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HIStalk Interviews Leland Babitch, CMIO, Detroit Medical Center

October 18, 2010 Interviews 25 Comments

Leland Babitch, MD, MBA is chief medical information officer at Detroit Medical Center, Detroit, MI.

10-18-2010 7-11-35 PM

Tell me about yourself and about your job.

I’m chief medical information officer for the Detroit Medical Center, an eight-hospital system in the city of Detroit and surrounding suburbs. We have both academic hospitals and also more community-based hospitals. About 1,600 beds total, and I think about $3.6 billion in revenue.

I’ve been in the position of CMIO for two years. Prior to that I, was the medical director for information services at the Children’s Hospital of Michigan, and worked closely with our CMO — because we didn’t have a CMIO prior to myself — on the rollout of CPOE, nursing documentation, and closed loop med administration from 2006 through 2007 at our eight hospitals.

DMC tried CPOE in 2003 and said it would regroup and try it again. What lessons were learned from that first attempt?

In 2003 we did try at one hospital — a more community-based hospital — on two units. We did it on our rehab unit, the psych unit. I think the first lesson we learned there was that it was really just designed as, or worked out as, an IT project. I mean, it was really IT-led and there wasn’t clinical involvement from the get-go.

There wasn’t really a leadership pattern that had physician and nursing components to it. There wasn’t a design phase that included a lot of clinicians. There wasn’t leadership buy-in from the hospital. We took the product from the vendor and implemented what they gave us. It was really doomed to fail from the start.

How would you compare Cerner and Epic?

I think they are very similar corporations. We do not have Epic at any of our sites. We’ve been with Cerner since 1998. I think at the time that we were making the decision around CPOE, we entertained the option of switching from Cerner to somebody else, including Epic.

As we looked at Epic, especially back then, the problem was that Epic didn’t scale very well. So whereas it might do well in a large clinic setting, or even in a single large hospital, going up to the scale and size of the database that we had — and it’s continued to grow — was not something we were convinced they could do well. I am not a technical person, I will warn you. That’s what I’ve been told by our CIO and other IT people. It really was an issue of scalability.

If you look at the two vendors competing head-to-head, people talk about the usability of Epic maybe being better. I think they will spar back and forth with each other and the other large vendors in terms of usability, and there are places were each vendor excels.

At the end of the day, the success of a CPOE or EMR launch is partially dependent upon the technology and the vendor, but really it comes down to the team that’s implementing it. It’s the experience and the policies that are in place around it. The clinical transformation is really what makes it work.

We are soon becoming part of the Vanguard System, and Vanguard does not have Cerner. They’re primarily McKesson and Meditech at their existing sites. We are far more advanced than they are at any of their hospitals right now. We’re at HIMSS Level 6 at all of our sites and they just finished nursing documentation at their last site in the past couple of months. They won’t have CPOE in any of them until 2011.

They’re looking, nonetheless, because there’s a lot we’ve learned, in terms of infrastructure and lessons learned, that are applicable regardless of the EMR. The things that we’ve done will work just as well in a McKesson and Meditech environment as they did in the Cerner environment.

How do you think it will change selling out to an investor-owned chain, which are usually less far along in informatics?

It’s not going to change the mission of Detroit Medical Center, especially in the medium run. We have guarantees built into our contract in terms of what we do with the community. We will not close any of the hospitals for the next ten years. We will not change our policies on charity care for the next ten years, at least.

I think in a lot of ways, just because of where we are, we can’t change that significantly. I mean, they can’t come into the DMC in the middle of one of the poorest inner cities in the nation and expect that they’re suddenly going to turn us into a Mayo Clinic where we’re getting tertiary referrals only and picking and choosing patients that come our way. We’re always going to have a base of taking care of our community at the core of what we do.

It makes us think of financials in a different way. There’s really no difference between a for-profit and a not-for-profit. If there’s no margin, there’s no mission. Before, we didn’t call it a profit, it was technically that we were retaining earnings. But nonetheless, if we were losing money, we were in trouble.

