John Maher: Hi. I'm John Maher. I'm here today with Janice MacDonald, vice president of Community Hospital Advisors, which is a consulting firm dedicated to helping hospitals effectively install McKesson Paragon.
Janice is a physical therapist by training, and she became a community hospital chief information officer before coming to work for CHA. Today, we're talking about nursing in a McKesson Paragon Project. Welcome, Janice.
Janice MacDonald: Hi, John, nice to be here.
John: Good. Janice, I've heard the phrase "This is not an IT project." It's still the IT team that needs to build the system, right?
Janice: I have mixed feelings about that phrase, John. IT departments are famous for saying, "This is not an IT project. It's a clinical project." The reality is, it's a little bit of both.
It's a complete partnership between IT and clinical, but I understand why the IT department, say this over and over and over again, because it's clinical engagement. It's nurses and therapists who are actually going to be the users of the system that we're delivering.
Paragon McKesson is a set of tools that we're giving to the clinicians that they're going to use to take care of patients. They're going to use it to document. They're going to use it to get all of the vital care information. They're going to use it to administer medications.
They're going to use this to care for their patients and get all the information day-to-day that they need to do what they do, which is make sure that their patients get well and get the care that they need.
The IT department is giving them the infrastructure, giving them the pieces and parts, but without those nurses and therapists understanding how this is going to work, how are they going to use it every day, then the project just falls apart.
If it gets built by the IT department and handed to the clinicians, it's an invasion into their work space. It is, "What is this that now you're saying I have to use?" It just becomes this thing that I have to do that has nothing to do with taking care of patients.
John: Right. What about the normal day-to-day work that a nurse has to do? Does it really change that much?
Janice: You know, John, it really does. It's a huge change. There are some hospitals that are going really from all of their documentation and care is on paper. Still, today, most of their things that they're taking care of, the vital signs, how the patient's doing. It's all on forms.
Forms that they're used to. Spreadsheets that they're used to filling out. Pieces of paper that they're jotting down when they're with the patient, and then they're going back to the nursing station.
And they're sitting and putting the whole picture back together, or it's just on a clipboard that they're carrying, that taking notes as they go. Now we're asking them to take a computer to the patient's bedside.
Use that computer now to document all of the information as you're assessing your patient, as you're looking at your patient, and you're getting all the things that you look at in their condition and how they're feeling, and their vital signs, and enter it into this computer.
There's nurses that I'm working with who, they don't use computers to do their Christmas shopping and book their flights online, so this is really...
John: It's a complete radical change for them.
Janice: Absolutely. It's really scary. They want to make their patients feel that they're confident and that they're competent at what they're doing. When you put this computer in front of them, and it's shaking their own faith in their ability...
They're not uncomfortable with it. It really just interrupts their whole ability to take care of their patients well, because their focus is not on their patient care. Their focus is on this computer system and this thing that feels so foreign to them.
We really have to do a really good job of one, understanding what it's like for the nurses out of the floor. What they have to do in their work flow, and how we construct these tools so that it isn't this huge, radical change.
They've had good training. They've had a lot of practice. They've had a lot of ways to make this transition go much easier, so it's not a big, scary thing the day we turn it on.
The other comment I wanted to make, even for hospitals that are going from one electronic system to another, you've probably gotten over that hump of the fear of having electronics and computers at the patient bedside, but [laughs] going from one electronic system to another electronic system...
Things are not in the same place. The tabs don't work the same way. It's like you just took all of your paperwork and reformatted everything, and nobody can find anything. It can be just as challenging. It's just challenging in a slightly different way.
John: It's like Microsoft going to Office 2010, and all of the sudden everything is changed, and you're like, "What is this menu system? I don't understand this!"
Janice: [laughs] That's right. It does the same stuff, but it doesn't do it in the same way at all.
John: Right. Is this the end of clipboards at the end of patients' beds? Do we not have those anymore?
Janice: We are getting rid of the clipboards, and if there's nurses out there listening to this, the big thing is, we're getting rid of what's called the Kardex, the nurse's Bible, the day-to-day little shortcuts of, "Here's everything I need to know about my patient on one little index card."
If you've ever looked at a nursing Kardex, it's like pencil erased over and over and over again, so that the paper is almost worn through. Losing that Kardex is just giving up a child.
It's really, really difficult. It's just the way the nurses have done things, and it's worked very effectively, so sometimes it's like, "Why am I giving up this tool that works for me?"
I always tell the nurses that I'm working with, "It feels like such a cliche to say sometimes. I really believe in the electronic and medical record."
But I do. When I was a hospital CIO and working in a hospital, and we put in the McKesson Paragon product, I really do feel like this is information that flows to everybody at the same time. It's suddenly transparent and visible.
I had doctors say to me, "I don't have to go chase the nurse down, and find the vitals that are on the strip of paper in her pocket. I can see them.
I don't have to go and look through six pages of the chart to find out when they had this medication last, or what their reaction was to it, because the medication was all done in a closed loop, electronic chain. I can see everything immediately."
John: I can do that from my office, and then make a determination about which patients I might need to see right away, and that thing.
Janice: Right. The physicians can see the information right away. It takes that nurses' documentation, and I think this is where I've had a very good success in connecting with nurses.
Because they can now see that all of that work I'm doing to take care of the patient, is suddenly visible to someone who cares and can influence their care, immediately; and not just from right here.
The doctor can see it from their office. With tablets and everything now, they can see it from the golf course if they need to. But they can also communicate that information really quickly if a patient has to be transported.
