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