At least now we will have some capital that’s put into to allow us to do some of the things that we haven’t been able to do for years and years, in terms of improving our infrastructure. Things that put us at a competitive disadvantage with our suburban counterparts in the same area who had a better payer mix or may have had some reserves that they were able to put away and were able to build the hospitals with Zen gardens. I don’t think we’re going to be wasteful with our money, but it will give us the opportunity to take some of our infrastructure and make it better than before.

From an EMR perspective, I think Vanguard is expecting us to continue along the same path. We fully intend to meet Meaningful Use at the very first opportunity to report, somewhere around April 1, and to receive the first round of checks. As far as Vanguard is concerned, we will take our lessons learned and share them with them and help them to get there, too, so that they don’t miss out on their opportunity.

We’re lucky because out of our eight hospitals — seven separate physical buildings — we have six provider numbers. A lot of the institutions that have the problems of going under one provider number, we don’t have as much. Vanguard in San Antonio, I believe, is all under one provider number. There’s less incentive for them and other hospitals systems right now the way they designed Meaningful use because the dollars just don’t scale to all the separate buildings that they may have.

If Vanguard were to ask whether you could demonstrate higher quality or lower cost since you reached Stage 6, could you?

The press release that got us to this conversation points specifically to pressure ulcers and saving money, and being able to document our before and after because we went into it with that goal. It was part of our launch of that project. The Cerner Lighthouse project was a profit-sharing model, so they went at risk with us. We implemented it, and therefore, we can demonstrate an agreed-on return on investment.

The lessons learned are diffuse. They’re hard to measure. What we want to point out is that this one case, we’re saving $4.5 million. With CPOE and closed-loop medication administration, we had a 75% reduction in medication errors.

In other areas, it’s much harder to put a dollar price tag. We do know, for instance, compared year over year if you look at our Blue Cross perfect scores on core measures, $2.5-3 million increase on quality outcomes, and measures for Blue Cross / Blue Shield reimbursement initiative. How much of that was because of the EMR? Likely a significant portion. I mean, a lot of the changes we made to our EMR in 2008 and 2009 were focused on Core Measures.

There are lots of returns and I think Vanguard realizes that our quality metrics are very good. To a large extent, that is because of the EMR.

Tell me how the Lighthouse Project works.

Cerner essentially packages together a bunch of components. They may be PowerForms, which are for nursing documentation. Parts may involve physician documentation or M pages, which are Millennium pages, an HTML-based view of data from around the EMR, and physician documentation is a component of that. All of those can be packaged together into a Lighthouse. There’s a few dozen of them now. They focus on things like DVT, stroke, and community-acquired pneumonia.

When you look at your key patient priorities, what supporting technologies do you think you’ll need?

Right now we’re really focused on bloodstream infections. We are looking are looking to implement the Cerner Lighthouse for that. We are also interested in the early identification of sepsis and have just put in some tools to alert users of patient status changes for the worse. I also want to take pieces from a Lighthouse that focus on transfusions because I think there’s some low-hanging fruit there in terms of our utilization.

I think that we have a lot that we can do in terms of nursing satisfaction and nursing productivity if we can continue to roll out our automated infrastructure and bring data from monitors and other integrated devices directly into the EMR. We trialed the technology on a few of our floors with success. The problem there is the upfront cost of connecting and/or upgrading the devices so that they can interact with the system.

We actually demonstrated the technology for getting floor vitals into the EMR last year at Cerner health conference. We’re going to be demoing and trying newer units internally over the coming months.

I think we are getting to the point where we will have the luxury of starting to get information out of the system rather than just feeding it all the time. We have some rules and alerts that we’ve gotten from another Cerner client around sepsis.The rules take existing data and report concerning trends and then present those to end users, allowing them to activate rapid response teams faster and earlier.

I think that’s really what the future’s about. It’s the system giving us much more clinical decision support aside from just drug-drug or drug-allergy alerts. At the end of the day, we want the computer to do some computing. You want it to some of the thinking for you. That’s something I’m very excited about.

I’m presenting on the use of the iPad and iPhones at their health conference. Between Android and iPads and iPhones and whatnot, I think that there’s a lot of opportunity to view and enter data and interact with the EMR aside from using WOWs or fixed desktops, depending on what situation the end user is in because those aren’t all the available resources for them.

If you look out five to ten years, where do you think healthcare IT will change the most?