If I'm a nurse up on a med surgery floor and the patient is coming up from the ED, I can look at the information on the patient that's coming up to me, and I can see how they're doing before I even get to them.
There are all these connections that you really can see and the clinicians can see, how much value that this can bring if we could just get over the barriers of the change. That's the hard thing. It's just change management.
John: You have some hospitals that are switching from one electronic system to another; others that maybe are still doing things largely on paper, then they're switching to a system like McKesson Paragon. How much training is necessary?
Janice: Regardless of whether they're going from paper to the McKesson Paragon system, or they're going from one electronic system over to this one, you know it averages about 16 to 20 hours of training per nurse, which is a huge, huge effort.
The last hospital I was at, we had 850 nurses to train.
John: Is that individual training with each nurse? Or do you have classes where a group of nurses come together?
Janice: We've been really successful with a format where nurses were engaged very early in the project, nurses that were actually engaged to build the screens that are used for the care of the patient.
I'm a real, real strong proponent of, you've got to engage your nursing staff directly, and pull some of them that aren't IT nurses. They're not informatics nurses, they're just working floor nurses, they have to be engaged in the project.
They've built the screens. They've helped work through all the really tough decisions about what we're keeping and what we're changing, and what new work flows are coming in. They've toughed it out testing things.
If you've engaged those nurses all the way through, you can also then have those nurses help to deliver training to all the other 850 nurses, because they know their life. They know their pain; they know the good things and the bad things that they deal with.
If they can also deliver the training to those nurses, they really do understand. They're delivering it in a way that, for me to come in as an outsider and say, "I'm going to train you in this system," all I can do is train you in the nuts and bolts of the system.
I can't train you how to use it to care for your patients the way your hospital is set up; the way certain doctors are, the way certain patient flows go. But a nurse that knows that floor, can.
We have been really successful with the constructing training that's called "work flow based." We give you examples to practice that would actually happen within your hospital.
We make sure that there's a nurse from each of the units that understands how it works, so that we can really deliver training that's customized.
There's no such thing in a hospital as just "a nurse." You have med surgical nurses, and IC nurses, and ED nurses and OR nurses, and outpatient clinic nurses.
I'm not even getting to the other line, which is the physical therapists and respiratory therapists and social workers, and all the clinicians.
John: They're all different, and do different things.
Janice: Yeah. Their patient care is different. The way they document is different. Who their information needs to flow to is different, and their training does need to account for how they work.
Otherwise we hit that big barrier of, "I've got to take this computer and go into a patient room." And if I don't know how to do it with that thought of, "All right, how am I going to use this?"
Well, I know that I start my day and I can bring up what's called the action list and I can see that I've got medications to do and I can do my medication rounds. Then I'm going to do my head-to-toe assessments on all my patients.
If we train nurses along that same work flow and we develop training materials that respect their work flow, but you can only develop training materials that respect work flow by working with the nurses that actually are in that.
We can make certain assumptions, but it's 16 hours of training. Some of it's very basic. It is, this is what the screens look like; this is how they work; this is what this button does.
That's something that we can deliver to hospitals and hospitals shouldn't have to pay their staff to recreate this stuff from scratch or from a blank piece of paper.
Then you take that content and shape it very specifically to the specific units and you put in their screen shots and you put in the names of their units and their doctors.
And floors and things and we flow patients through their hospital and we do training that really, really recreates what it's going to be like for them.
But it's a big deal trying to get 850 nurses through 16 hours of training. They're usually fairly large classes, depending on the size. Again, smaller hospitals can do smaller classes. However, there's a great camaraderie in the classes.
The difficulty for hospitals, though, is they've got to take their nurses and pull them out of patient care to provide this training.
But we've actually come up with some really creative ways to do that, split shifts and do other things to help make that not such a financial burden on hospitals, to get this training through.
But there's no short cutting that you have to do training. It is absolutely critical and it makes such a difference at go-live. I just have had that wonderful experience of having nurses really look at me during go-live and go, "I can't believe I'm done."
John: "I know how to use this now."
Janice: Yeah. They're really excited and that they feel confident, and that things that they thought were going to be so hard were just really not as bad as they thought.
John: Right, because the last thing that you'd want is to have a go-live and then have all the nurses go, "What do I do now?"
Janice: Yeah. When you do a go-live, and we've talked about this in other podcast's, everybody's getting hit with change on the same day. It's not just the nurses.
It's the doctors. It's the finance people. It's the registration people. There's a lot of bumps along the road. The doctors really lean on the nurses for support.
Not only do the nurses have to know their own stuff. In a sense they need to know what the changes are for the docs too, because that's very much a partnership and they're going to be supporting each other.
They have to feel strong and confident in where they're coming from, because the physicians are going to come in looking to them for guidance and help as well. It's an interesting thing to watch.
John: We've been talking about the nurses and training the nurses on a system like McKesson Paragon. What about the doctors?
Janice: [laughs] The doctors, absolutely, as I said from the beginning with the nurses, they need to be engaged from the beginning. They need to be part of this.
They need to work all the way from building the screens of the software to training their own in how to use it.
That works the same for the doctors, but it's in a completely different way, again because it's work flow. Their work flow is different.
The doctors are in and out. The nurses are there with the patients all day long and their work flow is different and they're delivering data to the physicians.
The doctors' work flow is different; the doctors' structure and politics and executive level is different, so I think it would probably take me another hour to talk about what we would need to do for the physicians [laughs] , so we might want to save that one for another day.
John: Sounds great. Janice MacDonald, thank you very much for speaking with me today.
Janice: Thanks, John, good to be here.
John: And for 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.