John Maher: Hi, I’m John Maher and I’m here today with Janice MacDonald, Vice President of Community Hospital Advisors which is a consulting firm dedicated to helping hospitals effectively install Paragon. Janice is a physical therapist by training and she became a community hospital chief information officer before coming to work for CHA. And today, we’re talking about effective use of McKesson Accelerated Services. Welcome, Janice.
What is McKesson Accelerated Services?
Janice MacDonald: Hey John, how are you today?
John Maher: Good, thanks. So Janice, what is McKesson Accelerated Services?
Janice MacDonald: Accelerated Services is staff augmentation to complete Paragon application build. There are other things that Accelerated Services can come in and provide additional staff for you but one of the key things in a paragon project is McKesson can offer to give you skilled people who can come in and help build the Paragon applications for you.
Benefits and Challenges of Accelerated Services
John Maher: Okay. So what would make a hospital feel like they needed to use Accelerated Services?
Janice MacDonald: Paragon requires a lot of building. There are tables that need to be put together. There are screens and layouts that clinicians and business folks will use to gather and document information and over the course of the whole project, that can be hundreds and hundreds of hours’ worth of work. And sometimes, that work is extremely repetitive.
To take your very, very busy hospital staff, your business office people, your clinicians who aren’t giving up their day jobs for the Paragon project - they’ve still got other work that they’re trying to do and very, very valuable clinical staff at the bedside - to remove them from care, from their day-to-day jobs to have them doing all these build work… I think you can see that it would be very appealing to say, 'Look, we can kind of give you a service that can come in and do some of this keyboard work for you.'
John Maher: Right. 'You don’t have to worry about this. You guys are busy, let’s just take care of it you.'
Janice MacDonald: Right. 'We’ll take care of this for you,' and so it’s very appealing and it is… hospital resources are tough to come by, skilled, experienced people, and taking them on the Paragon project. It can be a real challenge.
John Maher: Right. So then, what can go wrong with the hospital using Accelerated Services?
Janice MacDonald: Yes. And now, this is a very fine line because it is a wonderful service and it sounds great, and you think, 'Why would I not take advantage of this?' It’s just there are risks and downsides to it. There’s a very, very appropriate use of Accelerated Services but things can go wrong. How it works when hospital uses Accelerated Services is that someone in the hospital still has to define what needs to be built. There are decisions and design work that has to be done somewhere.
John Maher: Okay.
Janice MacDonald: If the people that are doing that decision making and design work don’t understand the ins and outs of how the application works, they tend to do layouts on paper and hand them off and then somebody will build what’s given to them, but it doesn’t always work. Translation from paper to the electronic world, it’s just it's never a straightforward thing.
So, it’s that decision in design work that someone has to do before you hand off to someone and say, 'Okay, here’s exactly what we want. Now go ahead and build it and get it done.' There’s just this gap, there’s this risk right there in that hand off.
And so, what we really recommend or what we’ve seen is that if you don’t take some of your resources in hospital, you don’t pull your nurses, you don’t take people off staff and you take a very small group of people and have them make the decisions and hand things off to Accelerated Services to be built, the people who end up using the application are not happy. It doesn’t work the way they thought. There are actually mistakes that can get made, there’s just a lot of risk that gets created in that hand off if there hasn’t been a group of hospital resources that did some really, really good ground work testing, vetting out of how this is going to work before handing things off to be built.
John Maher: Can you give me one or two specific examples of problems that might come up?
Janice MacDonald: Yes. I’ve actually got some good examples that we saw at a hospital and built -- I’ll be a little bit simple with some of these but, but I think I can give you two good examples. If you think, for example, about patient information that needs to be documented in four different areas of the hospital. For example, I’m a nurse and I need to document a patient’s blood pressure, pulse and temperature. I’m oversimplifying a bit, but I’m going to document their blood pressure, their pulse, and their temperature.
So I’m going to do those things on a medical surgical floor, in an ICU, in a pre-op area and in the Emergency Department. If the build for those screens was sort of put together separately - which often happens, we had the ED folks look at their screens and what do you need? And we had the med search people look at their screens and what do you need? We had OR and so on - Well, everybody gets blood pressure and temperature and pulse recorded. But for example, on the med surg floor, first I do blood pressure, then I do pulse, then I do temperature. Then, I go over ICU, well, first I do temperature, then I do pulse, and then I do blood pressure, and then I go to the ED, and it’s blood pressure first, and you just start to mix up the order and the layout of things.
John Maher: Right. So there’s no consistency between the departments.
Janice MacDonald: Right. And if you’re a nurse that floats from one department to another, which is very, very common, the screen that you got used to suddenly looks different and it slows you down and confuses you and it, it’s kind of a simple example but if you lose that consistency, it just really, really throws people off and can cause people problems down the line.
