HIStalk Interviews Sanjeev Arora

Sanjeev Arora, MD is professor of medicine, director of Project ECHO, and executive vice-chair of the Department of Internal Medicine at the University of New Mexico Health Sciences Center, Albuquerque, NM.

Please give me an overview of Project ECHO.

Project ECHO stands for Extension for Community Healthcare Outcomes. Our mission is to develop the capacity to safely and effectively treat chronic, common and complex diseases in rural and underserved areas and to monitor outcomes. It’s funded by the Agency for Healthcare Research and Quality, the New Mexico legislature, and the Robert Wood Johnson Foundation.

We started this project about five and half years ago to treat hepatitis C, which is a global health problem affecting 170 million people worldwide, of which 3-4 million are in the US. In New Mexico, we had 28,000 patients who had hepatitis C. In 2004, less than 5% had been treated because there weren’t enough specialists in rural areas to treat them. There were 2,300 prisoners who were diagnosed with hepatitis C and none had been treated. We had the highest rate of chronic liver disease/cirrhosis deaths in the nation, so it’s twice the national average. 

The disease was treatable and it can be cured. Hepatitis C has six main kinds of virus. If people had Genotype 1, we could cure them about 45% of the time. If they had other kinds of genotypes, we could cure them about 80% of the time. The problem was that if patients were given this kind of treatment, which consisted of weekly injections and daily pills, they got severe side effects.100% of patients became anemic. Their white cell count went down. About a quarter of them got depressed. 

Primary care doctors didn’t feel comfortable treating this disease. There weren’t any specialists in the rural areas and in prison. That was the problem that we were trying to solve. 

Rural areas of New Mexico are a very underserved area for healthcare services. Thirty-two of 33 New Mexico counties are listed as Medically Underserved Areas. Fourteen are designated as a Health Professional Shortage Areas. We said we could use this new model to develop the capacity to safely and effectively treat hepatitis C in all areas in New Mexico and to monitor outcomes. We felt, if we could do that, then we would have a model to treat complex diseases in rural locations and developing countries.

We developed a partnership between the University, the prisons, health department, Indian Health Service, and community clinicians who were willing to treat hepatitis C in rural areas. ECHO’s model is based on four key ideas.

One is the use of technology to leverage scarce healthcare resources which may exist only at a university or in a tertiary care center.

We use a disease management model, where we focus on improving outcomes by reducing variation and processes of care. We create a best practice protocol for treating hepatitis C and then we share it widely with our partners. We all manage off the same label. This is to improve quality.

The third key idea is case-based learning. That’s when a rural provider goes to medical school or residency. They learn from real patients and mentors. When they go to the rural area and a new disease like hepatitis C gets discovered in 1989, they’re expected to read books and then treat this disease. They don’t feel comfortable because it’s a very complicated disease. So we said, “Why should we not bring case-based learning back into the lives of the rural provider by co-managing patients with them? We have a centralized database to monitor outcomes.”

We train physicians, nurses and pharmacists in hepatitis C. Then we conduct these telemedicine clinics, which we call Knowledge Networks. Many rural clinicians sign on simultaneously onto an interactive video network with specialists from the university. One by one, they present patients with hepatitis C to experts at the university. The specialists at the university help them manage these patients, tell them what to do, what tests to order, what treatments to take, and help them manage side effects of treatment.

They come every week, once a week, for a couple of hours and present their patients. This creates a learning system which we describe as a Learning Loop, where these clinicians learn from each other as much as they learn from university specialists. They also learn from short didactic presentations.

We give the rural providers no-cost CME credits. We give nurses credits for participation because they are learning from experts at the university. We like to improve their professional satisfaction and we give them access to multiple specialists at the same time.

Everybody gets the chance to present their patients. We use all different kinds of technology, including videoconferencing bridges, videoconferencing recording devices, and electronic records to enhance communication. We described this first for hepatitis C, but it’s applicable to any disease that is common, management is complex, new treatments are coming, high societal impact, if there’s a serious outcome of a untreated disease, and if there’s effective treatment.

We have a few concepts that make Project ECHO work. One is we are trying to provide the same level of care at a community health center as we give at a university. We can do this by means of technology, best practice protocols, and case-based learning.

From the Pareto Principle, the 80/20 rule, if you create Knowledge Networks for just a few diseases, you can have a huge impact on healthcare. You don’t need to have Knowledge Networks for 500 diseases to have a huge impact. A few diseases account for most of the morbidity and mortality.

We use the concept of a Force Multiplier. Because of the specialist shortage in rural areas, we can use existing community clinicians like nurse practitioners and physician assistants and enable then to provide the same level of care as specialist, therefore multiplying the capacity for specialty care in rural areas.

One challenge that comes up is that there is not only a shortage of specialists in rural areas, there’s also a shortage of primary care doctors. This is the next generation of Force Multiplier, which essentially shows you that we are training now community health workers and medical assistants and nurses also in these chronic diseases so they can be part of the chronic disease management team to help the primary care clinicians.

Existing methodology for training and development of widely distributed learners has major limitations. They tend to be expensive and out of sight, out of mind. You call them in for a conference into your city, spend thousand of dollars, they go back, and they forget what you have taught them.

In our model, we help them apply this knowledge and, using technology, we can do this training at a much lower cost. Also, we don’t have the problem of knowledge obsolescence because it’s a weekly interaction where we are slowly making them experts.

We also have a prison peer education program where we train prisoners in New Mexico to teach other prisoners about hepatitis C.

We have 15 separate areas in which we have Project ECHOs going on: hepatitis C, cardiac risk reduction, asthma, rheumatology, chronic pain, substance abuse, high-risk pregnancy. Some are supported by the Robert Wood Johnson foundation. We have many others. Overall, we have more than 140 programs around the state.

With hepatitis C, we have done 375 HCV Telehealth Clinics. More than 3,500 patients have entered the HCV disease management program. We have provided thousand of hours of CME credit at no cost to clinicians.

We’ve taken community clinicians and assessed their skills and abilities on different domains of hepatitis C care. On the question of, “What is your ability to treat Hepatitis C patients and manage side effects?”, on a scale of one to seven, they were two out of seven when they started and it went up to 5.2 in 12 months alone. So, very major improvements occur as they engage with us in this learning process.

Asking if they could serve as a local consultant for hepatitis C in their clinic and area, it went from 2.4 to 5.6. Overall competence went from 2.8 to 5.5. When asked if this kind of activity is of moderate or major benefit to them, it ranged from 94% to 98%.

Subsequently, we did a hepatitis C trial in which we compared the care in the university to the care in the rural areas and prisons by primary care clinicians. Rural primary care clinicians deliver hepatitis C care that is as safe an effective as a university clinic. We can also improve access to care for minorities. Almost 69% of our patients in the ECHO groups are minorities, versus much fewer in the university.

