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Pssst, Here’s an Excuse for you CPOE Vendors: The Problem Isn’t Your Product, It’s Your Choice of Customers

June 20, 2010 News 20 Comments

By Mr. HIStalk

KLAS just released its CPOE Digest 2010. It’s a pretty fun read, although not too encouraging. A full 86% of US hospitals fall short of even the paltry 10% CPOE adoption rate that the proposed Meaningful Use rules would require.

That’s probably why hospitals are whining (while looking the gift horse in the mouth) about the modest conditions that are attached to the millions in free taxpayer money they’ll get for merely using the systems they already own.

The KLAS report seems to send this message to hospitals: you’re in trouble if you’ve chosen a crappy CPOE vendor.

Everybody would agree that the whole CPOE issue is vexing. It’s healthcare IT’s Vietnam, having dragged on for years without progress while experts opine, outsiders roll their eyes, and boatloads of cash exchanges hands in a failed attempt to turn the situation around. Technical superiority is getting its butt kicked by a committed and stealthy enemy called paper.

Until Meaningful Use, hospitals had pretty much given up on CPOE. It’s like naively buying a fancy new car without doing your homework, then finding it so annoying and unsuitable that you just put it up on blocks in the back yard and cover it with a tarp so you don’t have to be visually reminded of your bad decision every time you go out.

So news from the CPOE front is not so good. But I might quibble with KLAS’s implication that it’s all because of low-quality CPOE software.

KLAS correctly observes that some CPOE products are majorly screwed up when it comes to usability and integration. The vendor names are hardly shocking: (a) smallish vendors whose customers didn’t really care about CPOE anyway, and (b) mega-corporations who dabble in HIT not because they care about patients, but because they run their business like an unfocused mutual fund and needed sector diversification.

But then you have Epic, which shames everyone by throwing off the grading curve. While the also-rans are locked in a desperate struggle for tiny percentage gains to their scores in the low 70s or worse, Epic surveys the spectacle from rarefied heights and splatters the heads of the combatants below with its droppings pretty much whenever it pleases.

Epic’s software is better than most (although a strong argument could be made that Eclipsys Sunrise has better CPOE). However, it’s naïve to think that Epic’s software is THAT much better. Or, that hospitals can move their CPOE needle by just doing a mating dance with Judy.

Epic’s secret sauce, I think, has a second ingredient: its choice of customers.

Epic knows that most hospitals don’t have the right stuff to handle big projects, especially those involving IT. They are indecisive, change-resistant, and unable to move beyond the tactical to the strategic. Epic sends those prospects away to fail under a competitor’s watch. That vendor cashes their check, but gets dinged in the KLAS report because the good customer predictably turns into a bad user.

(If you believe that software alone drives CPOE adoption, consider this: would you instantly whip out your hospital’s checkbook for a system that boasts nearly 100% CPOE utilization at every one of hundreds of hospital sites? You won’t need the checkbook – just order your free CD copy of the VA’s VistA).

One way Epic ensures that its customers are committed is by charging them exorbitant prices. Hospital C-levelers to get uncharacteristically involved in a so-called IT project when it’s costing them $50 million or more.

But more importantly, those high prices pre-qualify prospects. Badly run hospitals don’t usually have $50 million burning a hole in their pockets. Or, they may back down from their lofty ambitions, recognizing that deep in their DNA, they don’t have the right stuff to make expensive IT work. They fold their cards and slink away to a lesser-heralded and cheaper vendor rather than confidently throwing their big chips into the Epic kitty.

(I once had a sweet, competent employee who was also recruiter for a cult. She tried to get me to attend an introductory class, surprising me when she said it would cost me $100. The reason, she explained, is that free classes attracted mostly people without commitment who weren’t likely to join. Not to mention that prospects with $100 probably had more assets worth swindling once their brains had been programmed).

The KLAS report talks about vendors, but I think the real issue is one that should resonate with us IT people. It should also make hospitals think twice before dumping their current CPOE vendor to chase the Holy Grail of a higher-rated one (even Epic).

It’s PEBMAC — problem exists between monitor and chair. It’s not what you have, but how you use it. Much of the Epic ballyhoo is because they sell only to hospitals already qualified as having a high probability of success – they have enough money and motivation to want to undertake an Epic project in the first place.

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Currently there are "20 comments" on this Article:

  1. Great theory — except that it completely overlooks that many organizations move to Epic after failed attempts to bring up CPOE.

  2. Great theory but it doesn’t explain some of the dysfunctional IT depts and administrations in public health orgs in the SW who were “allowed” to buy from Judy. One of them supposedly holds the Epic record for most prolonged install ever.

  3. As someone who competed with Epic with on the sales end (working for Eclipsys) and who lives with Epic on the physician user end, I rate your analysis as excellent. I was with a senior VP at Eclipsys when he got the word of Kaiser buying Epic- he/they laughed saying Kaiser will destroy Epic! The client selection is the key but you identified the mechanism by which it works so well.

