HIStalk Interviews William Bria MD, Chief Medical Information Officer, Shriners Hospitals for Children

William Bria III, MD is chief medical information officer at Shriners Hospital for Children, Tampa, FL, and  chair of the Association of Medical Directors of Information Systems (AMDIS).

What kind of response have you received from the AMDIS recommendation to not include CPOE in the first round of the HHS”meaningful use” criteria?

It’s been excellent. I’ve gotten response from our membership, but I’ve also had a number of discussions with everybody from the press to those that are in high places, shall we say, and other organizations, like the American College of Physicians. What I’ve gotten back is that both the caveat that we put in our response and the emphasis that we put the patient consideration up front was very well appreciated.

Considering the vast majority of hospitals in the country don’t yet have a fully implemented EMR, I think the concern in this economic climate of what it means to individuals personally as well as organizationally was the biggest impact, particularly when they saw how much they were going to be asked in 2011 to come up with in the draft proposal from Paul Tang and his group.

I think the patient focus of it gives us a way of balancing that concern with a very important political consideration, if I may, in that if this change in American healthcare is painted as a regulatory or a governmental imposition on the practice of medicine which some, as you well know, in the press were already doing, then it actually aligns physicians and patients against it rather than what we really believe is true, that this is one of the tools. It’s not an answer to all of the problems, but it’s a tool that can act in a very fundamental key change kind of way to empower patients and give patients the information they’ve needed forever.

My most recent experience was this afternoon at around four o’clock when my son, who has a chronic illness, a very serious one, called me and said his doctor had broken his leg in an accident. My son — he’s in his twenties — is very fastidious about seeing his doctor and careful about follow-ups, but he called the office and was told that the next appointment with his doctor was in 2010. He was trying to make an arrangement for something that was within the next two weeks before the doctor had his accident.

You know, that’s a real basic patient communication aspect that should be as difficult as saying, "Your flight was cancelled, but you can select these other flights," or "Your hotel reservation is not possible, but we can take care of you at this other hotel." The idea of some of the basic communication in the business of delivering care in America, because of the lack of automation at the level of the patient, is still far too frightening and daunting, and don’t even get into how much it’s costing to have a mostly non-automated process for delivering care in America.

Do you think ARRA encourages organizations to move too quickly in ways that may have unintended consequences when it comes to patient care? 

I think there’s no question about that. I think the first draft — and that’s all it was, it was a draft, and I think it would be wrong to make out that it’s more than that — the first draft on this saying we are going to accomplish CPOE adoption, a full EMR adoption, EHR adoption, and then successful reporting on quality and metrics out of the same system, that really speaks to me from a point of view of someone who hasn’t really done it yet. If you think it’s that mechanical that you can drop these systems in even a modest-sized healthcare setting, and moreover, settle down and actually be able to generate data, and then be able to automate a process of quality and safety reporting, it doesn’t speak to folks that actually have the experience of having to do that.

So I think that was perhaps a challenge, perhaps a way of creating controversy that levels it, because as we all know, it’s really going to be CMS that’s going to make the final decision on this, and the idea of sending the wrong message about reasonable expectations in what timeframe that should be done at some point, no question about it. Absolutely. If we didn’t put quality reporting and safety reporting as part of the expectation of the entire delivery on meaningful use, absolutely. That would be crazy. That would be a major mistake.

However, saying that it all can happen in a two-year time frame, that really puts a concern about reality testing.

Are you concerned that, since it’s an economic stimulus that requires the money to get out quickly, that they’ll just chuck out everything except the minimal criteria and say, "Look, just think of it as a slightly encumbered grant"?

Well, could that happen? Could that be a reaction formation that goes all the way or the other way? Yes. Is that what we want? Absolutely not.

From the standpoint of insisting on the introduction of tools, on the introduction of preparedness and analysis of concept redesign and genuine commitment to achieving success in introduction of the basics — departmental systems, scheduling, reporting, and data acquisition and reporting– is the key to starting the engine of information for an organization — large, medium or small — to even approach the challenge of subsequent data reporting and analysis.

