EP447: Why an “EHR Strategy” Isn’t Enough, With Ashleigh Gunter

[00:00:01] [SPEAKER_03]: Episode 447 Why an EHR Strategy Isnt Enough, With Ashleigh Gunter, Relentless Health Value, Stacey Richter

[00:01:19] [SPEAKER_03]: Episode 547

[00:01:22] [SPEAKER_03]: Why an EHR Strategy Isnt Enough, With Ashleigh Gunter, Relentless Health Value, Stacey Richter

[00:01:36] [SPEAKER_03]: Why an EHR Strategy Isnt Enough, With Ashleigh Gunter, Relentless Health Value, Stacey Richter

[00:01:41] [SPEAKER_03]: Why an EHR Strategy Isnt Enough, With Ashleigh Gunter, Relentless Health Value, Stacey Richter

[00:02:11] [SPEAKER_03]: Why an EHR Strategy Isnt Enough, With Ashleigh Gunter, Relentless Health Value, Stacey Richter

[00:02:48] [SPEAKER_03]: Why an EHR Strategy Isnt Enough, With Ashleigh Gunter, Relentless Health Value, Stacey Richter

[00:03:14] [SPEAKER_03]: Why an EHR Strategy Isnt Enough, With Ashleigh Gunter, Relentless Health Value, Stacey Richter

[00:03:55] [SPEAKER_03]: Why an EHR Strategy Isnt Enough, With Ashleigh Gunter, Relentless Health Value, Stacey Richter

[00:04:11] [SPEAKER_03]: Why an EHR Strategy Isnt Enough, With Ashleigh Gunter, Relentless Health Value, Stacey Richter

[00:04:58] [SPEAKER_03]: Why an EHR Strategy Isnt Enough, With Ashleigh Gunter, Relentless Health Value, Stacey Richter

[00:05:19] [SPEAKER_03]: Why an EHR Strategy Isnt Enough, With Ashleigh Gunter, Relentless Health Value, Stacey Richter

[00:05:35] [SPEAKER_03]: Why an EHR Strategy Isnt Enough, With Ashleigh Gunter, Relentless Health Value, Stacey Richter

[00:05:43] [SPEAKER_03]: Why an EHR Strategy Isnt Enough, With Ashleigh Gunter, Relentless Health Value, Stacey Richter

[00:06:34] [SPEAKER_03]: Why an EHR Strategy Isnt Enough, With Ashleigh Gunter, Relentless Health Value, Stacey Richter

[00:06:41] [SPEAKER_03]: Why an EHR Strategy Isnt Enough, With Ashleigh Gunter, Relentless Health Value, Stacey Richter

[00:07:11] [SPEAKER_03]: Why an EHR Strategy Isnt Enough, With Ashleigh Gunter, Relentless Health Value, Stacey Richter

[00:07:57] [SPEAKER_03]: Why an EHR Strategy Isnt Enough, With Ashleigh Gunter, Relentless Health Value, Stacey Richter

[00:08:37] [SPEAKER_01]: Hi, this is Rob Marty. The Relentless Health Strategy Isnt Enough, With Ashleigh Gunter, Relentless Health Value, Stacey Richter

[00:08:56] [SPEAKER_03]: The Relentless Health Strategy Isnt Enough, With Ashleigh Gunter, Relentless Health Value, Stacey Richter

[00:09:10] [SPEAKER_03]: Why an EHR Strategy Isnt Enough, With Ashleigh Gunter, Relentless Health Value, Stacey Richter

[00:09:39] [SPEAKER_02]: Why an EHR Strategy Isnt Enough, With Ashleigh Gunter, Relentless Health Value, Stacey Richter

[00:09:41] [SPEAKER_02]: Why an EHR Strategy Isnt Enough, With Ashleigh Gunter, Relentless Health Value, Stacey Richter

[00:09:41] [SPEAKER_02]: We have this mindset of, if we communicate to people then they're going to like it, right?

[00:09:46] [SPEAKER_02]: We're going to tell them in advance and they're going to understand that we are inherently good people

[00:09:51] [SPEAKER_02]: and we're making this change for them. The reality is that communication in and of itself isn't change management.

