Learn how Cleveland Clinic was inspired by the Getting Rid of Stupid Stuff (GROSS) initiative to tackle frustrations with the electronic health record (EHR).
Cleveland Clinic was one of the first organizations to implement Epic in 2001. Nearly 20 years later, the organization recognized that certain tools and processes no longer aligned with clinical workflows. Help was needed in identifying opportunities for improvement.
In November 2018, the Medical Staff Officers introduced a new feedback tool called Staff Chat. The first question on the tool was, “Do you feel Cleveland Clinic provides you with the tools and resources you need to support your practice, as compared to other like-size organizations?” Many physicians answered no, and, as expected, focused their comments on the EHR. Inspired by the successful Getting Rid of Stupid Stuff (GROSS) initiative at Hawaii Pacific Health, we saw an opportunity to address this frustration and provide a permanent vehicle for physicians to make their voices heard.
It was obvious that our predecessors' success was largely due to use of an eye-catching name that communicated humility and a willingness to change. Sticking with this original name, we partnered with the Office of Professional Staff Affairs to generate leadership buy-in, align our physician engagement strategy, and build excitement.
The initiative was kicked off with a comprehensive communication strategy, including intranet articles, presentations, and newsletters. The target audience was our physicians; however, we welcomed ideas from all caregiver roles within Cleveland Clinic. The message was clear: tell us what is “stupid” in Epic. Share the unnecessary tasks, duplicative documentation, and extra clicks that increase daily workload.
There were 2 routes to submit a GROSS idea for consideration:
A “GROSS” button on our physician-facing and Epic intranets
A “Submit Request" icon in Epic
Submitters included the following information in their GROSS submission:
Identify “stupid” EHR stuff they would like to get rid of
Explain why the EHR item is an issue (eg, duplicative documentation)
Suggest potential solutions on how to accomplish this idea
Submissions were categorized into the following buckets:
Quick wins that could be implemented easily and are assigned to the appropriate team
More complex suggestions that required a dedicated project team, submitted through a formal project intake system
Changes unable to be made due to regulatory requirements or other limitations
Opportunities for reminders and re-education around existing features and tools
Since implementation in February 2019, over 675 suggestions have been received. Twenty-five percent of the ideas were related to outpatient workflows and another 25% were related to clinical decision support, orders, and documentation. Close to 10% of ideas were submitted by nursing and front-end employees, and over 4% of submissions were chart corrections pertaining to specific patient information, rather than workflow.
Many ideas have been incorporated into existing projects, such as an initiative to declutter the in-basket and to reduce alert fatigue. Several others have been implemented as quick wins. Examples of successful changes included:
Removal of inappropriate and outdated “Permanent Comments” (patient level comments intended to convey information such as “needs wheelchair”) from patient records.
This field is owned by the front-end team who opened a ticket with the EHR vendor to accomplish this change. This coordination took several months, but the clean-up was able to be performed in the course of 1 day by our vendor.
Removal of outdated messages with a dedicated in-basket clean-up project, along with creating settings that caused certain message types to expire after 90 days.
This work was already in progress; however, the large number of GROSS requests on this topic expedited this initiative. This work was owned mainly by the ambulatory team and was completed in partnership with the Office of Professional Staff Affairs.
Modifications to several disruptive alerts, such as telemetry order reviews.
The clinical decision support lead analyst led the efforts to update these alerts. The clinical decision support oversight work group reviewed and gave final approval of the suggested changes. These changes reduced clicks on chart opening, saving clinicians approximately 30 seconds to 1 minute every time they opened an inpatient chart.
Customization of Epic's widescreen view and other tools, such as synopsis, to align with each department's unique workflows. These suggestions resulted from expanding the scope of the Specialty Transformation project.
Defaulting to the Log report for inpatient order review, displaying all order activity for the current admission.
This was a fast change done by the inpatient team that has saved clinicians several clicks to quickly review existing orders.
Removal of an unnecessary pop-up asking ordering clinicians to choose the size of tubes for lab draws.
This quick fix was done within days of the receiving the suggestion and saved time and clicks.
A fix was put in place for urine glucose and serum glucose results from a specific lab so that the results were no longer inaccurately being trended together.
Prior to GROSS no one had reported this error. This fix, done in partnership with the laboratory group, was completed within several days.
Many other submissions were identified as opportunities for re-education, including regulations requiring the “Mark as Reviewed” button, the appropriate process for chart corrections, and opportunities for personalizing the workspace.
For the submissions where change is not possible, we have found it helpful to develop standardized email responses explaining why.
As expected, the majority of suggestions arrived the first month, requiring many hours of work to categorize, follow-up, and act on each idea. The team learned quickly that the original plan to organize so many submissions into 1 shared spreadsheet made it challenging to efficiently track completed work and next steps. While we have not fully retired the original GROSS submission tracking spreadsheet, existing project management platforms such as Jira are now used for communication with the Information Technology (IT) teams assigned to the work. Initial submissions are still captured on a shared spreadsheet, making sure to include the submitter's name, the type of submission (such as quick fix or educational opportunity), the general theme where applicable (clinical decision support), and the primary IT team to engage. Furthermore, because the actionable ideas require resources to implement, there is still work to be done to define a prioritization process for quick wins versus the work already in progress.
To demonstrate the commitment to this initiative, an IT Medical Director follows up personally on the status of each submission. In addition, quarterly intranet articles provide updates, including tips and tricks for using existing functionality.
Cleveland Clinic is a nonprofit, multi-specialty academic medical center that integrates clinical and hospital care with research and education. More than 65 000 employees care for 2 million patients annually in locations around the globe.
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