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MD Leader 1/27/09

January 26, 2009 News 8 Comments

Ministry Health Care Will Implement CattailsMD

Ministry Health Care has chosen to implement CattailsMD electronic health record. For over 20, Marshfield Clinic has developed a comprehensive electronic health record, now available as a CCHIT-certified ambulatory EHR product known as CattailsMD. The EHR is also available with a data warehouse to actively drive decision support and population management.

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Conventional Wisdom

Conventional wisdom speaks against the use of an internally developed product. While conventional wisdom is often used as a rule of thumb, tunnel thinking can limit your options. Every software decision is the result of a complex analysis of objectives, risks, benefits, values, and mitigation strategy. The purpose of this post is not an exhaustive explanation of our decision, but rather a review of several factors influencing our thoughts.

EHRs Are Becoming a Utility

Within a few years, EHRs will be more of a utility than a unique product. Increasing CCHIT certification and government incentives are driving standardization of function. Many organizations are turning to SureScripts to satisfy the CMS E-prescribing incentive. SureScripts standards will be just one of many leading to an ever-increasing identical functioning of EHRs. Simply having an EHR will not lead to process improvement nor increase clinical quality.

EHRs Do Not Improve Quality

Most EHRs have not improved quality of care. Simply automating our traditional process should not be expected to fundamentally improve quality. Improvement occurs when we redesign our care systems and standardize our processes (often enabled by use of an EHR). It is not the EHR that magically improves care; it is the people and processes utilizing the EHR that improves care. If you are both vendor and end user, then you can first vision how care should be provided and then deliver the necessary software to support it.

Marshfield Clinic has effectively demonstrated the value of this approach by achieving improved quality of care resulting in decreased health care costs in an ongoing CMS Demonstration Project.

The Status Quo Will Not Meet Future Needs

Our health care system is broken, we simply are not meeting the prevention, wellness, and primary care needs of our patients. We do not have enough primary clinicians to meet our current needs and we are not producing enough primary clinicians to meet our future needs. In Wisconsin (warning: PDF), the demand for primary care clinicians in the next 10 years is projected to increase by as much as 33% with only a 5% increase in clinicians. We will need to redesign our health care delivery system if we hope to meet future needs.

Our use of CattailsMD maximizes our opportunity to influence the design of an EHR to meet the needs of our patients. Although our vendor is interested in the commercial success of the product, as a provider of health care, their prime objective is the same as ours: caring for patients.

It Is All About the Data

Ministry Health Care and the Marshfield Clinic have a large number of common patients and will share the same EHR. While a shared EHR with a single source of truth for medication lists, allergies, labs, and documents is appealing, the real value is an extensive data warehouse ten years in the making. The data warehouse currently contributes to a number of activities including population management, disease management, maintenance of numerous registries, formal research, and increasingly, decision support.

As our business intelligence tools become more robust, I expect increasing emphasis will be placed on activities such as searching the database for trends of best care, identifying potential drug interactions, post-marketing surveillance of medications, and identifying care opportunities that will improve the health of the communities we serve.

A Decision Without Risk?

Is our decision to use CattailsMD without risk? Nope. But then again, no decision is. During the 20 years I have been interested in health care IT, I have seen numerous vendors (both large and small) come and go. I have also been through the agony of “upgrades” in hardware, operating systems and entire new versions of software forced on us by our vendors.

What has not changed is our need for information to improve health care. We are on the threshold of having EHRs and data warehouses that do not just present information, but actively support the practice of medicine.

A Future Post

Ministry Health Care and the Marshfield Clinic have been actively working to build the infrastructure necessary to support a joint EHR. In a future post, Dr. Carlson (Marshfield’s CIO) and I will discuss some of the issues we have dealt with that will have national significance if government seeks to foster greater sharing of patient data.

While you are waiting for a joint post, please take some time to read Will Weider’s (Ministry’s CIO) advice for President Obama.

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Peter Sanderson, MD, MBA is a family physician and Director of Medical Informatics and Operations and Executive Sponsor, EHR Program, at Ministry Health Care. He can be reached at pete.sanderson@ministryhealth.org. He also blogs at MD Leader.

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Currently there are "8 comments" on this Article:

  1. Mr HISTalk, this is your agent calling.. Did you remember to collect the advertising fee from Marshfield Clinic for the big one page add yesterday?

    [From Mr. HIStalk] I don’t get your point. Marshfield Clinic is nonprofit and not selling anything (although they may commercialize CattailsMD someday or allow someone else to). Pete works for Ministry, also nonprofit and a “customer” of Marshfield. There’s no hidden agenda or commercial message that I know of. I think lots of folks are interested in their model and their product.

  2. Meanwhile, this is your other agent calling, and I’d love the idea of more promotion of the open source conference Fred Trotter et al are putting together. Even if it’s excessive and unbalanced reporting(?), I’m all for the “leaning toward supporting open source” kind of imbalance.

  3. Dr. Sanderson drives the case for being both the developer and vendor of an EMR product, as well as the user. Is this a practical way to go? I’m sure the substantial resources consumed in developing, testing and quality assuring the product have focused on his clinic’s preferences. As all of us who have spent a lifetime providing services and products to the medical community know, each practice is unique in its way of doing business, right down to templates and workflows. EMR’s by their nature have to be flexible and adaptable to accommodate this; but that configurability is what makes them more difficult to use “out of the box.” There are tradeoffs at every turn–easy to configure or more rigid in design? Either way, practices must change the way the doctor-patient encounter has traditionally taken place.

    With traditional EMR’s, that often means putting a technology device between the patient and the doctor, ergo the slowdown and loss of productivity that has so marred the EMR experience up to this point. In many ways, this explains why EMR adoption continues to be very low. That’s why hybrid EMR is rapidly gaining traction, especially in higher volume, multi-doctor practices and clinics. The trade-offs are much easier and do not hamper the patient-doctor encounter or slow it down.

    Practices should not have to develop their own products. That takes time, capital and resources which are then not available for providing better patient care. If traditional EMR worked like PHYSICIANS wanted them to, there would be no need for what Dr. Sanderson has tried to do. We need our physicians to keep spending quality time with us and giving us great care. Hopefully tools like hybrid EMR will allow them to do that without having to spend so much on building their own tools.

  4. Dr. Sanderson’s point was the EHR alone cannot achieve the desired results. There needs to be a lot of work around leveraging the technology. Do people disagree with that? Are people unaware of the numerous spectacular failures in healthcare IT?

  5. I don’t think Pete is advocating internal development. He is stating that we did not think that would be where we ended. We need to guard against these pre-conceived notions. We miss a lot of opportunities because of cliches that we rattle off as if they were laws of physics….you never get fired for buying IBM…Integrated solutions are always better than best of breed…there is no room for open source in the enterprise…most of our patients wouldn’t go online…blah, blah, blah.

  6. If what some physicians want was in existence, a number of those who have built their solution likely would not have made that choice.

  7. I totally agree. And I totally disagree. First, I do agree with the point that a tool does not by itself make things better. That tool must become part of a bigger workflow and process to leverage its capabilities. Many, it seems, think that procuring (or developing) a solution will fix everything. If leadership doesn’t drive process improvements – it won’t.
    Now, at this point in time, even the big boys like Microsoft are struggling to keep up in sw development despite having deep pockets and tons of very talented resources. Can a user really develop a best in class solution. Let’s pretend they have the skills. I cannot imagine they don’t have a better use of their internal resources.
    Lots of issues here. Willingness to change the process? SaaS? Customization? Local Integrators? Cost and funding source? Who derives the value? All possible reasons for low EMR adoption rates.







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