[00:10:00] [SPEAKER_02]: I will tell you 100% of the time when I actually go through the process with an organization of building a change management plan

[00:10:11] [SPEAKER_02]: and when we don't do that, and I've seen it over and over again, we get people who don't trust that management is doing this for their benefit.

[00:10:20] [SPEAKER_02]: They think that the executive team is just trying to save a buck. Healthcare is such an emotional thing.

[00:10:27] [SPEAKER_02]: Not taking the time to invest in the process of change management is really super detrimental to getting to the place

[00:10:37] [SPEAKER_02]: that you have good health outcomes and lower cost and providers who are paid fairly. It's so important.

[00:10:45] [SPEAKER_03]: Yeah, it just reminds me of there's a parable or quote which is sometimes the shortest way home is the long way around.

[00:10:53] [SPEAKER_03]: Let's talk about, I could see as being very vital, you know, let's just say there's a direct contract.

[00:10:59] [SPEAKER_03]: How does this work on the provider organization side of the equation?

[00:11:03] [SPEAKER_02]: That's a great question. Honestly, I think we all assume that doctors are really smart people because they are.

[00:11:13] [SPEAKER_02]: They've been to medical school and the challenges that oftentimes we just assume doctors are going to understand a different payment model

[00:11:23] [SPEAKER_02]: and a different process without us actually spending the time to educate and bring them along through the process.

[00:11:31] [SPEAKER_02]: And in my experience, doctors are incredibly smart people, but they didn't go to business school.

[00:11:38] [SPEAKER_02]: They went to med school and they have people in their office at the front desk and their nursing staff and their revenue cycle staff.

[00:11:46] [SPEAKER_02]: And there are processes that exist that aren't necessarily always set up to address these direct contracts.

[00:11:54] [SPEAKER_02]: And so the minute we change the process and an employee comes in with a card that doesn't look like the one they're used to at the front desk,

[00:12:06] [SPEAKER_02]: we create disruption for the doctors. So you have to go through the exact same process of creating this case for change for the doctors and their offices.

[00:12:16] [SPEAKER_02]: So they understand what's in it for them. And the answer to that is more control over how they get to treat their patients and greater revenue,

[00:12:27] [SPEAKER_02]: more time to spend with their patient population, but that there are some bumps in the road in that they need to be able to handle a situation that their current EHR isn't necessarily built for

[00:12:43] [SPEAKER_02]: and their current internal processes haven't been built for. So spending the time to educate them up front, create that raving fan.

[00:12:52] [SPEAKER_02]: And yes, this is the right answer for medicine and for me. And then building out those processes and the right technology support to ensure that providers can handle these direct contracts is incredibly important.

[00:13:06] [SPEAKER_03]: Yeah. And just to put a fine point on that, I was just reading reviews of an innovative direct contract that somebody had set up. So there was a health plan that was offering a kind of an innovative service

[00:13:25] [SPEAKER_03]: and did a direct contract with a number of different provider organizations. Employees go to those provider organizations and the front desk person says that she or he has never seen this card before.

[00:13:37] [SPEAKER_03]: They have no idea what to do with it. It's like, okay, that's a fail right out of the gate. Everyone just lost. So there certainly had a minimum, a measure of training as part of this process that obviously didn't happen.

[00:13:52] [SPEAKER_03]: You know, like this whole thing gets put into place with very little consideration relative to any sort of operational aspects, which I think it's funny because I was just having a conversation about this with someone the other day just talking about how so often in healthcare

[00:14:11] [SPEAKER_03]: it seems that operational considerations get ignored. Like for example, the whole thing with team based care, which is getting a really bad rap. Because if you just say, okay, we're going to work as a team, if you do that really badly, then now we went from someone being accountable for the results or patient outcomes

[00:14:32] [SPEAKER_02]: or patients in general to like no one being responsible. No one being accountable. Yeah, everything suffers. Let me give you this other example. So think about it from this perspective. A patient comes in the front desk figures out that yes, in fact, this is a directly contract patient.

[00:14:50] [SPEAKER_02]: Great. However, the person who is doing the coding doesn't get that message. And so they code as fee for service, as opposed to direct contract. And so all of a sudden, you've got this claim that is a fee for service claim in the HR getting sent out to the TPA.