The potential benefits of the model are improved quality and safety, improved access for rural and underserved patients, workforce training and force multiplier, improving professional satisfaction and retention, cost effective care by avoiding excessive testing and travel, preventing cost of untreated disease, for example, liver transplant, and integration of public health.

In 2007, applications were sought for disruptive innovations in healthcare, new models that would change healthcare nationally and globally. This was sponsored by ASHOKA Foundation and Robert Wood Johnson Foundation in a disruptive innovations contest. Project ECHO was selected a winner among 307 applications from 27 countries. We were one of three winners selected.

Using technology, best practice protocols, and co-managing patients with case-based learning is an effective way to safely and effectively treat chronic, common and complex diseases in rural and underserved areas and to minor outcomes.

This is the first program I’ve heard of where the goal wasn’t just to turn over patients to experts sitting on the other end of a monitor, but rather to educate and make local practitioners self-sufficient. Has anybody else done that?

We don’t know of anybody that has done it the way we do it. Basically, that is why it was selected, probably, as the most disruptive innovation in healthcare.

Commonly, technology has been used specifically in healthcare by telemedicine, where there’s a specialist at the university and there’s somebody in the rural area connected by camera. That doesn’t lead to the force multiplication that we’re talking about. We’re interested in long-term capacity expansion of care.

In the passage of time, these healthcare providers become less and less dependent on us as they become good at it. We are not aware of this model anywhere.

Healthcare reform always talks about who’s going to pay and who will be covered, but nobody has addressed the issue of having enough practitioners of the right types in the right places. Are you getting interest from the government or insurance companies about how they might use this model?

We have not focused so far on publicizing at all. This is the first initiative. We got a very large grant from Robert Wood Johnson Foundation and they hired a PR firm, which I think reached you. So I think that this is just the beginning, really.

Very few people know about this program in the way you have just learned about it. We have treated tens of thousands of patients through this methodology, but our focus has been on service, not so much on policy work or convincing healthcare providers. But we hope that some of the work you and your colleagues will do will help us get there.

We think that this is a very valuable tool for healthcare reform because we can train, not only primary care physicians, but community health workers to become experts in very common diseases like obesity and hypertension and diabetes.

Because of the shortage of primary care clinicians, how do you take care of all the chronic disease that is going on everywhere? We thought, if we trained the teams of the primary care clinicians in these very common problems, we’ll do a better job.

When a community health worker is used as a sole diabetes educator — that is, no doctor, no nurse, no certified diabetes educator — HbA1c can drop by 15%. Comparing the care provided by a community health worker and a nurse practitioner in the community versus a university-based primary care clinician, the community-based care does twice as good.

We asked ourselves, “Why is this community health worker intervention effective?’ These people live in the community. They understand the culture. They walk two moons in the patient’s moccasins. They appreciate the economic limitations of the patient and they often know family and can engage other the social resources. But most importantly, they spend more time with the patient.

If you are trying to change a diabetic or and obese patient’s behavior and doctor spends four 15-minute sessions with them over the course of a year, it’s hard to do that, whereas somebody like community health worker can spend seven one-hour sessions for one-tenth of the cost and actually make a bigger impact.

We have developed two tracks. The first one has already launched, the second one is in preparation. The first one we call the CHW Specialist Training Track, where we take these community healthcare workers and train them in diabetes, obesity, hypertension, cholesterol, smoking cessation, and exercise physiology. Then, over time, they start interacting with us on these Knowledge Networks until they really become experts in a very narrow area. This specialty CHW program uses low-cost technology to take specialty training to CHWs, promotoras, CHRs, and medical assistants where they live. It has a very narrow focus but deep knowledge, standardized curriculum.

We give them ongoing support via Knowledge Networks. They become part of the disease management team. Basically, the point that I was trying to make to you with reference to your question is, in healthcare reform, we have to train a much larger health workforce so that doctors work in teams, rather than individuals trying to solve the big problem.

I’m interested in your statistic on how well the community-based caregivers were able to do what they do. Do you think that would be true outside your population of the underserved or on a Indian reservation? Is it translatable to the rest of the United States?

There are some places in the United States where you have a highly trained work force, for example, Manhattan or Boston. There are hundreds of certified diabetes educators. So the moment somebody comes to you, you can refer them to a nutritionist, diabetes educator, or podiatrist. You don’t need a community health worker — you’ve got super experts doing all this work.

But when you go to a prison, a rural area, an Indian Health Service facility, there aren’t any certified diabetes educators. They don’t exist. The nurses there are not experts and there’s a shortage of primary care clinicians who are trying to see 25 patients a day and do it all themselves. In that setting, or in inner city areas whether it be south of Chicago or Bronx … I think where there’s a shortage of these healthcare resources, these models are particularly effective. We’re not trying tot change healthcare where there’s doctors on every street corner and every other health professional fully supplied. Our mission is to provide world class healthcare in cost effective ways in areas where there isn’t enough healthcare workforce.

It seems that there’s not much ego involved. You’re not saying that your organization or your doctors have to get all the credit. You’re just saying, “We’re going to help you and help the patients.” It must be hard to convince people that you don’t have a vested interest.

I think the fundamental issue with Project ECHO, as you have alluded to, is that we have to be willing to break the monopoly of knowledge that exists. The knowledge gets monopolized otherwise. Breaking that monopoly and sharing it freely for public benefit, without necessarily charging anybody for it, doing it at low cost on public dollars, would be much more cost effective.

What if President Obama came to you and said, “This works. This is where we want to go. We want to take this national.” How would you go about doing that and what would it cost?

I think the first thing that would happen is one would have to create some kind of a federal granting mechanism to academic medical centers around the country, in which we would essentially ask them to consider a different mission.

Right now, academic medical centers do three or four things. They basically provide very high quality tertiary care, but they also train doctors and nurses. These federal grants that would be provided to these academic medical centers would ask them to essentially refocus their mission to training a much larger workforce in America to manage chronic disease in a highly cost-effective way.

That is, finding out what is the lowest cost person who can be trained to provide education, behavioral change, and foot exams to diabetics in rural areas without having to have them travel. Right now, people in New Mexico have to travel sometimes five hours to come to an academic medical center.

Most of the academic medical centers are being financed right now by the clinical revenue generated by all these patients travelling. If you redirect clinicians, these highly educated specialists, from providing direct care one on one to instead enabling the workforce around the state in their rural areas to provide world class care by setting up these Knowledge Networks, you can actually get a much more cost effective healthcare system and get much better outcomes at much lower cost.