So we think that dumbing it down too far is a risk, but we are anything but that. We are definitely for steadfast introduction and insistence on introduction, which I think the CMS — part of its leadership — makes it clear to most organizations, even ones that haven’t been familiar with the idea of clinical data systems as being central to their business.

Interoperability seems to have been traded off in favor of just getting systems put into offices. Do you think there will be enough emphasis on exchanging data and rewards for doing that?

I think there’s been emphasis on it, but I don’t think there’s been enough clarity about who’s responsible for doing that. If you consider the scope of the introduction of any of the existing systems, and then start to consider the scope of interconnection through interoperability of information, the systems themselves don’t need to be interoperable, the database contained must be interoperable. Who is responsible for doing that?

The idea that while you’re trying to understand and implement and accommodate the introduction of an information system into your practice — in a large, medium or small clinical setting — that you’re going to have the persons and the skill set to interconnect that data seamlessly with the rest of your community, that’s not very realistic, I don’t think, in anybody’s perception.

There has to be the identification of HIEs or other entities that are going to, in fact, have that as their main focus as communities and regions start to introduce electronic health records.

Where do you see that interoperability push coming from?

I think the notion of saying that entities — and there needs to be more clarity on what entities are going to be charged — is it going to be the small, two-doctor office that’s going to have to worry about interoperability with their region? No. That’s not reasonable or realistic, and it’s my experience that then we will have a bunch of silos, where we now have paper silos, we’ll have also electronic ones.

But the notion of making that much more explicit about in what way and in what timeframe are those considerations going to be made, will there be clear standards with regards to data exchange to the vendors? Not to the customers, but to the vendors, in order to receive approval for certification and implementation in this national scheme. That’s a whole dimension of this discussion and the response to the first draft of meaningful use. I don’t think we’ve really spent enough time with it yet as a country and in applied medical informatics as a discipline.

Since it was an economic stimulus, the bill seems to push EHR adoption as opposed to EHR benefit. Do you think those two are inseparable? Should we be trying to bring up the laggards who have no technology at all or should we be rewarding the results of the technology and let them pull themselves up accordingly?

I really believe that the idea of a critical mass of American healthcare using information technology will so tremendously change the national dialogue and the national expectation about the practice of medicine using that technology — that is the first, second and third priority.

We have to get a greater penetration. That doesn’t need to be 90% — no, it’s not going to be 90% in the next five years, but what it needs to be is greater than 17%, or 15%, or 20% even at this point. It has to be at least twice that for us to start to say that this is truly an unstoppable transformation from the standpoint of the infrastructure necessary to practice medicine and for physicians to no longer be bystanders.

I’m not talking about informatics positions, I’m talking about rank and file practitioners to no longer be bystanders in this discussion in their offices, in their hospitals, and their communities, but to be active consumers defining what is needed first, second, and third in their improvement and then moving forward.

I’ve been talking about this and speaking to physician groups on this subject since 1982 when I finished my fellowship and took my first job that included both of these paths. So the idea, I think, of really making the case that there is a critical mass and that introduction — I won’t say adoption, because that apparently is considered a bad word — of information technology in the American healthcare to a significant degree is long overdue and absolutely essential to get to the next level.

You mentioned certification. Does AMDIS support certification, and if so, do you have an opinion on whether it should be CCHIT as the certifying agency?

I think the way in which CCHIT has operated in the past has been good for that stage. I think now with the money that has been directed towards it, the idea of being anything other than an objective certification body that has at its core both the timeline and the elements of the goal of the ARRA, the HITECH portion, is essential.

