Tom Stevenson, DO is chief medical officer of Covisint of Detroit, MI and a preceptor in the family medicine residency program of MetroHealth Hospital.
Tell me about yourself and about Covisint.
I’m a family practice doc — 17 years in rural family practice. I’ve been doing IT on the side for most of that time, including the six years now I’ve been in the industry. Lots of boards, president of different associations, that sort of thing.
The things that are interesting about it is that I’m currently using my third EMR. I’m not using our product. I still teach family practice residents one day a week, so I’m using Epic in my base hospital that I’ve been at for a long time. In addition to that, I was chair of the State of Michigan HIT Commission, so that’s how I got exposed in great detail to health information exchange and all that sort of thing.
In terms of Covisint, I wish I could pull out the elevator pitch, but the main thing is that we are a health information exchange vendor. We’re both an SaaS environment but also referred to as PaaS ,or a Platform as a Service Environment. It’s all cloud computing.
We have some of our own products that we put out for functionality for an exchange to come up on, but then we also have a number of partner vendors that we work with that have pre-integrated products that are able to be utilized by our end users as well. It’s called AppCloud. Think of it as the App Store, but with SLAs and other restrictions to them. We need to be able to integrate with them and be able to make it a package, as opposed to independent applications that you would run into with the App Store.
You’re on your third EMR. Do think that’s going to be common? What led you to have three EMRs under your belt?
A part of it was a change in locations and everything as I’ve moved around. I started about 15 years ago and actually became employed. I went from being in a small, rural practice to becoming a part of a larger hospital-employed practice so that we could afford to get an EMR in the first place. We used that one for a number of years. Unfortunately, just like many situations, we bastardized the system and never utilized it like it was supposed to be used.
The second one I was involved in was after I’d left private practice and went into the industry. I went into academic setting as well and used a different EMR in that setting. Then lastly, again I’m teaching residents now and it’s back to my old hospital and we’ve switched vendors with a new one. That’s how I ended up with three different EMRs.
But that was an interesting comment about it — is this something we’re going to be seeing in the future? Yes, I think there are some significant changes that are going to happen in the EHR environment. I think the EMR or the EHR of the past that tried to be all things to all end-users oftentimes ended up being very conflicting and difficult to use and very expensive and difficult to maintain — not always the most nimble and flexible type of system. I think there’s going to be some very significant change in terms of what the EHR of the future is going to hold.
What would you say have been the most positive and the most negative aspects of Meaningful Use so far?
The most positive is driving adoption. I’ve been saying for many years that if the industry really didn’t get their act together – and that included the physicians within the healthcare industry – and start adopting HIT that the government was going to get involved. That may be in a light way, it could be in a heavy way. It turned out to be somewhat in the middle of going towards heavy.
The problem with that is that with government incentives and everything come regulation policy, processes that are not necessarily dictated by what’s best for the environment, but what meets the government’s needs.
The biggest negative of Meaningful Use is that it’s driven it so fast that people are trying to make decisions on the fly. They’re doing it based on what they know, and what we know has been fairly limited. What people do is they resort to what’s been out there and that sort of thing.
I think where there was some innovation that was taking place in EHRs, now they’ve had to put all their energies and development into meeting Meaningful Use guidelines, which for the most part, they’re really not bad. I think what we got down to, finally, in terms of the Core Menu items for Meaningful Use, were really quite relevant. On the other side of the coin, though, is that not everybody was up to speed with them. To become compliant, a lot of energy went into that, as opposed to innovation and moving forward with EHR products.
Do you think that with Meaningful Use and reported data and outcomes that there’s at least an implicit buy-in of the idea that the government thinks it knows how to define optimal patient care?
Well, yes. This is where I’m going to get controversial a little bit. I’m not a huge believer in a lot of the quality initiatives because they’re so focused on a very specific set of diseases that again, it’s one of those things where people put a lot of energy into meeting the quality parameters for specific disease processes — which, don’t get me wrong, are extremely important, there’s no doubt about that — but it’s to the exclusion of the other ones out there.
In fact, in several discussions this week, I’ve already said, that in my view, I want to make sure that we not only become excellent at delivering the quality indicators, analytics, and reporting and tools for the physician to be able to meet those goals, but that we go far beyond that and bring in evidence-based medicine and the proper guidelines to support care across the broad spectrum of disease processes that are out there. Ever since HEDIS has been around, the practices that do well are the ones that meet those goals, and I don’t know if that’s always necessarily the best care for those patients.
It isn’t necessarily obvious that what’s good for Meaningful Use is good for the patient. Do you think Meaningful Use could actually make outcomes worse as physicians chase the goals?
I don’t think it will make it worse. And trust me, I don’t know that I have answer for how to do it better. It’s not necessarily the best physician who could look very, very good on paper because they figured out a way to meet those goals. They’ve got the right tools or they put some policies in place to be able to meet them.
I was part of a committee for our state Blues plan. I was a representative for our state organization. Meeting with the committee was a physician profiling team. That physician profiling team was taking the data — the kinds of data that they were gathering — and making decisions on whether a doctor was good or bad. Bad doctors where at the tail, the good doctors were in the middle.
I think it’s been very clearly demonstrated that that is not the case, that oftentimes the tails represent practices that are doing something a little bit aberrant from the norm. It’s not bad aberrant, but they just have a different focus in the practice.