It means re-thinking how we do healthcare, so it would mean reconfiguration. In order for the federal government to be able to support such an effort, they would need to support this transition in the mission of academic medical centers. I think if federal granting mechanisms were available, large numbers of institutions like ours would jump at the opportunity because they want to do this kind of work if they are made financially whole.

An HIT Moment with … John Shagoury

An HIT Moment with ... is a quick interview with someone we find interesting. John Shagoury is president of Nuance Healthcare.

Is the rich nature of the physician narrative getting too little attention in the rush to get codified data for interoperability?

Yes, as the healthcare industry and more recently policymakers work to make electronic health records commonplace, I believe that the concept of preserving the physician narrative has yet to receive adequate attention.

While the HIT Policy Committee has recognized “electronically capturing data” as part of the “meaningful use” criteria, the rich nature of the physician narrative needs to be specifically identified. In order to ensure that patients’ medical records do not suffer in quality, and that caregiver communication via shared notes does not lack necessary detail, electronic health records must not be reduced to point-and-click templates alone. The physician narrative should be accounted for and measured as part of quality care tracking under the American Recovery and Reinvestment Act.

This past June we surveyed more than1,000 of our physician customers on the topic of “meaningful EHR use” and learned that 94 percent of physicians surveyed either “agree” or “strongly agree” that capturing physician narrative as part of the documentation process is necessary for complete and quality patient notes. When you’re dealing with patient care and people’s lives, codified data only gets you so far. We must not forget that physicians treat people with problems, not just people’s problems; the details found in the physician narrative help to personalize the record, leading to high quality, patient-specific care.

Providers want a fast, sure payback on their capital investments. What’s your message to them?

If a healthcare organization is making any investment, including a capital investment in healthcare IT, it needs to align with a step-by-step workbook that outlines actual cost and benefits. All investments should be well supported with project goals at the technical, user, stakeholder and strategic levels. In addition to goals, the following should be crystal clear: what needs to be measured; how it will be measured; and how often it will be measured.

Another option to a capital purchase is an investment in a hosted (on-demand) solution. Regardless of what model an organization uses, I’d counsel providers to do both statistical and qualitative predictions and measurements. With the example of speech recognition technology (which is offered by Nuance as either a capital or on-demand purchase), an organization should estimate and measure the amount of traditional transcription cost that is expected to be saved, the projected physician satisfaction and efficiency levels gained, as well as quality improvement of patients’ health records.

While there’s no clear-cut playbook for which method of IT delivery fits which healthcare organization, working with an experienced vendor can help to ensure you invest in the right solution for your individual organization’s needs. Additionally, as the industry is increasingly identifying traditional transcription as an opportunistic area to boost efficiency, improve quality and reduce costs, we are seeing more organizations choose the on-demand model. It should be interesting to see if this trend continues.

While a capital purchase allows for full control of on-site software management, as well as data, security and process control, for many the on-demand model is more compelling. With on-demand, instead of installing software onsite, hosted software runs on the vendor’s servers. The vendor hosts the application and makes it available for users to access through Web browsers (via secure passwords). All of the customer’s data is stored at the vendor’s site; all maintenance of the software and server hardware, data backups, and tedious details of that nature are handled by the vendor. Healthcare organizations simply pay a monthly fee depending on their activity level; there are few extra costs or tasks associated with management and upkeep of the program for the customer. In addition to the benefit of less investment up front and fewer responsibilities on program updates and management, upgrades also happen automatically, and any glitches are the responsibility of the vendor.

The industry has taken some widespread negative PR and patient lawsuits over undelivered and uncommunicated critical patient results. Nuance acquired Vocada and its Veriphy solution in fall 2007. Was that a timely acquisition and will it be strategic going forward?

The decision to add critical test result management capabilities (CTRM – Veriphy) to Nuance’s healthcare portfolio was indeed strategic. The timely and accurate reporting of critical test results from the lab or diagnostic imaging group to the treating physician is an important aspect of patient safety. Unfortunately, and despite many regulatory and accrediting requirements, the typical “systems” for delivering and managing critical test results are mostly manual, disjointed, inefficient, prone to error, and frustratingly inconsistent.

In a recent study led by Dr. Lawrence P. Casalino, an associate professor at Weill Cornell Medical College, it was found that more than seven percent of clinically significant findings were never reported to the patient. As part of the study, the records of 5,434 patients at 19 independent primary care practices and four based in academic medical centers were reviewed. Casalino’s team extracted records that contained abnormal results for blood tests or X-rays and other imaging studies, and then searched for documentation that the patient had been properly informed of the finding in a timely way. After many interviews with physicians associated with the uniformed patients, the researchers found that of 1,889 abnormal results, there were 135 failures to inform.

Clinical laboratories are tasked with performing more than 10 billion tests per year and while critical results generally comprise less than two percent of all lab findings, the timely communication between the lab, physician, and patient is always crucial. Through use of critical test results management technology (Veriphy), leading medical centers like Virginia Commonwealth University Medical Center are automating the communication of patients’ critical findings so patients do not have to second guess if their results are normal and doctors do not have to worry about liability if a patient is not notified. VCU performs as many as 340,000 procedures annually, they went from being only 49 percent effective for critical message delivery and today critical results are communicated to the right caregiver within 13 minutes of being identified 99 percent of time. Phone tag is no longer relied on to ensure critical patient care.

Going forward, and increasingly as results like VCU’s become known, we expect Veriphy to be identified and deployed at more radiology, lab and even hospital-wide as healthcare organizations work to improve caregiver-to-caregiver communication and speed high-priority patient care.

Where are Nuance’s healthcare R&D dollars being focused?

With expertise in speech recognition, clinical communication and documentation, as well as diagnostic imaging, our R&D dollars are directed at expanding upon the capabilities and technological advancements we are already recognized for across the healthcare industry.

As mentioned earlier, preserving the physician narrative as part of patients’ electronic health records is extremely important. We will continue to improve the recognition capabilities of our speech solutions, expand our already formed relationships with EHR vendors and work to perfect natural language processing capabilities. We believe that data extraction and analysis of the unstructured clinical narrative, as well as the conversion of the unstructured narrative to structured, discrete documentation is critical for improved ongoing patient care.

Moving forward, we will continue to focus on ways for our customers to find value from the physician narrative for caregiver utilization in real-time, as well as to drive extensive analysis for enhanced care and operations moving forward. We will also remain focused on supporting current and emerging standards associated with HL7 CDA implementation guides to ensure the data the our customers capture is accessible and shareable for use within their enterprise, regionally and nationally as deemed appropriate.

