Arch Collaborative Learning Summit 2023
Arch Collaborative research continually demonstrates the effectiveness of education, shared ownership, and the ability to meet unique user needs in improving the clinician EHR experience. In July 2023, KLAS hosted the sixth annual Arch Collaborative Learning Summit—an opportunity for healthcare organizations to collaborate and learn how others are working to improve clinicians’ user experiences. 308 leaders from 105 healthcare, HIT vendor, and services firm organizations gathered to share expertise and best practices via panels on maintaining senior leadership buy-in and managing burnout and turnover (summaries of which are found below; recordings can be found on the KLAS website).
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Additionally, KLAS hosted table-top discussions to define three industry terms—governance, clinical informatics, and superusers—and create consistent messaging for these terms. To prepare for these discussions, Dr. Joel Gordon, Melissa Michener, Kate Bakich, Dr. Paula Scariati, and KLAS leaders met to talk about these terms and formulate discussion questions. The following report is a summary of the determined definitions as well as feedback from summit attendees.
Note: Outside of the table-top discussions, summit participants were also asked various polling questions. Discussion questions and polling questions, while often similar, were asked separately and resulted in different feedback from respondents.
Governance
As defined by summit participants, EHR governance is the strategic and operational framework established within a healthcare organization to oversee management, use, and optimization of the EHR. Organizations’ governance strategies should involve the following elements:
Decision-making: Establish a structure for making decisions related to the EHR (e.g., system selection, implementation, configuration, ongoing maintenance); ensure that decisions align with organization’s goals, clinical needs, regulatory requirements, and industry best practices
Training/education oversight: Ensure appropriate training/education programs are in place to support EHR users; provide resources and training materials to help users understand system capabilities, optimize workflows, and adhere to policies and procedures; establish ongoing education to help users stay up to date with system changes and updates
Accountability: Assign clear roles and responsibilities to individuals or committees within organization to ensure efficient use and proper management of EHR workflows; establish mechanisms to monitor compliance and address issues or breaches that may arise
Continuous improvement: Facilitate ongoing evaluation and improvement of the EHR and other related processes; establish mechanisms for gathering user feedback, monitoring system performance, identifying enhancement opportunities, and implementing necessary changes or upgrades; optimize system usability, efficiency, and effectiveness to support patient care and organization objectives
Summit Discussion Questions on Governance
1 How many different governance groups should there be at an organization?
The ideal structure of governance groups varies based on an organization’s size and complexity. The frequency of group meetings determines the speed at which changes can be made. Summit attendees’ organizations most commonly had six or more governance groups focused on the EHR. The number of governance groups can lead to frustration for clinical end users when they suggest EHR enhancements; what they view as a simple change may actually need to go through several committees before being implemented into the EHR.
2 How can an organization successfully involve clinical end users in the governance process (beyond submitting enhancement ideas)?
In order to successfully involve clinical end users in the governance process (beyond submitting enhancement ideas), several strategies can be employed:
- Have clinicians lead the governance process
- Ensure effective IT/informatics rounding (helps clinicians share ideas and give feedback on the EHR)
- Encourage end users to become advocates for ideas
- Have a ticket-tracking system that reports the status of tickets to end users
- Market the success of ideas suggested by end users (shows that their voice is heard and has led to positive EHR changes)
- Include end users in prioritizing ideas for IT to work on
- Keep lines of communication open; share status updates with end users who have dedicated time to submit enhancement ideas
3 How does your organization prioritize/determine which initiatives to push forward?
In general, most healthcare organizations have a process for prioritizing EHR initiatives, but the process may not always be followed—organizations who attended the summit estimated that less than 50% of their clinicians are aware of their prioritization process. To better prioritize EHR initiatives, organizations should follow these steps:
- Generate ideas for enhancement that come from both leadership and end users
- Determine the impact the proposed change would make; if multiple departments or groups are impacted, send the idea to a governance-approval meeting (various committees may be necessary)
- Create a consistent scoring system to use across groups; typical criteria include (a) hours required to make a change, (b) impact on patient safety, (c) impact on clinical workflow, and (d) ability to meet regulatory requirements
Clinical Informatics
Summit participants determined that clinical informatics is an umbrella term that encompasses a multidisciplinary field combining healthcare, information technology, and data analysis to enhance patient care and clinician efficiency. It involves the use of technology and data management systems to collect, store, analyze, and interpret healthcare information for clinical decision-making, research, and process improvement. Clinical informatics may also be involved in workflow analysis, system design, project management, and operational readiness. Professionals in this field serve as a bridge between IT, operations, and administration areas and often act as liaisons, advisors, and advocates for clinical end users.
