realisation.

Developing an EMR business case Developing a strong business case for an EMR and clearly defining the project and its objectives is usually seen as a precursor to securing project funding or evaluating suitable systems. Yet organisations looking for models for their own business case will find few in the public domain. If I was to ask everybody in the room, Would you share your business case?, I don t think too many people would put their hand up, said Bruce Winzar, Executive Director Information Services & CIO at Bendigo Health and a 2017 Australian Healthcare Week discussion participant. It s interesting that we talk a lot about doing clinical information system change and bringing in new infrastructure, he said. But the bottom line is you ve got to pay for it. Sustainability is really important and you need to know why you re doing it. Bendigo Health started its business case for the new Bendigo Hospital s EMR project by developing a benefits framework. It performed internal modelling of around 70 key performance indicators (KPIs). These were sourced from organisations like the Advisory Board and Gartner. The list was narrowed down to 25 that were relevant to Bendigo Health and 19 that it believed were achievable. It then asked one of the big four accounting firms for further modelling and research to validate the KPIs, which covered three areas: Quality and Safety, Service Improvement, and Direct Financial. Much of the discussion with the board over the business case development was reviewing the EMR benefits with hard cash savings in mind, said Winzar. How much money are we going to save? What s the cost avoidance? But you don t do it just for the money, you do it for the service improvement, and the quality and the safety improvements. When the clinicians presented their case everyone clearly understood the significance of the quality and safety benefits, not just the dollars and cents. Bendigo Health decided to report on its KPIs each month to track improvements against indicators such as: n Turnaround time for radiology and laboratory n Reduction in adverse drug events n Time to discharge a patient n Time looking for patient information and results n Length of stay and unplanned hospital readmissions n Plus more In developing a benefits framework, Bendigo Health established 19 key performance indicators from three key areas: Quality and Safety, Service Improvement, and Direct Financial.

If we can save each clinician 15 minutes per shift, that is a significant amount of time that can be dedicated back to patient care, said Winzar. Other discussion participants also pointed to the difficulty of developing a business case. One said, How do you develop a business case based on a clinical model of care that doesn t exist in Australia? Their organisation sourced research in the United States and Europe to demonstrate to clinicians that their proposed new model of care was safe and delivered a return on investment (ROI). You have to write a business case that s going to evolve, they added. You start with some quantitative measures and then you look at the qualitative measures around patients. Then you have to put in the appropriate benefit realisation model. We ve engaged research agencies to verify the findings because you need to be able to prove that the benefit is there. I wonder if you have ever been asked to do an ROI on the implementation of a new paper form? asked Redford. Yet we re all asked to measure the cost benefits of computer systems. In my view, an EMR is the cost of doing business in the 21st century. There are some things we need to measure but we re never going to be able to measure every element of ROI. In her presentation, Katharina Redford, Deputy CEO of South West Alliance of Rural Health (SWARH) in Victoria, pointed out that it was impractical for some healthcare organisations to develop a business case.

Benchmarking performance Developing a business case may be challenging, but so is the governance around ensuring it is realised. Any organisation that wants to demonstrate improved outcomes must be prepared to benchmark its performance. Under its governance model, Bendigo Health made business unit managers responsible for collecting baseline data so it could model potential KPIs, a process that started well before the EMR implementation began. You ve got to be able to check outcomes against some baseline measurement and often there s not a lot of baseline measurement going on, said Winzar. When you try to work out KPIs around adverse drug events, for example, where is that recorded now? How accurate do you think that is in your organisation? And, when you find some research that says you can expect a 15% improvement, does that fit your organisation? SWARH has taken a different approach to performance measurement. Because it implemented an EMR over 10 years ago, it was not possible to baseline its previous environment. SWARH is committed to demonstrating ongoing performance improvements from a maturing EMR, however, and has gone down the HIMSS Analytics Electronic Medical Record Adoption Model (EMRAM) route. A gold star implementation fades quickly if the policies, governance, and individuals do not maintain momentum to ensure a process and culture of ongoing enhancement, review, education, and executive governance support, said Redford. We decided that we needed an objective independent assessment of where we were. HIMSS EMRAM is a validated tool and a validated methodology. I think it has some gaps for Australia, certainly for regional areas, but if everyone is benchmarking against it then you have some sort of measure. In 2015 our median score was about one point something. In 2016 we ve taken the 12 agencies in SWARH to 2.32. We have one agency at EMRAM stage 4 because they re using medication management, and we plan to get all the others there by the end of this year, said Redford. While the model is not a perfect fit, SWARH has benefited from undertaking a structured assessment. Levels 2 and 3 of EMRAM are critical to building a critical mass of data the areas of clinical notes, observations, assessments, and discharge summaries apply to almost all episodes of care and therefore provide the basis of decision support for clinicians, said Redford. Diagnostic results and studies are other key areas to be able to view these within the EMR underpins best care through better decision support. Any organisation that wants to demonstrate improved outcomes must be prepared to benchmark its performance.

