VA is a much more complicated rollout since there are so many different interactions and configurations of VistA. In addition,…
Peter Stetson, MD, MA is chief medical informatics officer at ColumbiaDoctors, The Physicians and Surgeons of Columbia University of New York, NY; assistant professor of medicine and biomedical informatics at Columbia University; and associate director, quality informatics at New York-Presbyterian Hospital.
Tell me about yourself and your job.
I’m the chief medical informatics officer for ColumbiaDoctors. We’re a multi-specialty physician group of about 1,000 physicians here in New York. We have about 150 practice sites in the Tri-State area of New Jersey, Connecticut, and New York, with our primary base at Columbia University Medical Center. We’re affiliated with New York Presbyterian Hospital, which you may know is the recently re-ranked sixth in the US, so we’re proud to be partners with them. Our physicians admit to the Columbia campus, New York Presbyterian Hospital when their patients go in the hospital.
My other position is assistant professor of clinical medicine and clinical biomedical informatics, trained here at Columbia in informatics. I’m a hospitalist — I work in the hospital part-time while I’m not doing the CMIO thing. I also do research and patient safety and quality using healthcare IT.
Quite a busy guy.
Yep, it’s a busy time.
You’ve got skin in the game, to some degree, with both Allscripts and Eclipsys. What was your reaction when you first heard about the merger and what do you think of it?
We look upon the merger favorably. We actually work pretty closely with both vendors, and have for a couple years, to do integration work.
We felt that this was a natural outgrowth of some of the things that we had explored with the two vendors. We think that it’s going to have a positive impact on patient care and quality of life for the physicians in the long run. We’ve spoken with the presidents of both companies here at Columbia and participated in some conversations with them and other client sites that share Allscripts outpatient and Eclipsys inpatient. I think, as a group, we look favorably on the news.
Would you have stuck with Eclipsys and/or Allscripts had the merger not been announced?
The hospital is deeply committed to Eclipsys’ inpatient Sunrise Acute Care. They’ve had it installed since 2005 , starting with order entry at the Columbia campus, and had Eclipsys Sunrise Clinical Care in place on the inpatient setting at Cornell. As you may know, New York-Presbyterian is both the Columbia University and Cornell’s common hospital. They’ve put a lot of years of investment into Eclipsys products. There was no plan for changes there as far as I know.
We selected Allscripts for the faculty practice after a bake-off of a number of vendors run by an independent evaluation group, a physician-led independent evaluation group within our practice. We selected Allscripts as the product that we wanted to roll with. That was back in 2007, before there was any discussion of merger, obviously. Knowing that we had two different systems, we began our rollout in 2008.
Just give a word or two, if you don’t mind, about where we are in our implementation with Allscripts for the faculty practice, which is ColumbiaDoctors. We are 85% rolled out across those 1,000 physicians and have about 3,000 users. We’re coming to the close of our initial rollout. We’ve gone live on all modules, including electronic documentation — all the features that would be defined as a fully functional EHR, according to Blumenthal’s New England Journal survey.
Even before we started with the first group, we began working on ways of connecting Allscripts and Eclipsys. We’re the first group in the country to connect them using HL7 messages that contain the text of a Continuity of Care Document that we send from Allscripts to the hospital, automatically triggered by admission events in our ADT system for the hospital. We’ve been working with other clients that share Allscripts and Eclipsys to let them know how we accomplished that, and participated in a number of technical calls on that. That went into effect around May 2009 and we’ve been running that live since then.
Is that the route that Allscripts is going to go, sending the CCD over?
Well, I’m not sure. This is the subject of quite a bit of discussion, obviously. Are we going to have two different systems or one? Are we going to have two different databases or one? We’re in a period of pre-SEC approval, so they’re not at liberty to divulge a ton of detail about what they think the future vision’s going to be. The discussions have been pretty focused on patient care and physician quality of life to date. There’s going to be a number of discussions ongoing about what that future looks like as they’re permitted to discuss it.
One of the things that this has meant for the two business partners, ColumbiaDoctors and New York Presbyterian Hospital, is we’ve been asking ourselves internally, what would we like the future to look like; and is there an opportunity for us to influence how that would look with the two vendors? We’ve been having conversations with them about it and how to set that up.
You’ve got probably more experience than anybody trying to make these products work together. I’m sure they’re going to look to you for advice. From your experience, how hard will it be to integrate the two product lines and how long will it take?
I have been very impressed with both vendors, actually, in their ability to do integration work. Let me say a word or two about that, technically. Both applications have, as you may know, open hooks. Objects Plus, which is now Helios, for Eclipsys and Stanley Crane’s Universal Application Integrator toolset for Allscripts. We’ve been leveraging those and building solutions. We’re in the final stages of development integrating note writing and professional physician charging. We’re using those two open toolsets to do this work.
The ability to do that work using those tools is pretty easy to do if you have the experience with those toolsets. That gives me quite a bit of confidence that they will be able to do integration work. Whether that happens at a deeper level, or using this toolset in each case, or additional tools that they have like dbMotion for Allscripts or some other solution that might come from Eclipsys … you know, I’m not sure how that’s all going to play out and they’re not at liberty to say at this point. But, I can tell you from experience that we can hook things together using these open hooks that each of the applications have, and that’s what we’ve been pushing forward on here at ColumbiaDoctors.