I think that it’s going to stop being about entering the data and it’ll become more about using the data. I think that what we have to get over is the CPOE, the nursing documentation, the physician documentation. All of which, quite honestly, especially in today’s systems, are a little bit harder than to do it the old-fashioned way.

I believe that there will be convergence in functionality and usability, so that the need to train end-users will diminish. I have looked at examples of workflow and screenshots from multiple vendors for the same process and it is remarkable how similar they look.

I think it was and article from the 1830s in The London Times where they said, ”This device is getting in the way of the physician-patient relationship and will never be widely accepted.” They were talking about the stethoscope. I tell people all the time that I am a stethescopist. Early on, you’ve got to convince people that the tool is safe, effective, and useful. Eventually, they accept it, bring it into their regular routines, and even ask for innovations around it.

But by the time I retire, I anticipate that my job will be obsolete. You will be able to move from one hospital system to one down the street and there won’t be a large learning curve in using the EMR. There won’t even really be a thought process in it anymore. There will obviously be enhancements, upgrades, and constant innovation, but it won’t be about the type of sales and promotion that I have to do today.

Any concluding thoughts?

I think this press release on our savings has gotten a lot of air play — you know, bloggers and others. I’m a little surprised by it. Our goal was really to do a little to counteract the New England Journal article from Boston where they were saying that there is no good evidence of real savings from an EMR implementation. It shows there are real examples of real returns and aside from the monies that the Feds are going to give us, which will not quite match what we’ve spent so far.

There are immeasurable returns, and those that are more measurable, and all of that will be considered. This is a process that we undertook, not because of dollars and cents, but because of the common sense behind it. It’s about patient safety at the end of the day. I really do believe that we are adding to the patient’s safety.

We are seeing improving financials year over year for the past several years, and that was part of what attracted Vanguard to us. We were using it as a cornerstone of our profile. We were one of the first on the block. Maybe the first, really, using the EMR as a marketing tool and leveraging it in that way, saying, “We have100% CPOE at our hospitals. Does your doctor do that?” or ” We scan all of our meds before we give them to you or your mother or your kid. Does your hospital do that?”

We see it as a differentiator. We know in the long run it won’t be. It will become something everybody has. But we saw it as important for the physician and the goals of the organization, such that we really turned on a dime.

From our CIO walking through the door and saying, “Our first and foremost goal right now is system stability” to saying, “System stability is key, and critical, but our first and foremost goal is to get the most advanced and safest EMR and systems that we can have.” That was in a very short timeframe that we went from one mandate to another because our CEO and our board really had made the decision to move forward with it.

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Currently there are "25 comments" on this Article:

  1. I think that what Dr Babitch touched on here is dead on… It is the implementation, not necessarily the system. I have done multi-hospital implemenations in Cerner and Epic and have seen success with both systems, as well as failures with both systems. The project needs buy in from the medical staff, but it also needs a lot of IT buy in as well. It has to be a network wide effort. Those sales demos are great, but I challenge anyone to ask “What exactly does it take to get to that point?” And any vendor saying less than 1 year is blowing smoke where the sun doesn’t shine. There is a lot of design and build and agreements and politicking that must be done for a large site. Also, reporting is nearly worthless without standardization. If 5 hospitals have 5 different ways of recording or ordering, data is going to be missed. I think that is a key part of MU that will be missed because these new EMRs are being slammed in and just replicating the same bad decisions made with the old EMR. Nice to see an article where Cerner was not listed as a complete failure.

  2. Implementation is a large part of success, sound policies and physician by in are needed.

    As for Epic not scaling up well, Kaiser certainly uses them for a reason and I’d imagine scaling must be part of it.

  3. wasn’t scalability the big knock on Epic during the Kaiser install? if i recall correctly, they had serious problems handling the volumes of data. not sure how much build Kaiser had to do to correct Epic’s deficiencies. by my understanding of the architectures, McKesson’s Horizon clinicals is actually the most scalable EHR on the market; don’t quote me on that, I’m certainly not up to date on all the architectural platforms of all the vendors. Dr. Babitch makes an absolutely correct observation – the implementation teams, IT department, and hospital management team have much more to do with success than the software. one can find all sorts of examples of health systems struggling and succeeding on the same software.