Summit Discussion Questions on Clinical Informatics
1 What training/expertise do your clinical informaticists have?
Clinical informaticists typically have a clinical background, and they also commonly have backgrounds in IT or data analytics. Many have advanced degrees in informatics. Certification with an organization’s EHR vendor is a common best practice for education. Informaticists are likely to conduct workflow analyses, work toward quality improvement initiatives, and provide EHR training and support. Most are also involved in the implementation of HIT solutions.
2 Are clinical informaticists expected to continue in their clinical role?
Feedback from summit attendees indicates that it is more common for physician informaticists to maintain their clinical practice, whereas nurses more often move into a full-time informaticist role. Among summit respondents, more than half shared that their clinicians are expected to spend some of their time in the clinical setting.
Superusers
As defined by summit participants, an EHR superuser is an individual within a healthcare organization who possesses an extensive understanding of EHR workflows within their area of focus. Superusers are key resources for clinical end users in terms of ensuring successful adoption and optimal utilization of the EHR. Responsibilities of EHR superusers may include:
Aiding communication between IT leadership and clinical end users: Disperse information to end users regarding EHR updates as well as other clinically focused IT initiatives; gather feedback from end users around common pain points and fix requests to help the IT department prioritize upcoming projects
Helping users and resolving issues: Act as the first line of contact for end users who are experiencing EHR troubles; be empathetic with users, deescalate issues when necessary, build relationships, and resolve issues or route users to appropriate IT support channels
Ensuring optimal workflow adoption: Help clinicians adopt optimal organization- and department-level workflows to promote EHR efficiency and standardization
Assisting in system optimization/upgrades: Represent the clinician voice while testing EHR updates and provide feedback before changes go live for end users; help end users understand context around system updates
Providing education/coaching: Provide subject matter expertise to trainers as they build curriculum; lead EHR education/coaching sessions as needed
Supporting system configuration and customization: Have needed technical training and licenses to make changes to the EHR (changes should only impact a small number of clinicians within a given area)
Note: While there are many similarities between superuser responsibilities and clinical informaticist responsibilities, the summit discussions did not delve into those similarities or the differences between these two roles.
Summit Discussion Questions on Superusers
1 How does your organization maintain high superuser engagement and energy? Do you allow engagement to fluctuate with project/upgrade needs?
Maintaining engagement and energy among superusers requires a combination of effective communication, proper training, incentives, flexibility, and recognition of their role’s importance. While fluctuation in engagement can be a practical approach (which many summit participants reported using), healthcare organizations should ensure superusers are equipped to handle ongoing needs and provide value beyond major projects.
2 How are superusers identified and selected at your organization?
Participating organizations reported using various methods to identify and select superusers, including self-identification, leadership appointments, and peer recommendation. The goal is to ensure the superuser group contains motivated, qualified, and engaged individuals who can provide effective support to EHR users.
Panel Summaries
Panel 1: Creating and Maintaining Buy-In from Senior Leadership
Groups working to improve EHR user satisfaction often face challenges with needing more resources while also dealing with budget cuts. Resources are tighter than ever, and healthcare executives continually have to make difficult decisions. During the summit, Dr. Amy Maneker moderated a panel with Dr. Mark Guy, Niki Mayfield, and Dr. Ray Keller to discuss how organizations can get approval for EHR improvement projects amid budget cuts.
The panel determined the following best practices for attaining leadership buy-in:
Align proposal with organization goals; understand the perspective of senior leadership and look for common ground—avoid siloed approaches
“There is no one tactic that works. Being aware strategically of what executives are facing in a very tumultuous time and figuring out how people can communicate effectively within their incomplete understanding of technology is important so that the executives can get a vision for how the technology is needed to do the work. For me, this is an informatics job. Informaticists have to translate technology for the executives just like they have to for clinicians and operational leaders. A lot of it comes down to communicating, understanding where folks are at, understanding the pain points, and finding the strategic moment that the executives are in.” —Dr. Mark Guy
“One of the biggest successes I have had is having an ally team. We built a team of people who are behind the project, starting from boots-on-the-ground providers and clinicians as well as an ally on the executive team who could get buy-in from that group. I particularly built a good relationship with our CIO, who was able to get me at the table of the executive team and help me understand the organization’s strategic plan. I was able to align my road map with where the organization was going. The executive team was really focusing on our ambulatory side, with every provider seeing one more patient a day. In order to get their buy-in, we focused on aligning that strategic goal with our concept of onboarding sprints and EHR training efficiency and proficiency.” —Niki Mayfield