[00:15:13] [SPEAKER_02]: And you've got this mess on your hands when the claim gets denied. Everybody's confused and frustrated. The patient is thinking, well, wait a minute, you know, this is this is supposed to be covered as a part of my direct contract. What you know what's going on here.

[00:15:28] [SPEAKER_02]: So it's this really challenging situation where you want to ensure you are educating the operational folks, whether it's rev cycle or your front desk or or whomever it is. So they truly understand you're using a different model, whether it's, you know, prospective payment, or it's just a direct contract at percentage of

[00:15:56] [SPEAKER_02]: Medicare or whatever the situation is, but ensuring that it's all flowing through the doctor's office appropriately and avoiding that headache for both the patient and the practice.

[00:16:08] [SPEAKER_03]: It's a challenging situation that doesn't need to happen.

[00:16:11] [SPEAKER_03]: It's like an avoidable readmission, right? Like just doing it right up front can prevent these downstream headaches which wind up taking five times as long.

[00:16:23] [SPEAKER_03]: It had just been sort of thought through upfront from not only a what do we want to do standpoint but from a how are we actually going to operationalize this how are we going to communicate.

[00:16:34] [SPEAKER_03]: So let's talk about change management for a sec. Like is it a science? Is it a discipline? What is it? What are we talking about here?

[00:16:42] [SPEAKER_02]: It is a science, but it's also an art. Change management is the process that an organization and good leaders use to help move through the process of change.

[00:16:55] [SPEAKER_02]: There's nothing rocket science about it. I honestly when people say change management, often people think it's either a communication plan or it's something super esoteric that causes us all to sit in a circle, hold hands and sing kumbaya, which is absolutely not the case.

[00:17:10] [SPEAKER_02]: It is truly a set of steps that we go through to build some leadership, build a case for change, help engage the stakeholder population, help them understand what's going to happen in this change, communicate over and over and over again, and then actually celebrate once that change is made and talk about the amazing things that we've accomplished as a team.

[00:17:36] [SPEAKER_03]: From what I understand, there are five main steps in a change management process. You mentioned before that the first step is great leadership. What do you mean by great leadership? What does great leadership look like?

[00:17:49] [SPEAKER_02]: Change starts at the top in any organization, whether it's healthcare or any other situation. You have to have a sponsor who fundamentally believes that making a change in your benefits plan is the right thing for the employees and the right that they're doing.

[00:18:06] [SPEAKER_02]: You have to have a leader that's willing to say that over and over and over again. And then we ask that leader to build a team around him or her to help be the advocates for that change. Without that leadership team, it will fail without leadership.

[00:18:26] [SPEAKER_03]: If the leader is not on board here or is not modeling their behavior in alignment or congruently with the change, then you get what could be, I could see an insurmountable sort of disconnect.

[00:18:41] [SPEAKER_02]: Right. You get a disconnect because if my leader's not engaged, why should I be engaged? There's no incentive for me. There's no benefit for me to do something if my leader doesn't think it's important.

[00:18:55] [SPEAKER_02]: So leadership sets the tone. And then step two after great leadership is creating the case for change. That's right. One of the things that makes a change so hard is that it's so complicated.

[00:19:08] [SPEAKER_02]: When we talk about this conceptually, the idea makes perfect sense at a 10,000 foot level. But when you start to drill down into the details, there's lots of complexity there. And so to get through the hard work that it takes to make a change, you really have to create that reason to do it.

[00:19:30] [SPEAKER_02]: So what's the company reason to make this change happen? What is it that they're trying to achieve that they can achieve through making this change? So getting really clear about that and also getting clear because if we think, oh sure, Mecca exists out there,

[00:19:51] [SPEAKER_02]: we can go to this wonderful place, but I don't have any way to get there. Then it's much harder to rally a group around trying to get to Mecca if you have no mechanism to get there. So what is it that you're going to do to make this change happen and putting that in plain English? Explain what's going on.

[00:20:10] [SPEAKER_02]: That's so important when you're creating that case for change.