With unnecessary imaging procedures costing between $3 billion and $10 billion annually, we will also work to expand upon and promote our RadPort solution as a viable, and cost-effective, solution for managing high-tech diagnostic imaging utilization. Earlier this year, Nuance co-founded the Imaging e-Ordering Coalition, which is an alliance of leading healthcare providers, technology companies and diagnostic imaging organizations working to promote electronic decision-support (e-Ordering) as a solution to assure that all patients receive the most medically appropriate diagnostic imaging test for their specific condition.

RadPort is an electronic decision-support tool that provides ordering physicians with clinical information at the time they are ordering a patient’s exam. By producing a "utility score" for the requested exam, physicians can assess the medical appropriateness of the exam to ensure it will be reimbursed by the patient’s health plan and most importantly to verify that it aligns with the patient’s conditions and care needs.

In addition to decision support, we are working with many customer sites to collate and analyze their ordering, documentation and patient outcome data via a Rubik’s cube like data warehouse, called RadCube. Over time medical groups can determine how often their providers’ selections of higher utility scans improve patient outcomes. RadCube collects a tremendous amount of data, automatically structures and classifies it and then provides a visualization of current activity to drive improved care, business and management decisions.

What does the short- and long-term picture of healthcare IT look like from the company’s point of view?

For the first time, healthcare IT is in the spotlight. In the short-term, we’ll see a combination of big promises from vendors that are simply unable to deliver matching technological advancements alongside market leaders that have been focused on addressing specific healthcare pain points for some time.

It is an exciting time to be in healthcare. As healthcare reform has captivated the nation, HIT has also risen in recognition and priority. As part of the American Reinvestment and Recovery Act, $19 billion is allotted for incentive payments starting in 2011 under Medicare and Medicaid for providers determined to be “meaningful EHR users.” As we anxiously await the definitive meaningful use definition, which is expected in the spring of 2010, Nuance is working to educate policymakers on how speech recognition can help national EHR adoption and utilization.

It is proven that a major EHR usability hurdle for physicians is the task of typing. Speech recognition does two things to improve EHR utilization.

• It makes physicians more productive. Because the majority of people speak faster than they can type, clinical documentation can be done more efficiently when speech recognition is applied; this allows doctors to spend more time practicing medicine.
• By allowing physicians to speak vs. type, they are empowered to create a highly detailed narrative of the patient encounter that can not be fully represented in structured templates alone, or perhaps would not be as complete if a physician was tasked with typing the note. EHRs will only be valuable if the information captured within them supports improved, ongoing patient care. We believe speech recognition can help to improve the quality and detail of information captured in patients EHRs and will be more broadly used in the short-and-long term.

In addition to speech recognition as core to EHR workflow, we are also working to educate policymakers on Capital Hill about the value of electronic, evidence-based clinical decision support to help eliminate medically unnecessary diagnostic exams. The technology, RadPort, rates medical imaging exams (at the time a doctor is ordering them) on a scale of appropriateness of 1-9. The rating is based 100 percent on the likelihood in which this particular exam will or will not contribute to positive outcome for the patient (will it help them?). Nuance is also a co-founding member of a national Coalition (The Imaging e-Ordering Coalition), which supports providing physicians with guidance regarding the ordering of patient-appropriate imaging services. Obama has talked exhaustively about the importance of reducing unnecessary exams and we are confident this technology can help.

Over the next 3-5 years, the healthcare space will move from IT laggard to more of a leadership position. The meaningful application of IT to healthcare is incredible and necessary. It can drive advancements in efficiency, cost savings, and patient care. Whether it’s clinical decision-support or applications to document the patient encounter without the keyboard or pen, we’ll see doctors’ tech toolkits evolve with new solutions to improve care.

Moreover, we’ll see the impact that strategic enterprise-wide HIT can have on a healthcare organization as a whole. The ultimate long-term goal will be interoperability and the availability of a patient’s medical history across any care-providing site, affiliated or not. With the right application and management of HIT, we can expect to see improved patient care and physician efficiency, while the cost burden associated with the current health care system is dramatically reduced.

HIStalk Interviews Tom Liddell

Tom Liddell is executive director of the Michiana Health Information Network of South Bend, IN.

Every RHIO and HIE sounds successful, but clearly some aren’t. What yardstick should they be measured against?

I think the yardsticks they should be measured against are sustainability from the standpoint of broad-based community support. That would be support not only from the institutional community — hospitals, laboratories, radiology centers — but from the physician and clinical community as well. That’s the foundation of an exchange in a medical service or medical trading areas.

The second one is, they really do have to have an economic or financial model that is accountable not only to the servicing organization but to the physician provider. In our particular market, we ask financial participation from most, if not all of the parties that are involved. That’s been an interesting secret, because then the value is not only perceived, but it is realized. You actually then have to deliver.

The third thing, I think, is the actual delivery of results. In our particular case, we are extremely focused on enabling the physician provider to have what we call 100% of the data in relevant care of an individual. So physician-led care that is driven by as much appropriate information that should be available.

If you have all those things, I think you then really have that sustainability, and it can provide a good long-term success.

What are some of the most innovative aspects of your service?

In terms of innovation, our approach is to try to be innovative in the service delivery components. By that, we do probably two things that are unique. We are standards based, so whether it’s HL7 or CCHIT qualifications or the emerging meaningful use qualifications, we try to stay pretty close to those bodies of work.

In doing that, there are times when we have to shape an interface delivery service where there’s an electronic health record that’s not quite there. But we try to have its origination as close to the standards as possible. I don’t know if it’s innovative, but we think it is, and we still get the job done.

I think the second innovation that we came to a few years ago was we said we want to have some available service for every provider, be it fax replacement, pushing clinical results, or, what we call clinical messaging: a community health record that is extendable, meaning over 9, 10 years worth of data, or interface integration.

Innovation is an innovation in service. We have something for everybody. If you’re a nursing home, we’re going to make you more efficient. If you’re a specialty provider, anything that you’re copied on that a primary care doc orders is coming your way, whether it be through a delivered portal or through your integration or interface integration.

The other thing that we’ve done, which I don’t know if it’s innovative, but it’s really working, is that we are one pipe into that physician provider. We are really taking care of so much of the burden that a physician practice would have if they had to go out and say, “Hey, I need to connect to laboratory, and then I need to go to this hospital, and then I need to go to that hospital.” We literally take it all the way down through the vendor and watch results go into that electronic health record. That’s been a huge spark and fuel that’s been there.

The last thing that we do is what I would call it a best-of-breed provider. I believe that the market is still pretty early with an incredible amount of business opportunity, meaning I think we’re going to see a ton of innovation over the next five to ten years. We are not, “Hey, it’s only going to be Cerner’s architecture.” While we think it’s great, we see that Axolotl had a fit for us, and we see that Medicity might have a play with their box. We also see that there are places where something like the Mirth engine might fit.