Another example - and that’s almost a little bit more of a risk and again we’ve seen this too. Sometimes, when a nurse is documenting, they’re going to answer a question and a simple example I’m going to put, “Does the patient have their wristbands on? Yes or No.” and that’s a yes or no answer. Either the patient has their wristband on but they don’t have their wristband on.
John Maher: Right, it can’t be both.
Janice MacDonald: Can be both. So the way that should be built is that you’re only allowed to choose one answer that’s called a radio button and that data type is something that’s locked in. Just the way Paragon works, once you build it and publish it, it’s locked in. And if you want to change that data type, you have to rebuild it.
So if you wanted a radio button type, a yes or no answer or only one choice from this list, first is some other thing where I’m documenting skin condition and it can be warm and pink and the whole selection from a list of check boxes, I can have three or four or, or no answers. Those are very different types.
And what we’ve seen is mistakes get made because the people that where building the layout didn’t really understand the difference between having to designate whether this was a radio button or a check box. They didn’t know what that meant, they weren’t experienced with it. They handed off to Accelerated Services. And when things get done, and built, and published, that comes back with the wrong data type. So something that I should be able to make only one choice, I can check both answers, something that I should be able to check three or four, I can only check one. And that’s very frustrating because that actually then needs to be rebuilt.
John Maher: I was going to say, can’t that just be fixed easily after the fact or is that something that takes a long time to fix?
Janice MacDonald: These are some of the of the quirks of the Paragon application - things that you would think might be a simple fix actually means that you have to go back and sort of redo that whole box of data. You have to obsolete the old one, recreate it over again and change the data type. It’s just certain elements get locked in. And it’s just kind of one of the quirks of the Paragon build.
That might sound kind of minor but if it happens in 20 or 30 places, and these people have to go back and you have to kind of keep making these changes and it’s just -- Now, you’ve created more work on the backend fixing things that really could have been caught upfront if we had a team from the hospital that really understood what they were handing off to be built.
John Maher: Right. So isn’t this something that the hospital might expect from Accelerated Services that they would come in and catch these kinds of things from the beginning? Or is it literally that the hospital makes some decisions about what they think they need, hands it off to Accelerated Services, and then, Accelerated Services is just building the system the way that the hospitals said to, and not really questioning anything.
Janice MacDonald: Yes, absolutely. I think, ideally, the hospital would really want the Accelerated Services folks to be able to catch all this stuff, and to be able to send it back to them and say, 'Hey, did you want this type or this type?' And sometimes, that happens but when you really put this picture together, what happens is, the build gets handed off to the Accelerated Services people in pieces. They’re seeing one piece of a jigsaw puzzle. So they often don’t ever see the picture of how it’s all put together because they’re just building their piece.
John Maher: Like the example that you said where a different department has a screen -- the four different departments in the hospital, maybe, have a different screen that maybe being built by a different person from the Accelerated Services team, and then, they’re not really talking to each other or coming up with a coordinated effort.
Janice MacDonald: Right. The four different departments could be built by four different people who aren’t seeing how that flows all together. The Accelerated Services people aren’t the ones doing all the testing and you said everything, so although it would be great if they could catch everything, it’s not always a really fair expectation just because of the nature of the work and the way it’s being segmented off and handed to them.
So sometimes, that happens but again, we see sometimes you think simple things just go wrong because the hand off creates a risk and if the people who are going to use it just haven’t tested it and vetted it, it's just going to create a great opportunity for inconsistencies and errors and lack of flow, and again, then at the end of the project, now your Accelerated Services people believe they’ve done their job because they built what you gave them to build. Now you’re suddenly stuck with all these fixes and things that really --
It’s frustrating because there are potentially really easy things that could have been resolved in a good, solid upfront design phase with people… As I said, there’s really no -- there’s no substitute for the experience you gain from building it yourself. Not just one person but a small team of clerical people understanding how the build affects the use.
And you can only get that from actually building, and then, taking what you built and using it to walk through a patient’s situation that’s when you suddenly go, 'Oh, Aha! I’m missing this. So, I put this in the wrong order,' or 'I never assess that first, I always do this,' or there should be choices. And when you miss that upfront, which again, with this package Accelerated Services will do your build for you.
Well, they can do your build for you but they can’t make your decisions for you. They can’t layout your screens for you. And they really are a large group of resources, and no one of those resources is responsible for you or a big picture. You as the hospital are responsible for putting all those puzzle pieces together.
Solutions to Accelerated Services Challenges
John Maher: Okay. So we’re getting at the solution here. So how does this all come together and how do we get the hospital to work correctly with Accelerated Services in order to make this all come together properly?
Janice MacDonald: And yes, that’s where the CHA group -- We really have seen great value to hospitals from Accelerated Services but that value can just be magnified by -- You just have to bite the bullet a little bit and pull some of your hospital resources; your nurses, the people that are going to be your end users.