  4. Leland says: ” We took the product from the vendor and implemented what they gave us. It was really doomed to fail from the start.”

    Leland, such doom equates to injuries, deaths, and other adverse events. To where did you report the adverse events, or were they all due to user error?

  5. DMC tried CPOE in 2003 and said it would regroup and try it again. What lessons were learned from that first attempt?

    … In 2003 we did try at one hospital — a more community-based hospital — on two units. We did it on our rehab unit, the psych unit. I think the first lesson we learned there was that it was really just designed as, or worked out as, an IT project. I mean, it was really IT-led and there wasn’t clinical involvement from the get-go. There wasn’t really a leadership pattern that had physician and nursing components to it. There wasn’t a design phase that included a lot of clinicians. There wasn’t leadership buy-in from the hospital. We took the product from the vendor and implemented what they gave us. It was really doomed to fail from the start.

    That these lessons were only learned in 2003 suggest professional incompetence leading to a massive waste of money that deserves investigation.

    DMC and ex-DMC officials, were you unaware of the informatics literature including Shortliffe’s text dating to the early 1990’s, profuse articles in the AMIA literature, work by informatics authors such as Lorenzi and Riley, their 1994 book “Organizational Issues in Health Informatics” the publicly avaliable work of informatics specialists like Scot Silverstein, the work of Social Informatics experts at U. Indiana, etc. that if you’d read could have prevented these costly mistakes before they ever occurred?

    Detroit’s corrupt, broke and falling apart; the last thing it needed was a failed CPOE done by people who’s apparently never read about issues long known to healthcare IT experts to waste yet more money.

  6. What an amazing coincidence that Scot posted an article on this topic on his blog shortly after Found on Road Daid posted here.

  7. I think the biggest part of the article that needs to be the prevalent question in the marketplace NOW is about outcomes improvement. Most people are still stuck in layering on more and more CPOE anecdotal and social quips than focusing on change and improving health of those in the community. Scalability aside (Kaiser is on Six Separate domains of epicare or more) we have to look at the larger environment and push for interoperability. No one vendor will own all the data and no solution will come from anyone inside the beltway.

  8. If you are saving so much, Dr. Babitch, why are you being taken over by Vanguard?

    “What we want to point out is that this one case, we’re saving $4.5 million. With CPOE and closed-loop medication administration, we had a 75% reduction in medication errors.” Big deal!!

    Your case is weak, very weak, to justify radical alterations of care with poorly usable devices without proof that overall outcomes are improved and that costs are reduced. But then again, that is what you are paid to do, and Cerner will not be happy if you tell the truth about what happened in 2003.

  9. What happened in Detroit circa 2003 with failed CPOE is similar to the vintage cases reported in the Children’s Hospital on the East Coast in which the death rate of babies increased by 2.4 times after CPOE was started. Was it the the same vendor’s CPOE? I think so. Does anyone know?

  10. It is surprising to find so much vitriol in what should be a discussion among experts and colleagues.

    To answer a few points:

    1) There is no secret about what happened in 2003. The failure of that launch, as stated in my interview was not about the product, but about the method in which it was implemented. The project was abandoned because of end-user dissatisfaction, and a failure to integrate the workflows of the isolated units with the rest of the hospital, which remained on paper, not because of patient harm. We learned from our mistakes, and were able to successfully launch CPOE, nursing documentation, a new pharmacy system and closed-loop medication administration at each of our 8 hospitals over a 13 month period. It took a coordinated effort, with a clinical focus, to succeed.

    That formula has continued to be our success story. The people who took part in the later launches were, for the most part, not the same ones who were there in 2003. I don’t think that a failed launch on two units at one hospital in 2003 had any significantly negative impact on the city of Detroit, but I do believe that having 8 hospitals at HIMSS Stage 6, an $800 Million investment from the Vanguard Group, and a Beacon Grant shared amongst 6 leading institutions will help the town.

    2) We point out the savings from our pressure ulcer initiative as an example of financial return in a world where it can be hard to measure impact. The DMC has been financially successful, despite being in one of the most challenged cities in the country. That is what made us a good match for the folks at Vanguard. We approached them, in a search for capital, that was otherwise hard to come by.