So we’re a best-of-breed, meaning we want to keep ourselves open to not being only locked into a single vendor, a single strategy.

How many employees do you have and what do they do?

We have 14 full-time, two part-time, and two interns. They’re largely boxed in three areas. The first area is our development area. That is the area that we have services around the creation development, the deployment of, that which is exchanged. That could be anything from standards creation for an interface bringing a new hospital onboard, bringing a large multi-site physician provider practice and literally doing that development. That’s coding interfaces that’s creating the roadmap for those things. In some cases it’s sort of boring, benign, making sure that we have a common set of standards that are deployed. That’s the development group.

We then have the service and operations team. That’s where hardware, technical, and application support reside. That’s everything from working with our servers and data farms to data management to our Oracle database as well as we have other database management tools to the team that runs what we call our frontline services. We try to, if anything, overemphasize that first-line service, and that we answer calls all the time. There’s no other drop boxes for that. We believe that that’s important, because if anything, it’s right at that point that that coordination and service needs to be there. That’s that group.

The third group that we have houses what we call our physician services. That’s comprised of anything that relates to the physician or clinical service that goes out to the community. They do all statements of work, all integrational projects around, whether it be pushing results to our clinical messaging system and rolling it out for a hospital. We do work with Dragon, those kinds of things and add-on products. It’s really enablement in that physician clinic space for that.

Inside of that, sorted of grafted on to that group, we also have what we call the institutional team. That’s just one person working on the institutional side to make sure that their efforts are coordinated. That’s your hospitals, labs, etc.

The last little group we have is really myself and one other guy that do what we call our business development, which is when we go and talk to a new customer, RFIs and RFPs. What we’ve done is we actually outsource with one of our partners, one of our owners, some technical services. You can almost say we’ve got two additional FTEs that do technical capacity work for us.

Our interns — we’ve done a couple of things. We have a medical student — in fact his whole summer was dedicated to, and is still keeping track, and he’ll be back in the holiday season — we’ve been studying what we call medication management. Everything from how many people have adopted by county, by specialty, to what’s happening on medication reconciliation and what a patient needs in the hospital. It takes about 24 months to set up a service properly.

The second intern we have is a programming intern. We’ve really tried to call out both clinical users as well as people that are more in the technical line of services out there.

You are working with the GAO on PHI disclosure. What are your thoughts around that?

I guess I could say we completed the first round of work. We were the first place they called, so I guess that was exciting. They were very nice and accommodating. A team from Atlanta came and spent the better part of a day and into the next day. We went through everything.

It was actually a great example where we were able to bring security specialists from the institutions and we lined up basically according to the services. If you were doing clinical messaging, we hooked them up with a clinic, so that they could understand how that would go. If you were doing interface integration, we brought them over, and a CEO of a 25-provider oncology group showed them how they their release and how their information kind of flows. And then we did a roundtable with them in the afternoon.

I think it was a very eye-opening and kind of a learning process for those guys. I think what they also understood in the end was that we are mimicking the delivery and replacing the delivery mechanisms that are already in place today. If a provider is copied on a laboratory result, we’re basically just improving that method of delivery and really making it more secure in that. So I think it was beneficial there. Then we had a follow-up and help them see what other exchanges are operational across the country that they could coordinate with.

It’s very important, because as ONC not only lets funding out at the state level, that coordination be able to monitor if those dollars are going out appropriately. Are they being spent appropriately? Is there security and protection for that individual consumer? I think these are important integrations to that.

Many people wouldn’t think of Cerner in the practice EMR area. What’s been your experience with that product?

In my experience from my WebMD days and when I was a senior VP of product management and had a lot of work in developing an EHR, you start to see the tremendous capabilities that the tools that they’ve built have. They are committed clearly to making sure that the enterprise, whether it’s an institution, clinic, laboratory, etc., are able to be co-joined, commingled, and integrated into that process.

They’re working their tails off to change perception and image. I can only tell you that it’s pretty operational for me, with my sleeves rolled up, that the product itself has an incredible set of capabilities. If anything, you want to try to gear those back. That’s probably easier to do in the long run than to try to catch up and add an incredible set of features.

One of the nice things that I have the benefit of is for those that use the component, which is more of an EHR in our market, it’s not a question of “could we do something?” It’s how they want to do it. For me, that’s actually pleasing, because I can have a discussion that says, “Do you want to proxy to your inbox for something that was just ordered or copied to inpatient/outpatient?”

Unfortunately we want to make healthcare simple, but it’s a pretty complex enterprise, especially around health information.

Having said that, like anything, there are lumps along the way. We busted our tails to make sure that e-prescribing and all those things are up. There’s a lot of parts that are moving, whether it is Surescripts RxHub or whether it’s having a clinical summary available in an HTML or XML format.

In fact, we had a strategy call yesterday with two other executives. We do it regularly, and it went almost two hours. They can tell you they’re listening. I can tell you we’ve had a pretty significant summer in terms of adding providers to their core business as well.

How sustainable is your business model?

First of all, there’s been these naysayers out there saying, “Should we work to build these kinds of businesses and services?” I guess I would say you have to have value, and if you deliver value, I think people come and are willing to pay for those services.

Certainly health exchange has an element of a political aspect to it, but I don’t mean on the national level. I mean certainly against the competitive entities and those kinds of things. But once people get beyond the notion “don’t compete on health information; compete on everything else” you can start to make the exchange sustainable — you can make that case for doing that.

But I think in all things there has to be that perceived value. One thing I do know is when you settle all the noise around it, there has to be an entity that is a facilitator of those common services, whether it’s building a referral management network, whether it’s moving or integrating data. At least it’s demonstrable in places where you don’t have that. It doesn’t get off the ground, or it doesn’t sustain, because there’s nothing to sustain itself with.

I’m certainly not naïve to say, “Are there risks in any business?” Certainly there are, but the big key, I would say, is that you’ve got to be willing to adapt. When I came in 36 months ago, the only real interfaces that we were going on were basically from suppliers and I just said, “Listen, in twelve months, we’re going to be able to deliver any piece of data we have to an EHR and have it happen in there.” Well over 65% of our total market has data integrated into their electronic health record, and we feel that by the end of next year, 15 months from now, we can be over 80%.

What effects are you expecting from HITECH?

It’s been almost a tsunami so far, in that it certainly has caused all of healthcare IT to have to think differently. I don’t mean just on the funding level potentials, but to say, “How are we going to work together in and out of markets? How are we going to work together at the state levels? What can the role of a health exchange be whether it’s a working component of the extension centers or whether it’s how we pass data from exchange to exchange?” We’re in the throes right now of connecting two different exchanges just in our particular state where we can move relevant data.