[00:20:13] [SPEAKER_03]: What I'm distilling you saying down to is that established behavior patterns, change is always a little scary and a little bit frightening. And it might be a little bit more time consuming because I'm going to have to learn the new way to do it.

[00:20:27] [SPEAKER_03]: I'm going to have to learn how to navigate in this new space. So if I clearly understand what I'm getting, like what though what's in it for me is a much more willing to deal with this sort of short term pain because the long term gain is clear.

[00:20:44] [SPEAKER_02]: That's 100% it and that is why the next step is focused on creating change champions. Let's talk about change champions. This is the single biggest thing after creating great leadership that I think is the most important thing.

[00:20:57] [SPEAKER_02]: I think an organization can do to create success when making a change in their benefit plan.

[00:21:05] [SPEAKER_02]: Bring in individual contributors or supervisors or folks who are on the front line who are vocal in the organization, maybe have some influence in the organization and that other people listen to them.

[00:21:22] [SPEAKER_02]: Bring them into this conversation. Help them to understand, just like you've helped the leadership team to understand, okay, here's what's possible.

[00:21:35] [SPEAKER_02]: Let's talk about crafting a plan together. So bring them in early. Let them participate and let them be the advocates to their peers.

[00:21:45] [SPEAKER_02]: It's in those situations that I see the trust being built. The message is coming from multiple places and it builds trust.

[00:21:55] [SPEAKER_03]: Yes, and I think that's very well established. I'm just recalling Jeffrey Moore, the old crossing the chasm book that where this is proven pretty endlessly that having peer champions who really understand this very well

[00:22:12] [SPEAKER_03]: and can talk to their colleagues in the language of their colleagues, you can't say enough about that. It's a step that lots of people forget.

[00:22:22] [SPEAKER_03]: It's the same thing and I know we're going to get to this later but people stick something in the EHR and then wonder why nobody's using it or there's an app and they wonder why.

[00:22:31] [SPEAKER_03]: And then, you know, it's kind of like well how many doctors were on the committee? How many nurses were on the committee? How many patients were in that room when this was decided and yeah, it's no surprise.

[00:22:43] [SPEAKER_02]: It's interesting though because, you know, oftentimes when companies think about change, they don't apply a change management approach just because they think, oh, this is a simple change.

[00:22:54] [SPEAKER_02]: Well, when you're talking about transformation and doing some bundled contracts or direct contracts or any of the things that you might undertake that lead toward value based care.

[00:23:08] [SPEAKER_02]: It's a real change and it should be treated just like any other major change in the organization.

[00:23:14] [SPEAKER_03]: Well, I mean not only is it a major change but it's also healthcare. So like there's that. Let's talk about step four then which is over communicate.

[00:23:25] [SPEAKER_02]: My favorite statistic is from John Cotter who is the expert on change and as a professor at Harvard Business School.

[00:23:34] [SPEAKER_02]: He says that most executives underestimate the need for communication by a factor of 10. And it's so interesting to me because I see this in my own company, right?

[00:23:45] [SPEAKER_02]: I communicate something and I think I've done this really good job of I told a group of people. I told the leaders I had them cascade.

[00:23:54] [SPEAKER_02]: I send out a message and you know, I put it in the company Slack channel and I find people who have no idea, you know, what I've communicated.

[00:24:05] [SPEAKER_02]: And it's simply because there is so much communication that happens in any given organization that the messaging just gets diluted.

[00:24:14] [SPEAKER_02]: And so as a leader who is undertaking a major change, it's something you have to focus on over and over and over again.

[00:24:24] [SPEAKER_02]: And you probably get sick of saying it but that's the way that you get to the point that the employees hear the message.

[00:24:32] [SPEAKER_02]: And so communicate, communicate, communicate.

[00:24:33] [SPEAKER_03]: Yeah, and it's the same sort of thing in marketing. Like there's a often cited marketing trope or truism that you have to communicate a marketing message nine times before someone remembers it.

[00:24:47] [SPEAKER_03]: And again, although this is very well established, the whole nine times thing, not many people manage it when rolling out internal initiatives.

[00:24:56] [SPEAKER_03]: I mean, maybe they're pressed for time. Maybe it's boring to say the same thing nine times.