The bad doctors, the truly bad ones, are trying to beat the system and everything like that are very good at that. They can make things look normal, while at the same point, they’re not doing things that they should be doing.
Do bad doctors know they’re bad doctors?
No, not necessarily. You can categorize bad in a number of different ways. One is they just don’t practice good care. In other words, they don’t deliver care in a fashion that’s beneficial to their patient. I think for most of those people, they just don’t know.
Medicine is a mentoring approach. Our mentors teach us things and we tend to retain those and that’s what we do from there on out. It takes a lot for us to change those habits that we developed in our post-graduate training. So there’s some of that out there — you just don’t know.
There are plenty of bad docs out there that are trying to beat the system. In my mind, those are the ones that are crooks. Medicine is a microcosm of society. There are good people and bad people in all aspects of society, and medicine is one of those as well. So those bad ones — I think that they probably know that they’re bad and they are beating the system. Those are the people that know how to cover their tracks.
Everybody agrees that Accountable Care Organizations are going to need a lot of technology, especially data reporting. Do you think there’s a way that technology can help independent physician practices avoid giving up control to those groups that have all the technology?
If I have anything to say about it, yes. I was a long-time independent practitioner and I feel very strongly that there are many good aspects to having not all docs affiliated with large organizations. There’s definitely an art to medicine and some of that is lost when all of us have to practice the same way according to rules that are established by parent organizations.
As far as I’m concerned, there are some drivers that in the current ACO model that have pushed a lot of folks to acquire as many physician practices as possible. I hope that is not going to be a continuing trend. That’s fine if it works in your environment and you’re already part of a strong affiliated physician group — doing that physician alignment if it includes employing docs and that sort of thing, then that’s good for your environment.
I think the vast majority of locations, though, are dealing with physician alignment with independent docs who want to stay independent. I certainly know that we are working to be able to facilitate the ability of physicians to maintain their independence while still being able to meet the needs of the ACO.
You mentioned the art of medicine. Do you think anybody really believes in that any more? Everybody wants to do things that they can measure and they want to pay for things that are widgetized. Do you think the art of medicine is something you just have to do on your own time while doing all the other check boxes that someone else says you have to do?
Yes. I think that’s actually a very good way to put it. The thing is that the art of medicine is what really makes the difference out there. If you talk to patients and you do appropriate patient survey, there still is a strong emphasis on having a good relationship with their physician. The patients that tend to be happiest in a practice are ones that do have a good relationship with their docs, who they feel are taking the time to treat them well.
Now that doesn’t mean you can’t work in an environment that really meets the checks and balances of all these regulations that are put out there and still have a relationship. The doc that can do that is a skilled practitioner – that can juggle all those things at the same time. I think we’re going to see more and more as we go along that this very clinical approach to delivering care –this really regimented type of thing to make sure you’re hitting all those checks and balances — are going to continue to put barriers in the doctor-patient relationship.
In my academic time, one of the classes I taught was doctor-patient relationship. The value of having that ability to have an appropriate relationship with your patient can mean all the difference in terms of bringing the appropriate information that you need as well as the patient feeling confident and comfortable enough to be able to actually divulge what they came in for that particular day. Quite often, what they are really there to see you for has nothing to do with what they called in and scheduled their appointment for.
Covisint’s in the interoperability business. Do you think insurance companies and the bigger healthcare systems are using interoperability to gain competitive advantage?
They certainly would like to. I think that anybody that’s in the business is going to try to leverage the environment to improve their presence and improve their marketability and where they stand. I think that there are certainly several instances of that sort of thing taking place and … I’m going to leave it at that.
When you look down the road five to 10 years, what is most encouraging and discouraging as a practicing physician about the way both technology and the industry is moving?
Some of the negatives first. I think we’re getting back to some of our early discussion. We’re seeing an increasing adoption of HIT. Unfortunately, I think people are buying up things in a reactionary mode. I’m not sure that everyone’s going to be happy with what they get.
It’s going to take a few years before this settles in and so we can re-learn how we interact with patients, how we can leverage the technology to do things I feel are very important, and that is to automate these manual processes, especially the ones that are more regulatory in nature as opposed to actually imparting appropriate clinical care. Some of the fallout of all the things that are going on right now is the slowdown in the ability to improve overall healthcare delivery, including the doctor-patient relationship.
The good side is that as HIT and HIE take place and we actually take some of these new models such as ACOs or whatever ACOs end up being, there will be some potential significant benefits. For the individual patient, the clinical decision support we’re able to provide that doc to help them to recognize gaps in care or better ways to do things has a tremendous opportunity, the catchwords “quality, safety, and efficiency” aspect. As we go along and we’re able to automate these processes and be able to take care of a lot of back-end functions without having to think about them from the physician’s standpoint, we can spend more time concentrating on our patient.
I didn’t go into HIT because of my love for it. I do really enjoy it and I want to do the best that I can with it, but the biggest reason I got involved in HIT was the regulatory impediment to my relationship with the patient became more and more notable after my first years of practice. The amount of paperwork that was done, the amount of regulation we had to meet, the E&M coding guidelines just became bigger and bigger barriers to my ability to deliver care in the way I felt was appropriate.
The reason I’m in it is that I feel HIT gives us the greatest opportunity to meet those requirements and remove those barriers from the day-to-day basis so I can see my patients, get to know my patients, and deliver the best care possible to them.