  4. Very well written and an altogether plausible theory. EPIC’s main customers are those in which they have employed physicians (Large Academics). It’s harder to mandate CPOE when you are sharing your physicians with other hospitals in the area like so many Community Hospitals do in the US. Let’s not kid ourselves, Physicians control the $$$ in the hospital and they are fully aware of that known fact. This is primarily the reason for low adoption across the nation.

    I also agree with your assessment that EPIC’s software in itself is not exactly superior to the vendors it competes against. It is a good system, but it has flaws and has it’s share of black eyes (that remarkably don’t get the press…hmm). The large difference in cost of EPIC in comparison to it’s competitors can’t sustain as those buyers are few and far between (especially as everyone is scrambling to find a date to the ARRA dance). It will be interesting to see over the next year or two how EPIC will change their tune if they truly want to roll up their sleeves and “transform healthcare”.

  5. right on the money with your analysis..Epic has hi adoption and utilization exactly because they are restrictive in who they will sell to. There is no guarantee of success with them or any vendor and there is a component of software, methodology and madness which will impact the success of a project. But the opportunity to be successful is so much greater in those organizations because of their financial and staff resources. The truly successful vendor is the one able to acheive high levels of adoption in environments with limited financial and staff resources..ie. the typical community hospital

  6. Do you think that folks that have spent twice as much are more likely to rationalize their excess spending by giving good ratings on surveys?

  7. I would agree with peacheater, publish the prices. When I hear of hospitals spending $100M on Epic, knowing full well they could’ve purchased McKesson, Eclipsys, Siemens for half that, I chuckle. Maybe these vendors should do like Epic and insist customers pay thru the nose for excess implementation resources.

    Rolls Royce makes a pretty good automobile, but oddly enough, I don’t see a lot of them on the road!

  8. Interesting idea and well said, but you too are blam-
    ing the user. If the equipment had been subjected to critical review of safety, efficacy, and usability, there would be better acceptance of the technology if it was approved for use. As it stands now, Epic may be rated the best of the worst devices to ever affect medical care. Problems will be known soon.

  9. Good points Mr. H…
    But I’ll add one more:
    Epic is successful because it sells (and gets commitment) from the right people. The physicians.

    What is truly amazing is that its software is NOT any more functional than others. In fact its Lab system is AWFULL!

    But when you get the docs on board before the sale and they tell the CEO …this is what we want, you know that the docs will make it work. They got skin in the game. The system was not shoved down their throats, it was their idea from the start, not the CIOs or CEOs.

    And that’s one way they ‘pre-select’ clients. If the MDs won’t hard sell it to admin, Epic will walk.

    And that’s why you never hear of Epic bombs…(believe it or not Epic HAS lost clients over the years) but somehow your never hear about them. No wonder.

  10. I love this article, and think it is so true. However, it will be interesting how this plays out once Epic is widely rolled out as an Affiliate strategy… your premise may fall apart, as affiliates will not need to have the profit margin nor the huge sums of capital to be able to implement Epic. I’ll report back in a year or so, as we are about to embark on that journey… we are a current Meditech customer where the docs refuse to use CPOE, moving to Epic as an Affiliate.

  11. To Hmm: It’s amazing what you learn during those “failures”. I suspect those who have to do it again come in with an improved sense of what went wrong and what to do better next time.

  12. Agree with Mr. HISTalk — There’s no reason the private sector can’t replicate the CPOE adoption success of the VA with VistA and that’s exactly what our customers — from big urban medical centers to tiny critical access hospitals to psychiatric facilities — are doing. Medsphere customer hospitals are enjoying close to full adoption whether their MDs are hospitalists or not.

  13. I used to work for Epic in Implementation.

    Epic has a “good maintenance, good install” program which gives clients financial incentives (discounts on Epic’s services) to meet implemenation milestones. CPOE adoption by physicians is one of those criteria. I don’t know of any other vendors who financially reward clients for using things they already bought.

    The performance of implementation team then, internally at Epic, and through the financial incentives, on the client side are evaluated based on CPOE adoption as well.

    I do agree that the CPOE software is not easy to use and is cumbersome for physicians. However, Epic allows docs to save personal/facility order presets. All vendors NEED to do that if they want docs to use this stuff. Nobody wants to click on 17 buttons for every order.

  14. Could not agree more. After several years in HIT, I was dumbfounded by the lack of focus and quality in the C-suite and IT arena for most of the hospitals I worked with.
    Rather than continue to work with the crumbs that fell from Epic’s table I left quickly to return to one of the BOB vendors…so I could still maintain my professional integrity and not make commitments my customers nor my vendor could deliver on…the stuff just wasn’t in the sauce.

  15. There’s no doubt that Epic has higher compliance because of it’s clients, but I think it’s merely that they’re in a good position to mandate CPOE, both from the perspective that many of them are desirable to work at and they’re big enough that physicians are expendable. If Kaiser tells you that you’ll have 90% CPOE or else, what are you going to do? Leave if you will, but it won’t affect them.

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