Communicate effectively; build trust and strong relationships with all levels of the organization
“It is important to be trustworthy and a person of integrity. People have to deliver previous asks and make sure they are showcasing deliverables that they have brought in. That way, when they make an appeal to executive leadership, they bring their credibility, data, strategy, and integrity. That is an important principle for me.” —Dr. Mark Guy
“Sometimes I look at decisions as a win-lose situation, but that isn’t the right way. I don’t want to be speaking to someone and looking at the situation in terms of whether I am going to win or whether I am going to lose. People should look for common ground or maybe a different path forward. If they are looking with a win-lose perspective, they will be stuck on the what, but there may be another path forward or a way to get a little win.” —Dr. Ray Keller
Use relevant data and regularly showcase success/ROI of project
“It is important to build relationships and trust with your allies and team as well as communicate easy wins. As you continue to get wins, you will get more and more buy-in from the needed people. . . . Start with successes and continually communicate those successes so that people are hearing and talking about them and so that you can build on those blocks and build an ally team.” —Niki Mayfield
“One of my frequent missteps is not showcasing the good work people are doing and not bringing that progress to the leaders’ and group’s attention. In the past, I viewed that as bragging, but I think showcasing the team’s good work is really, really important. Our new leader has shown me how to do that well, with genuine sincerity.” —Dr. Mark Guy
Be persistent and passionate, but understand the importance of timing
“Our network CEO was very involved in the process. We had regular meetings to talk about the project. One of the things our CEO was concerned about was our 2019 Arch Collaborative survey results, which was our first survey. The CEO was very concerned that we were rolling [Epic] out and that our providers were not happy. We knew provider satisfaction was important to our CEO. We had just completed a pilot that IT funded internally of sprint programs; we did pre- and post-measuring and had great success. The point I am making with this example is that timing is important.” —Dr. Ray Keller
“There are a lot of principles. One is timing; one is data. We have to think about what data we are using because if I am giving data to the CFO, that person is going to want data on the dollar amount.” —Dr. Ray Keller
Panel 2: Burnout and Turnover
Across the healthcare industry, burnout is a prevalent issue—which is confirmed by KLAS Arch Collaborative data as well as the lived experiences of the summit attendees and panelists. Major burnout contributors include staffing shortages, after-hours workloads, bureaucratic tasks taking up too much time, and lack of control over personal workload. Cathy McCabe moderated a panel discussing burnout and turnover with Dr. Abiodun Omoloja, Dr. Bharat Magu, Candice Larson, and Michael Tutty, PhD.
The panelists shared the following best practices that their organizations are using to combat EHR-related burnout:
Good “hygiene” factors (e.g., good EHR, efficient login process, team-based care) won’t prevent burnout, but poor “hygiene” can worsen burnout
“American psychologist Frederick Herzberg proposed the motivator-hygiene theory of job satisfaction. He talked about motivators and hygiene factors, and the motivator factors are what make employees satisfied. . . . The hygiene factors will not make employees satisfied, but if those factors are not there, they will make employees dissatisfied. I consider the EHR to be a hygiene factor. If an organization has created a situation where the EHR works well, that does not necessarily mean clinicians will be highly satisfied. Satisfaction is driven by advancements, recognition, and purposeful work. However, if an organization has a poor EHR experience with increased after-hours work, a slow login process, and non-team-based care, these burdens can cause dissatisfaction.” —Michael Tutty, PhD
Implement a physician builder program to build autonomy and provide ability to control work
“Our previous CMIO suggested that we needed a physician builder program in order to really have a positive impact. Finally, we started that program. We had one primary care physician superuser who took the lead and got trained and certified in six months. Within the first nine months, we saw dramatic improvement, especially in the large primary care area where that superuser worked. Following that, we had four other superusers who have been certified over the years. This has improved physician engagement. We now have one-third of the attrition rate of the community hospital. We have a list of physicians who are in APPs who would like to be certified physician builders.” —Dr. Bharat Magu
Assess what activities lead to burnout; appoint a chief wellness officer who can demonstrate to clinicians that the healthcare organization is actively working to reduce burnout
“We built several resources and tools at the AMA to help physicians build the business case for leadership to explain why investments in addressing burnout are a sound investment for the institution. This includes how to build the evidence, how to implement a survey to get clinician feedback, and an ROI calculator that calculates the cost of burnout for the institution. . . . We know the high cost of turnover for clinicians at all levels. For physicians, it is hundreds of thousands of dollars in recruiting costs and decreased patient access. Even when a new clinician joins, the clinician has a ramp-up time. What is harder to calculate is decreased quality and patient satisfaction. When clinicians are burned out, they are less engaged.” —Michael Tutty, PhD
