SummaryMayo Clinic started an initiative involving clinicians and systems engineering analysts who worked together to better customize and align the clinic's information system (Mayo Integrated Clinical Systems) to support providers and patient care processes. As a key part of the team's work, staff "shadowed" providers, observing their interactions with patients and their use of information technology for managing information. The shadowing process led to direct feedback and open dialogue between clinical and project staff, which served as a catalyst for system enhancements, training initiatives, and other improvements designed to enhance work processes, efficiency, and patient care. Although no hard data were available, Mayo's joint technical–clinical staff committee appeared to have been successful, based on both the number of modifications and enhancements made to the system and direct, informal feedback from physicians indicating increased system use and enhanced efficiency. Information provided in February 2013 indicates that the program has ended.Suggestive: The evidence consisted primarily of the number of changes and enhancements implemented, along with informal feedback on usage and efficiency gains.
Developing OrganizationsMayo Clinic
Date First Implemented2005
Problem AddressedHospitals and health care systems are increasingly using electronic medical records (EMR). However, despite the promise of reduced costs, increased productivity, and improved quality of care, many providers report they do not fully utilize their information technology (IT) systems because of inadequate training, poorly designed user interfaces, or incompatibility with other information systems used.
- Poor communications between IT staff and clinicians: Feedback regarding the electronic information systems within Mayo Clinic was given informally, from one physician to another, or in the form of change requests or expressions of dissatisfaction. As a result, there was no effective process in place to help IT staff and clinicians collectively work together to develop technical solutions to support patient care processes.1
- Medical records located in multiple systems: Physicians working in outpatient and inpatient settings often struggle to view and enter patient information in the EMR. Providers often must check multiple places to get a complete view of the patient's record. For data entry, providers may need to remember different processes for various documentation systems.1
- Concurrent use of electronic and paper-based records: As in many other organizations, Mayo's electronic documentation system continued to be used concurrently with paper-based processes in some areas. In addition, although Mayo's outpatient clinics had an electronic medication ordering system in place for more than a decade, inpatient medication ordering continued to be paper based.1
Description of the Innovative ActivityMayo Clinic clinicians and systems engineering analysts worked together to customize and align the clinic's information system (Mayo Integrated Clinical Systems) to better support providers and patient care processes. As a key part of the team's work, team members "shadowed" providers, observing their interactions with patients and current use of IT for managing information. The shadowing process led to direct feedback and open dialogue with clinicians, which served as a catalyst for system enhancements, training initiatives, and other improvements designed to enhance work processes, efficiency, and patient care. Information provided in February 2013 indicates that the program has been discontinued. Specific examples of how the team identified and solved providers' IT-related problems are described below:
- Improving navigation and integration: Physicians shared their difficulties in navigating between screens or applications and stressed the need for better data integration so that information was available where and when needed without the need for many mouse clicks.
- New reporting capabilities: Physicians requested a tool to quickly review essential information before rounds or off-floor consults. To address this issue, the team developed an application to automatically generate the types of reports that were previously done manually, and they improved navigation through the electronic record.
- Integrating patient-reported information: Another challenge related to making patient-reported information accessible to providers. The team of clinicians and systems staff developed an online Web-based questionnaire (available through a Web site or a computer kiosk) to replace paper forms.
- Consolidating medication documentation: Inpatient clinicians wanted the technology to support one electronic consolidated medication list to replace the fragmented system that allowed both electronic and paper-based medication ordering. Mayo implemented a new computerized practitioner order entry system in the hospital that provided many quality and safety safeguards, such as automated checks and alerts related to drug interactions.
- Clinical problems management: Historically, physicians lacked a single, integrated, and complete list of clinical problems to use when documenting diagnoses in their clinical notes, ordering tests, or preparing billing information. A team was tasked with developing a single, accurate, and robust list that would document clinical problems and worked on the design of the software and workflow to satisfy the providers.
- Eliminating redundant documentation: Efforts to make all hospital notes electronic at the point of care were made, at the request of doctors, to avoid redundant data entry. Because of these efforts, physicians were able to electronically document admission, daily progress, and consult notes through dictation or self-entry, and short timelines were set to bring the remainder of staff and resident notes into an electronic format.
- Improving user training: When the observers saw how little time busy physicians had for training to use the Mayo Integrated Clinical Systems effectively, they developed new approaches to onsite training. Thanks to these new approaches, some practices used 5 to 10 minutes at the beginning of a standing meeting to learn about new system changes and tips for using Mayo Integrated Clinical Systems more efficiently. This approach highlighted the advantages of physicians training together, which led to sharing tips and best practices among colleagues. This new program supplemented other existing training opportunities, such as traditional instructor-led classes, Web-based interactive training, and physician-only classes.
Context of the InnovationMayo Clinic is a large, integrated academic group practice with medical and surgical specialties that work together to care for more than 300,000 unique patients each year. Patient care is provided in a multispecialty outpatient clinic and two hospitals with nearly 2,000 beds. A staff of more than 1,700 physicians; 1,700 residents, fellows, and students; and 24,000 allied health personnel are linked by a common EMR, called Mayo Integrated Clinical Systems, which was developed in the early 1990s. Despite using elements of an EMR for more than 15 years, many providers at Mayo believed the system caused them to work inefficiently. In response, Mayo's executive board established "improving provider efficiency" as a major institutional strategic goal in 2005. The board established a study team to investigate how to enhance efficiency and better meet the needs of providers and patients. Members of this study team included physician and administrative leaders, along with analysts familiar with Mayo Integrated Clinical Systems applications and associated clinical workflows. Other clinical representatives were involved in developing solutions and validating results.