[00:25:00] [SPEAKER_02]: They get bored. But but also what happens is people think I'm belittling them because I've already told them this they don't like to hear it again.

[00:25:09] [SPEAKER_02]: So it's interesting the number of rationales that I hear from people. The reality is you just got to say it 10 times.

[00:25:15] [SPEAKER_03]: Well, I think also, especially if something is complicated and there's a lot of nuances, the number of communications could help layer on additional understanding or aspects of it.

[00:25:32] [SPEAKER_03]: It's not like they go from zero to 100 on the 10th time is that every single time they hear it, they understand a little bit more.

[00:25:39] [SPEAKER_02]: That's absolutely right. We start with those kind of pieces of information that help an employee population get their hands around like what's the scope of this problem?

[00:25:51] [SPEAKER_02]: And then we begin to move into and and fixes exist, right? So there are ways for us to impact this problem.

[00:25:59] [SPEAKER_02]: There are ways for us as a population to be well and to save money and to compensate our doctors appropriately.

[00:26:06] [SPEAKER_02]: And then from there we start to move into specifics around, OK, so what does that mean here in our organization?

[00:26:14] [SPEAKER_02]: And then where do you get support and who can you call for help? Building from that sort of general of what are we even talking about here through to, OK, I understand.

[00:26:25] [SPEAKER_02]: I know who to call when I need help and I feel empowered.

[00:26:29] [SPEAKER_03]: It sounds like you start with the why you get into the what like what we're doing here, but then we can't lose track of the how.

[00:26:35] [SPEAKER_03]: Exactly, which I think is the very, very frustrating when someone finds themselves at loose ends because they know there's a new process, but they don't know what it is or how to go about it.

[00:26:46] [SPEAKER_03]: Exactly. OK, so let's move into step five in which we measure.

[00:26:52] [SPEAKER_02]: Yeah, so it's really important one that we're getting feedback.

[00:26:56] [SPEAKER_02]: How did that go?

[00:26:57] [SPEAKER_02]: Well, what would have made it easier because you can learn, but you also want to measure the success and then we're sharing that information back, not only with the executive team, but on the whole to say so here are the wins that we're achieving.

[00:27:11] [SPEAKER_02]: We know this was a hard road.

[00:27:12] [SPEAKER_02]: We know it required change.

[00:27:14] [SPEAKER_02]: We know it was a little bit bumpy at times because it will be but here are the results that we're seeing.

[00:27:19] [SPEAKER_02]: So sharing great stories about a particular person or whatever the story is that's relevant to that particular organization.

[00:27:29] [SPEAKER_03]: So it sounds like that last step there not only includes measuring, but then also communicating the successes.

[00:27:36] [SPEAKER_02]: Absolutely.

[00:27:37] [SPEAKER_02]: Celebrating those wins is a way to cement that we've made this change.

[00:27:43] [SPEAKER_02]: It was the right change kind of prevents buyers remorse that occurs sometimes when you hit a bump in the road.

[00:27:48] [SPEAKER_02]: Oh, yeah. No, this is why we're doing this. Here's the benefit for us and isn't that great?

[00:27:54] [SPEAKER_03]: Obviously change management. It's a thing. It's a whole discipline.

[00:28:00] [SPEAKER_03]: If someone is interested in the work that you are doing over at Translucent Healthcare Consulting, where would you direct them for more info?

[00:28:08] [SPEAKER_03]: What's your web URL?

[00:28:09] [SPEAKER_02]: It's translucenthc.com.

[00:28:12] [SPEAKER_03]: Ashley Gunther, thank you so much for being on Relentless Health Value today.

[00:28:16] [SPEAKER_03]: Thank you for the time.

[00:28:17] [SPEAKER_02]: I really enjoyed it.

[00:28:18] [SPEAKER_01]: Hi, this is Rob Marty. The Relentless Health Tribe has had a positive impact on my life since I first started listening two years ago.

[00:28:26] [SPEAKER_01]: Support this tribe by leaving a review, subscribing to the newsletter, and most importantly inviting others to join the tribe by sharing the podcast with them.

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