“One of the things we have done is called an organizational biopsy. That has been very helpful in terms of highlighting burnout issues. That has empowered me as a CMIO to go to management and show them data that supports what I have been telling them about burnout. . . . When we send out the message, it comes from both the CMIO and our wellness officer. That tells people that we are listening and that burnout issues are important. . . . When changes occur, we try to go to the person who suggested the change and tell them their suggestion was heard. Even if we can’t fix something today, we can tell them the change is coming.” —Dr. Abiodun Omoloja
Decrease time spent in EHR by streamlining documentation and messaging processes
“Pre-pandemic, clinicians spent an average of 190 minutes in the EHR during a 12-hour shift. That was a pretty significant amount of time. We were in the bottom quartile for time spent in the EHR. We had to do something, so with heightened awareness and engagement from our executive nursing leadership, so we made it a priority. Shortly after, COVID-19 happened, but we still had executive engagement and support. . . . We heard loud and clear that our nurses wanted changes and that previous change requests had gone into a black hole. We had great engagement from our frontline staff, and we would meet every two weeks to focus on prioritizing our admission history and getting that shored up. After two years, we have significantly reduced the time clinicians spend in the EMR; for a 12-hour shift, the rate is around 130 minutes per shift. Our nursing staff has more time to spend with patients or take breaks. We are pretty proud of that accomplishment.” —Candice Larson
“We have been tracking burnout in physicians since 2011, which peaked in 2014 and started going down in the subsequent years, even into the beginning of COVID-19. Lower burnout at the beginning of the pandemic was a bit of a surprise but highlighted how healthcare professionals at all levels came together to address the pandemic. But in 2021, burnout had reached its highest levels since we started measuring it a decade earlier. The healthcare sector faced staffing shortages, an increased politicization of healthcare, and the continuing stresses of delivering high-quality patient care. For example, the industry has pushed more patients to interact with the patient portal. As a result, we are seeing inbox messages increasing by more than 150% post-pandemic. This can be great for patient care but increases the number of messages for physicians to deal with on top of their busy schedule.” —Michael Tutty, PhD
Summit Attendees
Healthcare Organizations
Alberta Health Services
Aliados Health (formerly Redwood Community Health Coalition)
Allegheny Health Network
AllianceChicago
Aspirus Health
Baptist Health
Baylor Scott & White Health
Breakwater Health Network
Children’s Health System of Texas
Children’s Healthcare of Atlanta
Children’s Hospital Colorado
Children’s Hospital of Philadelphia
Children’s Mercy Kansas City
Children’s Minnesota
Children’s National Hospital
Circle the City
Cleveland Clinic
CommonSpirit Health
Community Health Care Association of New York State
CommUnityCare Health Centers
Confluence Health
Dayton Children’s Hospital
Department of Veterans Affairs
ECU Health
eHealth New South Wales
Frances Mahon Deaconess Hospital
Froedtert & the Medical College of Wisconsin
Gillette Children’s Specialty Healthcare
Harbin Clinic
Harris Health
HCA Healthcare
Health Choice Network
HealthLinc
HonorHealth
Houston Methodist
Illinois Bone & Joint Institute
Inova Health System
INTEGRIS Health
Intermountain Health
Kentucky Health Center Network
Lehigh Valley Health Network
LifeBridge Health
Loma Linda University Health
Louisiana Primary Care Association
Marshfield Clinic Health System
Mayo Clinic
Memorial Hermann Health System
Mercy Health
Michigan Medicine
MultiCare Health System
NYC Health + Hospitals
OCHIN
Ohio State University Wexner Medical Center
Ozarks Healthcare
Providence St. Joseph Health
St. Jude Children’s Research Hospital
SUNY Upstate Medical University
Sutter Health
UC San Diego Health
UCSF Health
UNC Health
University of Illinois Hospital & Health Sciences System
University of Iowa Hospitals & Clinics
University of Texas MD Anderson Cancer Center
University of Utah Health
University of Vermont Health Network
UTHealth Houston
UVA Health
UW Health
UW Medicine
Valley View Hospital
Wellstar Health System
Yuma Regional Medical Center
Vendors and Services Firms
3M
Amplifire
AQuity Solutions
athenahealth
Chartis
CHI (Investor)
CSI Companies
Dedalus
Divurgent
Epic
Evergreen Healthcare Partners
Goliath Technologies
Greenway Health
Holon Solutions
InterSystems
K&M Consulting
MEDITECH
Medix
Nordic
OnPoint Healthcare Partners
ReMedi Health Solutions
Tegria
uPerform
What Is the KLAS Arch Collaborative?
The Arch Collaborative is a group of healthcare organizations committed to improving the EHR experience through standardized surveys and benchmarking. To date, over 300 healthcare organizations have surveyed their end users and over 420,000 clinicians have responded. Impact reports such as this one seek to synthesize the feedback from these clinicians into actionable insights that organizations can use to revolutionize patient care by unlocking the potential of the EHR.
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This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price. Please see the KLAS DATA USE POLICY for information regarding use of this report. © 2019 KLAS Research, LLC. All Rights Reserved. NOTE: Performance scores may change significantly when including newly interviewed provider organizations, especially when added to a smaller sample size like in emerging markets with a small number of live clients. The findings presented are not meant to be conclusive data for an entire client base.