There’s no substitute for, I think what we’ve called in other podcasts, “super users” - those people from your hospital that are going to take the time to learn how this thing works, how it interconnects, how it all goes together. That they take the time upfront, do the groundwork, actually learn how to build. And it can be as a small group. In a 300-bed hospital, that can be group of six or eight nurses. We’re not talking 20, 30, 40 nurses but we’re also talking more than one, we’re talking more than the IT analyst, but a small core group representing all your departments, understanding how to do the build and putting it together, and testing it at a certain level.
And then, once they’ve decided, 'All right, we’re now happy with this. We vetted it, we’ve run it past some of our end users, we vetted it, we’ve worked with it, and we can guide that,' then it’s a perfect time to then hand off that vetted build to Accelerated Services. And you can even give them instructions about how they can, in sense, communicate back, who they should communicate back to if they have questions, and encouraging questions from the Accelerated Services folks, and working with their team coordinators.
So again, there are some real positives to it but if you don’t have that upfront knowledge, you will create gaps and issues in the build. And then, there’s one other thing that I wanted to make sure I mentioned. Once Accelerated Services is gone and your project is over and it’s six months down the line, there’s going to be new regulations that come out. There’s going to be new data that needs to be collected. There’s going to be some new clinical effort that requires that we keep building. It’s not a static process. It's not 'build it and you’re done.'
John Maher: Right.
Janice MacDonald: It is an on-going, changing, living thing - this software that you’re going to work with now. And so, if you don’t have some depth of knowledge of how to continue to build it and shape it and work with it, you’re going to kind of be stuck with how do you make the changes that you need to make in a timely and effective way to continue to grow and expand the use of the application, if all of your knowledge of how to build kind of went away with Accelerated Services.
John Maher: Right, because you just sort of -- you made an initial decision about here is what we need, you handed it off to Accelerated Services, but you didn’t have a team from the hospital that was directly involved in building this. Then, when it comes time to make some changes and build some new pages out or whatever resources that you need to add to the Paragon System, then you don’t have a team left in the hospital who knows how to do that.
Janice MacDonald: Right, and so you're either stuck with maybe one person who knows how to do it who’s overloaded with trying to handle more than they can, or now you have to pay somebody to come in and train your people again how to build it.
And in a sense, you’ve already paid for that resource as part of the project. Like I said, I think it’s a sort of the big myth is Accelerated Services can do this all for you. They can’t do it all for you. They can be a great, great resource to help do the repetitive tasks and some of that hundreds of hours of over and over but there’s just no substitute for your core team of clinical super users who really fully understand the build that underlies the use, and all the decisions that went into why it is the way it is.
CHA coordinates, guides, and helps the hospital teams
John Maher: And so, tell me again how CHA gets involved in this process. It sounds like you’re coming in and you’re helping to coordinate that core team from the hospital so that you’re guiding them in the right direction, helping them make these decisions, is that right?
Janice MacDonald: Yes, exactly, John. We come in and we can help them really understand what the decisions are. Because we know how to build the application, we can often do quick mock ups when they’re stuck with a decision point of 'I can do it this way' or 'I can do it this way?' Well, we can show them what those alternatives would look like. We can --
John Maher: 'We’ll show you both a ways and you can test it out and try it, decide which way you like best.'
Janice MacDonald: Yes. 'Let’s play it out and see which way is going to work for you,' because there really are alternatives about how you want to lay this out on which choices you want to make. So we can do work with them, so that they understand the decision points.
We also help people know how to test. How do you go in and actually test and understand all the connections between the Paragon modules because in order to test, 'Does this check box in my nursing documentation trigger the order that goes over to tell the social worker that I want a consult.'
And those are some of the things. And again, Accelerated Services can’t do the testing of the connections but your build is what triggers all those sort of interconnections between the applications and that’s, again, something that we found, for places that relied very heavily on Accelerated Services, they weren't really good at understanding, 'Well, how do I test that everything works and that all my bits and pieces talk to each other?' because they just had never played it through before. So it’s part of the vetting process. It's ‘what are the decision points’? We can help guide those decision points, show people examples, play those decision points through so they really understand the implications of their decision, and then, help them test in sort of mocked up patient care situations to really make sure that they vetted it through.
And then, that’s again - I keep coming back to the word vetting but that’s what we’re doing. We’re vetting their build. Then, when they’re confident, we can then help make sure, that also, that the things that they’ve handed off to Accelerated Services, we help them develop the rules and these rules sound really simple but things like, 'Do I want my font in all capitals or mixed case? Or 'What’s going to be the order of my screens?'
And although that sounds really simple, when those rules don’t get laid out, you get this really confusing -- inconsistent mix of things and it just really hurts your training, and your consistency, and your ability for nurses to float across all departments, and use the application that way.
John Maher: Right. All right, well, thanks for speaking with me today, Janice.
Jasmine: Thanks very much John, my pleasure.
John Maher: And for more information, you can visit the Community Hospital Advisors website at commhospital.com, that’s C-O-M-M-hospital.com, or call 888-811-4687.