Benefits realisation According to Bendigo Health s Winzar, the governance of benefits realisation is crucial to delivering a business case. The benefits realisation program for the new Bendigo Hospital EMR project started on day one. That included hiring a benefits realisation manager responsible for creating a governance structure and the collection of baseline data. Realising the benefit is much harder than just putting it into the business case, said Winzar. You need to be good at your governance. You need to hold the executives accountable, you need to hold the managers accountable that are responsible for the collection of the data and the reporting of the data. We link that to our strategic management program which is reported up monthly and reviewed by the governance team. Bendigo Health s benefit realisation models extend over 10 years because different benefits are achievable over the short, medium, and long terms. In the first or second years the percentages of the expected benefits achieved will be lower, in the last year they plan to get 100% of the expected savings. Achieving those long-term goals requires partnership with the EMR systems vendor, said Winzar. You need to have an ongoing relationship. Achieving those long-term goals requires partnership with the EMR systems vendor, said Winzar. You need to have an ongoing relationship. Project governance and risk management At Bendigo Health, the governance framework for both benefits realisation and EMR project delivery is formalised. While the two structures share common elements, the EMR and the benefits program have different executive sponsors. We have put a lot of effort into our governance structure and the board are very supportive, said Winzar. We have executive sponsors and a number of accountable executives on different groups. Business unit managers are responsible for the collection and reporting of data. Reports go to the board once a month via our monthly standard operational reporting tool. Bendigo Health uses a strategic planning tool called Sycle to record its objectives and operational plans and every month reports against them. There are structures and responsible people with targets that trickle down the governance tree, said Winzar. That is how we keep people accountable for the delivery of the EMR and the benefits realisation program. Other panel discussion participants also expressed strong views about the need to make people accountable for project delivery and the need to involve clinicians in project governance. As one said, In terms of governance I think what s really important is defining accountability. For us having really strong executive and clinical leadership has been absolutely critical. According to another participant, Any project that we do in IT has executive ownership and the sponsor of that project is responsible for all the risks and issues. The risks and issues are listed for each project and referred to at every steering committee meeting. Supported by the project managers, they are reviewed constantly and mitigation strategies are put in place to manage them.

Clinical engagement and clinical governance A number of discussion participants highlighted the value of aligning project delivery governance with existing clinical governance structures. This had multiple benefits, they said. It was important to encourage clinical engagement and involvement to assist with the design of the EMR and ensure its safety. It was also valuable in ensuring proper training, and to encourage clinical adoption of the new system. As one participant said, Our CEO made each executive accountable for a particular stream of the project and paired them with a member of the project team. It s not just about having a chief information officer and a chief medical information officer, it s about having lots of clinicians and lots of managers working together. As a project delivery person I can come in and we can build the system. But I can t make sure that there are proper training programs, and I can t make sure that staff are actually trained. Another said, One of the challenges is that we re not very good at owning workflows. If I asked you, Who owns blood administration?, you know there s lots of stakeholders but there s not one owner. For some of those really complex workflows you really need to identify who s going to own it. That s why it s important to leverage your existing structures. I like to embed the project structure within the existing governance structures of the hospitals. They already operate hospitals day to day and we don t want to set up committees for their own sake. In conclusion: Leadership key to EMR success The key theme the panel seemed unified around was the role of leadership in making an EMR successful. One participant summed it up perfectly: It has to come from the leadership, it has to come from within the business. The leaders have to be those people who are going to deliver the care, manage the care and monitor the care going forward. We did that quite successfully by taking those people and integrating their daily roles into the project governance, as well as into the development of the clinical model of care.