I think in the end, what it’s doing for us, or will do for us is, if anything, accelerate the level of activity that’s there. By that, I mean the services that we can deliver. It’s certainly bringing awareness to those things.

I think in the long run, what I hope doesn’t occur are some of the unnatural effects. As an example, in e-prescribing, it’s great to adopt it, but if it’s adopted in a silo, I don’t know that there’s a clinical benefit, that the clinical benefits are harder to get to. There is a clinical benefit long term, but I don’t know that the patient realizes that other than maybe a medication error. You have to kind of look at it holistically and say, “But if I can do that in a more organized, methodical way inside the complement of my full EHR, I’ll have a better perspective on the patient.” I use that as an example.

Overall, it’s great. It’s exciting. It’s causing the coffee to be made late at night and early mornings, but that’s why you play the game.

Why is Indiana so strong, do you think, in interoperability and informatics?

I think there are a few things. First of all, there’s a history of innovation across the state in terms of health IT. In the market that we serve, Northern Indiana and up in through Michigan, we had early adoptions early on — early adoption both by hospitals and by physician practices of automation.

In this particular market, there have been some pretty innovative companies that have gone on and created applications, and they’ve moved down the road. When you look to the central and southern parts of the state, both with our public universities as well as Notre Dame to the north, there’s a commitment to life sciences; there’s a commitment to health information technology. We have institutes across the state that have created products.

I think one of the things that happened is that all of a sudden, we pop up, and then a group in Indianapolis pops up. You look in Cincinnati and you can almost see a corridor developing from, I would say, the middle of Michigan all the way through Tennessee that is sort of powerfully evolving health integration, health exchange.

I think those are some of the core properties as to why there’s success.

The other thing we have going in Indiana is that we are committed as a group. We got together over a year ago and just said, “How do we start to work even more closely together? What makes sense is while we’re competing, we’re still committed to doing these kinds of things that enable it.”

We found a great working relationship in the people that are across the state that are very committed to an approach that not only takes us through Indiana, but through all the neighboring states here in the Midwest.

Anything else that you want to add?

Look at the seeds of where we are. We’re ten years old. We have services in a variety of areas that help our sustainability. We’ve had significant financial commitments in growing this exchange. All those things are all reflective of the commitment that our particular market has to the products and services that we’re about.

It’s interesting — this particular exchange started from the seeds of a workgroup that I participated in in 1994. There’s a long history of people concerned with where healthcare is going and moving, and asking, “How do we become parts of the process?” There’s been a long-term commitment to health information technology. There’s been a commitment for me in a market that I’ve been basically been around my whole life. So, there’s kind of a personal passion as well.

I guess the last thing that I would say is that I can’t say enough about the commitment of our people. They not only feel that they’re into something that’s very important, but there’s a personal mission that they have. Many of these people could be in other places, frankly even making more money, but their level of commitment is incredible. And their creativity is pretty incredible as well. So, I would compliment that in our team.

HIStalk Interviews Bill Shickolovich

Bill Shickolovich is VP/CIO at Tufts-New England Medical Center of Boston, MA.

You recently spoke at a conference about what hospitals should do now for ARRA. What did you say? 

I think you’re referring to a dialogue we had with HealthLeaders. That may have been back, I think, several months ago. Essentially, it was a nice round table with a series of folks nationally. I think the punch line that I was trying to get through and essentially what the others were aligning to is to first understand where you are relative to your own strategy. I think that’s first and foremost.

What we’re doing is resetting our strategy. We already have a strategy in motion relative to the elements of meaningful use. The stimulus is not making us do anything new. But it has drawn attention to understanding how much of what we’re doing lines up with the various financial opportunities.

So what I recommend people to do is to understand and have a strategy. If you don’t have one, get one. If you have one, ensure that you based on that with your leadership. Then go to a process of education. Overlay what stimulus means relative to your strategy. Simply, do you go in a different direction or do you accelerate, essentially, is what it nets down to.

That’s what we were recently in the process of doing. And it helps us to say, “Here’s the dialogue, here’s what the strategy in our program was prior to this opportunity, and here’s the various elements and scope of schedule and budget, and here’s now what it may mean relative to some of the things that we better understand now, and here are some of the things that we know, here are the things respectively that we don’t know, and of what we don’t know, we’ve gone out on a limb a little bit and through their resources tried to figure where that’s going to go, and help our leadership understand that we’ll be back to you in a monthly basis to talk a little bit about and as things mature, it has the opportunity to affect our direction the following ways.”

So essentially everyone talks about governance, but essentially I think it’s critical relative to this topic to keep leadership informed as to how your current strategy relates to what is happening and what may happen.

You’re actively involved in translational medicine. What are the IT implications?

We are, as you know, a CTSI awardee, and the clinical translation activities have broad implications to try to help various research enterprises collaborate. When we first looked at it, we were thinking, “Boy, this has very, very deep consequences.” But we’re now respectfully at the basic level of trying to just create various toolsets to at least understand and inventory what researchers are doing.

Furthermore, we’re creating some basic level of capabilities and, I hate to admit it, these are basic directories starting with human inventory. Who are the researchers, where do they work, and how do I get in touch with them?

So you’d think when this whole thing first came out, we had a deeper strategy that got into the weeds a little bit. We started to just say, “Let’s get started here a little bit.” And then we realized we’ve got to start at ground zero, and that is basic understanding of what the CTSA is in ARRA, an inventory of what people are doing, putting up a web portal and a collaboration tool, if you will, to try to help people share and exchange information, and help people understand who people are.

Those are some of the early things we found that we took for granted a little bit, because each organization does a certain amount of that on their own. But it’s taken us a little longer than we thought, relative to getting off the ground.

What we do now is we meet quarterly with various CIOs and their respective institutions and talk a little bit about what we’re doing, how it lines up, and how it relates to what other people are doing. I think we’re still in the formative stages, if you will.

What are your capabilities and plans about storing and analyzing data for quality improvement?

Great question. We are making heavy bets in our EHR program. Right now, our capabilities are around basic registry technologies, around claims data. We are working very hard to implement and deploy our EHR technology through eCW — we’re an eClinicalWorks customer. We are deploying that to our community physicians. We’re beyond our pilot now and are into our first wave of general deployment.

We are building in all of the necessary quality measures within that deployment. We’ve got a quality AQHC contract with Blue Cross that we recently completed this past year, and it’s imperative we meet those quality measures. So our quality strategy relative to information technology is leveraging our existing technologies, which consist of the patient registry and certainly our key information system, and working very hard to incorporate and ensure that any and all deployments subsequent to our deployment right now in the community encompass those various quality measures that we are contractually bound to.

It’s exciting. When you correlate investment and technology deployment to physician value and what it’s going to mean to them and to their paycheck, it’s an incredible moment.