ResultsAlthough no hard data were available, Mayo's joint technical-clinical staff committee appeared to have been successful, based on both the number of modifications and enhancements made to the system and direct, informal feedback from physicians indicating increased system use and enhanced efficiency.
Suggestive: The evidence consisted primarily of the number of changes and enhancements implemented, along with informal feedback on usage and efficiency gains.
- System was clearly improved: As a part of this project, a variety of significant changes and enhancements had been made to the Mayo Integrated Clinical Systems and EMR applications, as previously described in the What They Did section.
- Physicians trained: Eleven physician practices participated in customized and enhanced Mayo Integrated Clinical Systems training program.
- Physicians reported increased usage and efficiency: Direct, informal feedback, in the form of a poll of division and practice chairs representing medical outpatient divisions, suggested that roughly one-half of respondents believed that the changes led to increased use of the system and enhanced efficiency.
Planning and Development ProcessKey steps in the planning and development process include the following:
- Ethnographic approach used to study how providers used Mayo Integrated Clinical Systems: To learn why the EMR system was failing busy clinicians, systems analysts followed 100 physicians (representing 8.4 percent of all Mayo physicians), residents, nurse practitioners, registered nurses, and clinical assistants during their regular patient care processes for 2 to 4 hours in outpatient and inpatient settings. This observation was supplemented with informal interviews and followup correspondence.
- Documentation of difficulties and underuse: The observers documented potential inefficiencies, best practices in how physicians used Mayo Integrated Clinical Systems, and observations on how well the current Mayo Integrated Clinical Systems fit into the physician's workflow. The observers also collected feedback about perceptions of inefficiencies and suggestions for enhancements.
- Execution of quick fixes and listing of other opportunities for improvement: Issues that were deemed to be "bugs" in the system or that could be addressed with minimal effort were assigned to the appropriate team for prompt resolution. The remaining items, which generally affected patient care and/or provider performance, were labeled as "improvement opportunities."
- Development of physician-determined priorities: Physician representatives from each clinical practice prioritized the improvement opportunities, and multispecialty physician focus groups were convened, presented with the list, and asked to prioritize based on highest clinical value. Each physician in the team was given the list of issues and voted on which would most improve efficiency and clinical processes. The clinical leaders of Mayo Clinic of Rochester then approved the ranked list.
Resources Used and Skills Needed
- Staffing: Mayo used existing staff to implement nearly all the changes. Outside vendors were used only to modify their own software products used by Mayo Integrated Clinical Systems. Observers and technical implementers came from existing staff, as did the Mayo Integrated Clinical Systems project teams, infrastructure project teams, clinical application support groups, and individual practice steering groups.
- Costs: The costs were fairly minimal because existing programming staff made most of the system and design changes.
Funding SourcesMayo Clinic
The Mayo Clinic funded this initiative using internal resources.
Getting Started with This Innovation
- Set clear goals: Goals should be set related to increased system usage, enhanced provider efficiency, and improved patient care.
- Engage leadership: Encourage hospital or clinic leadership to make it clear that this program is a high priority for the institution as a whole.
- Commit resources: Dedicate adequate resources to the project, including technical staff (which can be internal staff or external consultants/vendors).
- Use shadowing to identify problems: Allow staff, including those who designed and implemented the EMR, to shadow providers and their teams for 3 to 4 hours, including direct observations of interactions with patients. At Mayo, this step was critical in identifying and addressing problem areas, both "quick fixes" and more comprehensive process and training improvements. This step also helped providers and staff build relationships and credibility with each other.
- Prioritize opportunities using established methodology: Develop and categorize a comprehensive list of potential short- and long-term improvements to the system. Categories may include user training, workflow processes, infrastructure, applications, tools and forms, integration, and quality and safety. Establish a methodology for assessing the efficiency gains and other benefits from the list of potential EMR improvements, and use this methodology to prioritize improvements.
Sustaining This Innovation
- Institutionalize the multidisciplinary initiative: Keep the study and usability committees going so that they can continue to refine and modify processes and systems to better integrate the EMR into established physician workflows.
- Maintain interface and navigation review: Recognizing how essential navigation, viewing, and integration of information and applications are to physician efficiency, Mayo created a workgroup, made up of IT staff and physicians, to explore ways to continuously improve and provide more consistent interfaces and navigation. Relying on feedback from each user community, this group made recommendations on how to improve the interface and navigability.
- Although the study was limited to physicians at the Mayo Clinic, the seven major themes identified—training, workflow and processes, multiple system environments, navigation-viewing integration, patient-reported information, clinical problems management, and consolidated medication documentation—are universal and applicable to any clinic or hospital's information system.
Contact the InnovatorJanine Kamath
Chair, Systems and Procedures
200 First Street SW
Rochester, MN 55905
Phone: (507) 284-5802
Innovator DisclosuresMs. Kamath has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.
References/Related ArticlesPuffer M, Ferguson J, Wright B, et al. Partnering with clinical providers to enhance the efficiency of an EMR. J Healthc Inf Manag. 2007;21(1):24-32. [PubMed] Available at: http://www.himss.org/files/HIMSSorg/content/files/jhim/21-1/07_focus_Partnering.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .).
Poissant L, Pereira J, Tamblyn R, et al. The impact of electronic health records on time efficiency of physicians and nurses: a systematic review. J Am Med Inform Assoc. 2005;12(5):505-16. [PubMed] Available at: http://www.jamia.org/cgi/content/abstract/12/5/505?ijkey=a7e8b9346ff6ac17002be3315ee6de6c94df5174&keytype2=tf_ipsecsha.
Walsh SH. The clinician's perspective on electronic medical records and how they can affect patient care. BMJ. 2004;328(7449):1184-7. [PubMed]
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Original publication: October 27, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: March 20, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: February 13, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.