  11. A 75% reduction is a big deal? According to the National Academies at least 1.5 million injuries were caused by medication errors each year circa 2006.

    I don’t think any intelligent person would try to claim that every product on the market is easy to use, but it looks like Detroit Medical Center (and hundreds-thousands of other organizations who have had successful implementations of good projects) has proven that usable devices can be implemented, at cost savings, and a reduction of injuries made to patients, thanks to medical professionals having good tools available. Good implementation of good products is good for patients.

    75% of 1.5 million would be 1.125 million — and we can likely reduce that 75% even further by making our use of these tools better (not more, but better. Not more wired, but more intelligently wired in the right places). Hopefully, use of good tools like electronic prescribing can help doctors focus on preventing and curing the problems that patients come in with, instead of dealing with the problems caused by their preventable mistakes.

  12. L Babitch wrote:

    It is surprising to find so much vitriol in what should be a discussion among experts and colleagues.

    I disagree. First, This is a public forum. Further, the sterility of political correctness and “warm and fyzzy” talk about healthcare IT and its potential to cause harm does not serve patients well. If you, Dr Babitch, insist only on “warm and fuzzy”, even among colleagues, you probably are not the best patient advocate when the going gets tough. (Such as when my mother was nearly killed this summer by a faulty EMR, forcing me to be her tough-talking advocate and by so doing, preventing several more medical errors from occurring.)

    As I wrote on political correctness in 1999 about a cath lab where truly terrible IT and terrible implementation methods were disrupting the lab potentially putting patient lives at stake:

    In a common hospital IT politics ploy, blame for the project paralysis and failure was shifted by MIS to the cardiac administrator and clinicians, using language about ‘process’, ‘ownership’, ‘nurturing’, ‘mentoring’, ‘feelings’, and other impressive-sounding but shallow and almost mystical puffery and rhetoric. This made the invasive cardiology clinicians, with a culture characterized by directness and action, even angrier.

    The clinicians were accused of being “vitriolic.”

    There is no secret about what happened in 2003. The failure of that launch, as stated in my interview was not about the product, but about the method in which it was implemented.

    I can’t speak about the former, not knowing the product, but regarding the methods, how in God’s name could such worst-practices “methods” have been employed in 2003, when these issues were commonly known and extensively written about as paths to health IT failure?

    If Boeing built an airplane in 2010 using methods written about by aeronautical engineers in, say, 1995 and found to cause early structural failure and crashes, would they not be considered negligent?

  13. Back away from the irony, comrade writes:

    What an amazing coincidence that Scot posted an article on this topic on his blog shortly after Found on Road Daid posted here.

    You, Mr. “Back away from the irony” seem to imply a problem with people who post here anonymously.

    it’s this kind of circular, irrational, logically fallacious thinking that in part results in poorly designed and implemented health IT.

  14. Not asking for civility or political correctness. Me and my team are patient advocates, and all of us have the cajones to use our real names in public discourse. EMR implementations continue around the country to follow less than optimal implementation strategy, just as many clinicians fail to employ best practice in their care. I would challenge any of you who have commented on our 2003 experience to share your leapfrog and core measure data. If your not hitting 5 bars and 100 percent, then stop throwing stones in your glass house.

  15. Wow! Well since we don’t have to worry about being politically correct I can quote this, “He who is without sin cast the first stone.”

    The point of this article is admitting that while it did not go smoothly the first time, they did learn from their mistakes and it is working correctly now.

    And the whole point of HIPPA and all of these EHRs is that nothing is done anonymously any longer. A user goes in and places an order, it is recorded. A lab tech provides a result, it is recorded. Someone just goes in an looks at a patient’s chart, it is recorded. So the healthcare world is not anonymous any longer.

    One other point I would like to bring up about the warts being brought up on the different EMRs available today…. the reason you hear about alot of these failures is because the companies are publicly held. So if a whole section of code gets shut down, or a hospital fails, or, worse case scenario, an error is made, the dirty laundry has to be aired. And if a company is NOT publicly held (as one major vendor is not), then there is no need for anyone to know about any failures. How many of those do you think get recorded into public?

  16. Dr Babitch,

    As a former CMIO and now HIT writer, my concern is that HIT failures such as occurred at DMC in 2003 remain ongoing.