Dr. Halamka and I had recently spoken; we collaborated on a dialogue. He had a great way to frame it. Certainly, when you speak of physician compensation, that is a very important driver to compliance. We’re finding that in order to get the adoption that we’re working very hard to gain, meeting the AQHC measures is critically important to our clinician base relative to their compensation.

How is the physician acceptance with your ambulatory and inpatient applications?

The acceptance has been very good. It’s not without its challenges, and I think you and the industry knows that. Our pilot has gone extremely well by the measure that we consider; our adoption rate has been very good.

But as we move out into general deployment, we are certainly uncovering some issues that we all have faced. It’s a constant balance between how fast you go and how much support and how much care and feeding do you give along the way.

And so our general acceptance of the technology and the strategy has been very good. It’s completely tied to our business strategy; our clinicians recognize it’s an imperative.

However, it doesn’t help us when there are various technology issues which compromise adoption. We’ve had a few of those recently, and we’re working very hard to mitigate this.

On the acute side, we are a Siemens Soarian customer, and we’re proud to say we’ve done what we consider a fair amount of work with it. We’ve actually got between 47 and 52 percent of our orders that are being entered electronically by our clinicians, and that’s on a voluntary basis.

We did not mandate that. That was actually something that our house staff came to us with and simply stated that the pressures that they are under to deal with throughput and deal with length-of-stay issues and deal with basic efficiencies, it was simply that they wanted to get off paper so badly that they were willing to work with us in a hybrid fashion to create a series of interim states relative to order processing. The house staff has adopted it extremely well.

So what are your top IT priorities over the next three to five years?

Our top IT priorities are to continue the deployment of our community EHR — that’s going to go through 2011. We’re working very hard to get in line and ensure that we have significant penetration, if not 100% penetration by then.

Two is to continue our acute information technology strategy, which includes completing medication administration, which is scheduled to be done in the acute side this fall, and move into the intensive care units, and to begin and complete the deployment of medication CPOE which is scheduled to start this winter.

Our top priorities for the next several years is to essentially meet and exceed the meaningful use criteria, so as not to leave any opportunity if subsequent funding comes on the table. We are not economically in a position to do so.

It’s not driving our strategy, because again, as I stated earlier, it’s something that’s already been in flight, but now that it’s out there, it’s certainly getting a lot of attention in light of our economic position and our competitive space in the market. We cannot afford to leave any of those funding, any of those dollars on the table if we can help it.

What would you say are your three biggest challenges as a CIO?

I think that the number one challenge right now is access to capital. I think that we all understand the economic climate that we’re in, and notwithstanding the value of healthcare information technology — I don’t think we suffer from understanding its value and importance to us; it’s reconciling the other various priorities and institutions, and ensuring that we can do the necessary things outside of IT for capital funding, and also IT.

So it’s access to capital. The markets haven’t helped us, obviously, in that way. It’s a scramble. I think that’s one.

Two, it’s respectfully dealing with the change management associated with deploying these strategies. These are not technical, and I understand not all that complex — they are tricky — but dealing with all the change management issues in a way that deploys technology in a meaningful way, pardon the pun, to get a meaningful business result in a short period of time is tricky.

Dealing with vendors that are still coming up the curve — I think they have a long road ahead of them relative to understanding what it really takes to have a successful deployment. I think we’ve come a long way, but I don’t think we’re there yet. I think the ARRA pressures will further compromise their ability to get it, if you will.

So access to capital and managing the confluence of change relative to clinical information system deployment, I guess, are my top two barriers right now, or challenges that we’re working through. I mean there’s a whole host of others. [laughs]

Keeping the infrastructure alive and running is sort of a variant to access to capital, but everybody wants the sexy new things, everybody’s pushing to deploy, and I think that’s good and we’ll be doing it for many years. But we can’t forget that there’s an investment required to have a stable and secure architecture or infrastructure.

That’s something that I think there’s a temptation, in my opinion in this space, that there’s a recognition and a deference to it, but in organizations that are financially compromised or challenged, it’s sometimes one of those things where people say, “Yeah, I know we need some more servers, I know we need some of these things, but we’re probably going to put that off because we need a new MRI machine.”

Those are difficult decisions, but decisions that are real and get made every day.

If someone asked you to list the three most important things you’ve learned as a healthcare CIO, what would you say?

Be relevant. [laughs] Relevance is probably the top of my mind. Coming from a managing consulting background, I don’t think it was hard for me to understand, but I probably underestimated it, respectfully. It was surprisingly something that I learned early on that can’t be underestimated. I think that that’s significant.

Two, I guess, understand what’s going on. It’s a variant of relevance. I think that one of the most important things that we should be doing is to understand how the operation, how the organization works. If we are to understand the business strategy, if we are to try to align our technology strategy to it, we cannot be irresponsibly neglectful to the operations of the institution.

I think that we have an opportunity or a tendency in the industry simply to look at the business strategy, look at IT high level strategy and just march toward and through it, and we forget what it takes along the way.

So a big lesson learned to me was: a) relevance, and b) understanding. Understanding, connecting all the dots, and not just the top two dots.

That was two, right?

That was two. [laughs] You need a third?

If you don’t have a third, that’s OK. [laughs]

There are so many. I think, communication. Being engaged — it’s all part of relevance. Relevance to me is such a broad and important topic that it covers these other things respectfully, variations of it. Yeah, I think I’m going to hang with my top two.

Anything else you’d like to share? Any wisdom?

I don’t know about wisdom. [laughs] I’m just a simple CIO, right? I think that it’s an extremely exciting time; I think that we all recognize it. The good news is, in light of the healthcare reform in ARRA, it’s shining a light on the topic that I think many of us have implicitly understood as needed, but we’ve struggled with one of the number one barriers, and that is cost. ARRA doesn’t make that go away, but it certainly greases that conversation, right?

I think that’s great. It’s a wonderful time, it’s a perfect storm. I hope we get it right. We are in an interesting time where it’s directionally correct, if I may use that term, where we understand how healthcare reform has to happen and it’s not something we should wait for forever to materialize.

Technology is important to the space in achieving its local and national goals relative to quality and safety outcomes, and certainly some level of fiscal responsibility around the space.

So it’s directionally correct, but the devil is in the detail. I hope that we find an effective balance between our drive and our desire to move forward as quick as we can in light of what we haven’t done, in the last 10 to 20 years, but yet I hope we don’t do so in a way that doesn’t take into account the necessary details that really need to be thought through.

That’s the tricky balance that I think, respectfully, we as an industry and the government has to reconcile. We all know good strategies that were directionally correct but got caught up in the mud and didn’t go anywhere, and we’ve also seen directionally correct strategies take off significantly without the appropriate — not vetting, but appropriate balance of reality.