What do I mean? For a number of years, since I was the chairman of the HIMSS Physician Community group, we have been asked to review the criteria that were being used at CCHIT, since HIMSS is a major partner in that. Every time, me and my colleagues, many of them from AMDIS, that were part of that re-review before CCHIT spins out its next version of criteria for certification, we said why are we delaying CDS for some future time? Why isn’t there an insistence on the existence of elements of data exchange and interoperability mandated as part of the standards of being able to have a certification of your electronic health record product?

The usual answer was that yes, they know that’s important, but they thought that that was a future development rather than an immediate necessity. That never sat well with me nor my colleagues in our review process. I would be very anxious to see that whatever new body or whatever new group was constituted that there was clearly no confusion about connection with the status quo, that it was directed towards the actual goal, the stated goals, of the ARRA itself.

You’re working on some formal informatics training programs. What do you think the industry needs in terms of the quality and quantity of people who have real informatics training, not just on-the-job training?

A lot more. (laughs) I think since the bar’s been set in this first discussion very high, I’m saying that it’s not enough to put in systems then say, "Congratulations, everybody can go home and rest," but rather data reporting and actually then make that the reason, the raison d’etre, of healthcare informatics, the quality and safety reporting and performance reporting in a national scale.

I think you’re going to need a lot more people that not only understand the information technology, which is an entry level issue, and rather get on to those who really know how to evaluate large data sources, be able to guide and manipulate information systems as necessary in order to improve performance, and a last but not least, we’ve talked for so many years about, "Are you up on CPOE yet, or did you just do results reporting? Anybody can do that results reporting stuff, but CPOE — that’s a real man’s job”.

But you know what the real man’s job? It’s to get data out of the system that is of sufficient quality, and have a dialogue with the clinicians in an organization to actually improve and change practice. There are examples of this, but boy, there’s not a lot of them. The ones that have done that as a production line, the same way we used to think about the production line of order entry and results reporting, those organizations – Cleveland Clinic, Mayo Clinic, Partners, Kaiser, etc. — those are the leadership healthcare organizations in this country. I don’t think that’s a mistake.

What are the most important projects you’re working on in Shriners and what challenges are you seeing?

We are working on clinical decision support. We are working on CIDSS, clinical information decision support services. The first one, as a practical matter, improvement in medication ordering and administration safety and quality care sets, tuning our alerts environment and refining it for the particular care line that we have — we’re a very specialized pediatric hospital system–and the CIDSS project is a data warehouse installation, evaluation, and targeting towards actual safety and quality necessities and reporting within our healthcare systems. Those are our important projects.

Do you think that outcomes analysis or process analysis in the data warehouse is going to make the underlying tool that created that data less important or more of a commodity?

Not yet, but that’s exactly what we have to get to. And again, the organizations that are leading — I don’t think people sit back and say, "Well, they did all this because of this vendor." Well, yes, it was important to have a product that had sufficient functionality and a data model and environment that could be leveraged for these reasons, but it’s really the organization and their ability to use data to make them more successful and make them appear demonstrably better than competitors. That’s the name of the game.

I truly believe that we’re going to head, in the next decade, from a time of talking about these elements of automation in the actual process of healthcare into saying, "This is the necessary tool, but that’s all it is." This is the instrument to allow leadership in organizations that are the most forward-thinking and the most attractive to the people who seek care, this has provided in the necessary grist, the fundamental data, to be able to demonstrate and succeed in innovation.

There are probably going to be a lot of organizations that are going to be pushed into buying technology only to realize that was only the little step, and the big one’s yet to come.

(laughs) Well, you know that’s how life is. Human beings need to take it a little bit at a time. If you knew how difficult it was to get married, have two kids, raise them well, help ensure that they’re going to be good people, you never would have done it. (laughs)

Anything else that we should talk about?

I just want to say that our organization, AMDIS, is for physicians and other clinicians that have now the challenge ahead of them of actually starting to deliver on all of its promise. We are so excited that the stars have come into alignment to make what we’ve been working on for many, many years now become one of the major agendas with the rejuvenation, and hopefully reinvention, of healthcare in America.