    Such failures are occurring locally, nationally (e.g., AHLTA) and internationally (e.g., NPfIT in the UK).

    As I mentioned, my own mother was nearly killed as a result of EMR problems early this summer, and is still disabled four months later with full recovery not possible. My occupation of writing on health IT risks and failure has become personal.

    My healthcare IT difficulties site is at this link, and many Medical Informatics-related articles dating to 2004 are on the Healthcare Renewal Blog (it’s multi author so only posts with my name in the final lines are mine).

  17. Dr. Silverstein writes in a comment to his own blog post about the DMC CPOE implementation experiences: “Finally, in my own experience as a CMIO at a 1000+ bed two-hospital medical center, the problem was 95% on the side of IT, acting like arrogant sociopaths and not giving a damn that patient’s lives were being affected, and that the physicians were liable, not the IT personnel.”

    I think that in coming from such a biased viewpoint explains the lack of constructive elements in Dr. Silverstein’s opinions, which makes them unworthy of serious consideration.

  18. LEAPFROG has recognized the dangers of CPOE devices, thus your statement “I would challenge any of you who have commented on our 2003 experience to share your leapfrog and core measure data” is irrelevant as a measure of quality care.

    Furthermore, are your attending internists and surgeons clicking in orders using pre fabbed order sets…or are the paraprofessionals and housestaff doing the clicking? Who is clicking in the post op orders for a patient who has been in the house for a few weeks?
    Tell us about your workarounds.

  19. Leland,

    No doubt, there are those who frequent this site who are not here for discourse and information sharing, but rather to provoke and annoy through sheer volume of comments, inflammatory words, and sky-is-falling warnings.

    Nothing is perfect – whether it be a computer or paper based tool. Computers do introduce new types of problems. Paper hides problems so that they are not seen. Regardless of the tool, it is the drive forward with an eye on continual improvement and honest evaluation that will help us be successful for our patients. Thanks for sharing your story.

  20. Anonymous at #19 wrote:

    I think that in coming from such a biased viewpoint explains the lack of constructive elements in Dr. Silverstein’s opinions, which makes them unworthy of serious consideration.

    By your own il(logic), anonymous, your clear bias against me makes your comment unworthy of serious consideration.

    I also think others here can make up their own minds about my 10+ years of writing on these matters, and don’t need to be told what to think in a patronizing fashion by anonymous posters whose main arguments are ad hominem in nature (themselves a logical fallact, a point for some reason I need to keep repeating, e.g., arguments that say “she’s biased, so nothing she writes has any merit” are inherently fallacious.

  21. I also agree with Dr. Babitch’s comment about dropping the anonymity game, i.e., in #15 where he wrote: all of us have the cajones to use our real names in public discourse.

  22. Dear Dr. Silverstein,

    Everyone has some kind of bias, and that should not automatically render their opinions invalid. The logical fallacy of assuming so is known as the “Poison Well” fallacy. My admittedly awkward and grammatically incorrect wording was an attempt for a conjecture, linking your bias to the lack of constructiveness in your comments. Jumping to conspiracy theories about cover-ups whenever there is an IT problem acknowledged by an organization does not really help improve the state of health IT.

    I am looking forward to comments that provide input and opinions on how to better design and implement Healthcare IT systems, and not to patronizing statements like “the problem was 95% on the side of IT, acting like arrogant sociopaths and not giving a damn that patient’s lives were being affected”.

  23. I’m not sure if my last comment was posted, so I will repeat its gist:

    Anonymous at #24,

    Thanks for the apology – sort of.

    The comment Jumping to conspiracy theories about cover-ups whenever there is an IT problem acknowledged by an organization does not really help improve the state of health IT is a strawman argument, however, another logical fallacy.

    If you believe only “constructive comments” have value in mission critical fields where lives are at stake, that’s your bias; I refer you to a book I co-edited where you may find the tone more to your liking:

    “H.I.T. or Miss: Lessons Learned from Health Information Technology Implementations”

    AHIMA Press
    https://www.ahimastore.org/ProductDetailBooks.aspx?ProductID=14181

    (Disclaimer: I and the other authors make no money whatsoever from sales of this book.)







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