From a high level, not necessarily even specific to those two products, what does integration look like to you between the practice side and the hospital side? What are the checkpoints of things you’d like to see it do?
We have what I like to call ‘meaningful interoperability’ that goes deeper than just the normal summary document exchange at transitions of care. That’s health information exchange, I guess, but I like to talk with my crew about meaningful interoperability which happens at a workflow level. One of the key things is discharge integration. You know, you’re in an inpatient space, but doing professional charging is typically something that’s managed by a practice organization. That’s one example.
As it is today, doctors have to manage a bunch of different lists of patients that they take care of, and the different applications, to make sure that they don’t forget to see patients and they generate handoffs. We’ve created a custom handoff application in Eclipsys as well, and so we’d love to see list management happen across both applications so you only have to do it once.
We’d like to see exchange of what I call ‘discrete document types’. Take, for example, patients who are coming into the ambulatory surgery area who then need to be admitted to the hospital. It would be nice at that point to ensure that the documentation from the ambulatory setting and any of the preoperative evaluations that took place for those patients are immediately available in the inpatient nursing station. Those are the points of contact that we’ve focused on developing, and they go beyond the normal ‘give me a snapshot’ — which is what we do today — of meds, problems, and allergies.
Then beyond that, the kinds of integration I think need to happen are around medications, problems, allergies, and immunizations. Those are the things that we target here. Medication interoperability is a challenging one. As you know, these two products use different drug formularies. Allscripts uses Medi-Span and Eclipsys uses Multum. Translating meds from different drug dictionaries at the transition of care is quite a challenge. We may see some changes in the way the combined entity addresses that issue.
Those are the things that I’d like to see emerge as solutions for the merged entity to tackle.
It seemed like the industry was fixated on the concept of physician portals, but doctors never really wanted portals because that meant that they had to go look up stuff. Do you think the industry has moved into the workflow piece that you’ve mentioned, so that doctors can do things automatically without being so aware of the venue of care?
I do. Particularly with the concept of the patient portal, we’ve stressed with the vendors that we speak with is that the docs, the quote I’ve heard from some of my emergency room colleagues here at NYP is that they “cannot have too many rocks to look under” — that’s the quote. If a doctor can manage to interact with their patients through a portal that’s integrated in the tethered model with their EHR, it’s easier for them because they don’t have to leave the application workspace that they use to manage their other patient care duties. I do believe that there is an increasing sensitivity to workflow solutions for docs so they don’t have to look in five different apps.
Are you seeing a lot of demand for or doing work with mobile devices? Are they changing the strategy?
There’s a lot of demand. I don’t think we chose Allscripts for this originally, but we’re really happy that they have an iPhone and now an iPad application that works. We are in very early pilot mode with the use of those devices and feeling out what our appetite level is with the doctors. But from everything that I hear when I’m on the road, in our institution, there’s a big appetite for mobility.
I think that mobility is a solution for managing some of the accountability mechanisms that EHRs have. Let’s take, for example, results verification of tests that are ordered. Sometimes you don’t have the time to respond to all of the messages you might get for critical, abnormal results while you’re in the office. But then when you’re out doing rounds or in meetings and conferences, there’s not a lot of time to get to a desktop PC to respond to those tasks or renew prescriptions and whatnot. The ability to have like a subset of the functions that you could do out of the office in a mobile platform is going to enable better quality, in my opinion.
I think that’s probably what’s driving the interest from the doctors’ perspective because they are accountable for following up on these things, but they can’t do it if they’re tethered to a desktop when they’re on the move.
You’ve done research on the quality of electronic physician documentation, and there’ve been stories lately where information was filed electronically, the doctor never saw it, and patient harm resulted. Are we overloading doctors with automatically generated and template documentation that really doesn’t have much clinical value?
For that reason, we’ve taken an approach with our physicians called ‘structured narrative’; where we embrace the concept that some of the stuff they want to say is going to be narrative, especially the history of the present illness section and discussion and assessment sections. We encourage them to use whatever means necessary to get narrative into the record, whether that’s typing, dictation, Dragon. We want them to do that. Then, where there are things that they’re interested in collecting for secondary use purposes like research or quality reporting at the organizational level and Meaningful Use requirements as they’re emerging recently with the final rule, we try to go after structure.
I’ll give you a good case point — transplant. We’re bringing our whole transplant group up on our ambulatory record with Allscripts Enterprise. There are some standard things that need to be collected for UNOS reporting and we’ve leveraged that as structure. But for the clinical care components that are really narrative, we encourage the use of narrative. That’s what we mean when we say a structured narrative approach.
I think that there is a link to the quality of documentation in two important regards. One is a sense of professionalism between the doctors who take care of common patients. The quality of output of notes that go back to referring providers. We’re a multi-specialty group. We take a ton of referrals into our organization. It is the professional handshake that goes back to the referring doc — the letter. We’ve spent a lot of time working on the quality of the note for professionalism, but more important is the ability of a doctor who’s picking up a case or cross-covering, or even the physician themselves who see the patients at intervals, to be able to tell what’s going on with the clinical care.
We’ve used the research principles that we’ve developed in my lab, and in the informatics department here, to implement documentation in a way that supports those two efforts, to the extent that the EHR can deliver it.
You mentioned Meaningful Use. What was your reaction to the final requirements?
We’re happy with some of the relaxation in the rules. I like the combination of core-minimum sets of rules, and then the additional five that you can select. In point of fact, I think as an organization, we’re going to need to be able to deliver all 10 of the menu set.
Depending on which practice we’re looking at, they may not be able to meet all of the individual items, so organizationally, we still have the full set to address. But within them, the relaxation of some of the rules is going to make it possible for us to meet … we’re optimistic we will be able to meet all of it.
Eclipsys is very strong in CPOE, so I assume you’re OK on the inpatient side.
I’m co-chair of the Alerts Committee for the inpatient for New York Presbyterian. We call it the Clinical Decision Support Committee, actually, and I co-chair it with Rob Green, who is an ED physician. We’re five years into CPOE at the West campus, and I think they are more like 10 years into CPOE at the East Campus we call it, which is Cornell.
We have probably thousands of order sets. We consider that an organizational asset. We have a lot of alerts in the system, and that’s an organizational asset. We consider quality a three-legged stool, with documentation, alerts, and order sets being the three legs of that stool. We actively curate all three. We think we’re in good shape on the CPOE stuff at NYP.
Are you using Sunrise for nurse documentation?
Yes. Nurses document and physicians have come along a little bit later, but my department and my service, actually the hospital service, has just moved on full bore to Eclipsys documentation.
One of the things that we learned in Objects Plus development here at NYP was that we could make calls into the application to get data to externalize it. We were able to create — not me personally, but a colleague I work with in the informatics department at Columbia named David Vawdrey — was able to externalize that data and re-represent it and get it into documentation using a function he calls ‘smart paste’.
To the point that I was making before about enabling structured narrative, that has made the notes faster to write, easier to read, and include data that is meaningful to the users. Nurses now actually can access that function as well, and they’re very progressive and started documenting in Eclipsys very early at our hospital. The doctors have come along a little bit later, but most of the major departments are now using not only CPOE for Eclipsys, but Eclipsys documentation on the inpatient setting as well.
What should the next generation of EHRs do that the current generation doesn’t?
I think that the challenges that we face are specifically in coordination of care. If you imagine trying to infuse an EHR with the principles of Patient-Centered Medical Home and the Accountable Care Organization, it’s going to require workflow solutions that enable communication and coordination.
I see elements that have Web 2.0 and 3.0 technologies being major factors in that design. We imagine enabling a heads-up displays that allows doctors to write their notes, but also write orders immediately and message each other, either within or without the outside of the EHR, to coordination of care — easier ways to mash up data for data visualization so that you can more easily see a temporal trend than a multi-provider-centered view. I see the infusion of Web 2.0 technologies into EHRs being critical to the success of EHRs to meet the coordination of care componentry that’s needed.
You may have read David Bates’ couple of editorials that he’s had recently where he’s talked about trying to improve diagnostic accuracy, improve coordination of care, and try to get the EHRs to move in that direction. I wholeheartedly support that. I think that’s where a lot of the vendors are already looking.
The second thing that I think is going to become more infused into EHRs, and is something that we’re working on here at Columbia, is to enable the representation, the manipulation and physician understanding of personalized medicine concepts — genomic and pharmacogenetic data. I’m not aware of many EHRs that support that as structured data or actionable data that physicians can use to make decisions right in the EHR. A lot of the stuff ends up being scanned for the time being, so as HL7 special interest groups and clinical genomics start to have their standards permeate the health IT space, I think we’re going to start to see ways of collecting and manipulating genetic and pharmacogenetic data in EHRs in ways that we haven’t seen today.
What are your priorities for the next five years?
From the perspective of what we’re doing at ColumbiaDoctors, we’re like everybody else who is two years into their implementation — focusing on finishing our remaining departments. When we’re done, we’ll have probably 4,000 users on the system.
Phase II for us has already started, which is leveraging our order sets, decision support rules that we already have in place, and creating custom ones to start to tackle issues associated with chronic disease management in a multi-specialty practice group.
Then we’ll focus on priority disease states, you know, the common ones; but we’re going to ramp up on our quality mission and start to focus on those things that demonstrably impact patient care and go, not just with Meaningful Use, but those things that also extend to those things we do from a specialty practice perspective.
What I see happening on a more global scale is the two issues we talked about, in terms of what do I see happening next in EHRs — better workflow support, better coordination of care support, and the embedding of genetic and pharmacogenetic data in EHRs.
Any concluding thoughts?
I would say we’re pretty excited about the merger. We actually are looking forward to working with both vendors to create solutions that work really well at NYP and other sites who have it, or might consider having the two applications.