This is so important not just to our healthcare ecosystem. It is almost a fifth of the economy. We’re talking about a significant element to who we are, that the stakes are so high that finding an effective balance is so critical. I think in the short term measured in months, call it six, and in the long term within the next three to five years.

I personally have a high confidence level in John Glaser and others as a former customer, and certainly as a colleague, who’s such a good rational thinker. I just hope that our governmental process gets it right.

After our interview, Dell announced its expanded presence in the PM/EMR world. It turns out Tufts was instrumental in helping Dell (and eCW) develop the basic framework for Dell’s offering. We went back to Bill and asked him if Tufts is working with any major corporations in developing their EMR strategies.

To summarize Tufts’ role, about a year ago Bill approached Dell and asked them to assist with the deployment of EMR to their community physicians. Though Dell and eCW already had a relationship, Bill brought the parties together to discuss how everyone could work together to create a new delivery model that would benefit the health system, the physicians, and the vendors. The health system lacked the resources required to provide physical support, including helping physician offices with infrastructure assessment, design, hardware procurement, deployment, and support.

Dell was interested in expanding its footprint in healthcare, especially on the services side. eCW’s expertise is software and not hands-on support.

In the end, Tufts established a support model that does not require an in-house help desk, but relies on Dell for physical support and eCW for software support. Bill anticipates the model will save 5-10% on support costs over five years, compared to providing services in-house or through a boutique vendor. Based on the success of the initial pilot installation with Tufts and ECW, Dell further tweaked its healthcare strategy into the model announced this week.

HIStalk Interviews Avery Cloud

Avery Cloud is CIO at New Hanover Regional Medical Center in Wilmington, NC.

Tell me how your Project S is structured, what it’s designed to accomplish, and your thoughts on portfolio and service management.

Project S is exactly that. It’s a service management initiative in disguise. I’ve tried to move away from this idea of talking in a language that means nothing to my customers. We basically took service management concepts and repackaged it into something that was explicable and digestible by our audience.

What created the need to do this in the first place was an analysis of where we stood and our ability to meet service levels or to create customer satisfaction, also to build an infrastructure that would support the coming strategic initiatives that we saw down the pike.

For example, we’re moving rapidly into full-function EMR. We knew that we have to have a structure that supports remote ambulatory care environments. We have to have different service levels for that.

Analysis showed that we just weren’t set to work quite ready for that. We had a maturity study done and we had about a 1.2 level maturity against a maximum of 5. It also revealed that we need to move somewhere around a 3.2, 3.3 maturity level in order to provide the kind of services that would be required to make our organization successful. That gap represented the tools, skills, policies, standards, procedures that are necessary to deliver high levels of service.

Our goal was to create stability: stability in our systems, stability in our service, stability in our satisfaction levels. That’s four Ss and that’s how we coined the term Project S.

Is the maturity level you mentioned CMM or is there something other that you measured that with?

IBM has a customized version of ITIL. They have a service level maturity or service maturity index.

How rigorous and involved was it to get that number back to tell you where you stood?

It was pretty rigorous. It was about a two-month-long analysis.

You got some help from Compuware in putting this together. What did you find you were lacking in terms of knowledge and abilities? Were there any new things that they insisted you bring to the table that you didn’t already have in your shop?

That’s a great question. One thing we lacked was a repeatable process. That’s where adopting ITIL came to bear.

Another we lacked was skills in the right areas. We had plenty of skills, but not necessarily the presence of the right skills for the right job.

We were also lacking tools. Tools essentially mean that we weren’t in a position to automate ourselves so that we could provide higher levels of service. As you well know, you can’t do everything in a manual fashion and be efficient and effective.

Those will be the areas that pretty quickly emerged, and that’s what led us to an analysis of what our toolkit should be.

We believe in the idea of integration. Integration is something that is quite absent in many IT organizations. We tend to be the worse, we’re much worse than our customers when it comes to buying one-off tools for every problem. What we try to do is buy an integrated toolkit that helps us run the business of IT.

That, in fact, was our mantra. We wanted to manage IT like a business, and therefore put in the business systems required. A good example is that we wanted to mimic our financial department, financial and HR. We have one product that manages finance and HR, and that’s Lawson. It has materials management, and then it has payroll, it has financial reporting, accounting, general ledger — you get the drift. It’s a well-integrated product which redoubles its ability to produce efficiency than if you had individual products for each of those foci.

We wanted to help this integrate into one product set, our monitoring initiatives or monitoring processes, our early detection and warning processes, but also our project management, change management, problem reporting, our time management, our budgeting process, our IT governance reporting process, our automated workflows.

That was really important to us. The system lets us embed the knowledge of experts and the systems, therefore driving a repeatable process. I said a mouthful there, covered a lot of territory, but I hope you get some sense out of that.

I don’t want to ask you what it cost, but how much of an effort and investment was it to move from where you were to where you are?

It’s probably the biggest thing this IT organization has approached since its inception.

How did you get the support to undertake such a project in these times?

It was simply outlining the gaps between customer expectations and our ability to deliver and matching a solution to those gaps. The organization wanted those gaps filled enough that the sale was much easier.

It’s kind of interesting. I had to highlight my failures, [laughs] which really is a risky and uncomfortable approach, but in fact, it is the right thing to do. I had to highlight the fact that I had a 30% drop call rate at the help desk. I had to highlight the fact that nine out of 10 problems that we encounter are called in to us by our customers rather than us notifying the customers of the existence of the problem. In other words, they find it before we do.

So you begin outlining all these things, and then you start talking about what’s coming in the future, and you’re going to have doctors who are going to need the services of that help desk with that low performance. You’re going to have doctors who don’t want to have their systems to fail when they’re in the middle of a surgery. You’re going to have nurses that can’t administer medications to patients in pain if the barcoded med system is down.

We were able to use kind of Walt Disney’s “imagineering” approach, just tell a story about how things are and how much better things could be.

ROI was not as necessary when you looked at it that way, because when you really looked at it, the case we were making was a case of staying in business. [laughs]

Overall, is the end result that you have restructured the department and changed the staffing mix and staffing levels?

Yes. We’ve done two substantial re-orgs through this process, continued to evaluate our staffing plans, and brought on a chief technology officer. We made some major staffing changes, major training changes. Our organizational processes don’t even resemble what they used to be.

If you’re talking to your CIO peers, what would you tell them is the key to know that you need to have this done and the thoughts to entertain before they start?

I think, you know, customer’s king. The key is to evaluate the customer’s level of satisfaction with services being provided. You can’t do that without getting very involved and face to face with the customers. So that’s number one.

Also, the study of where your organization is going is vital. You’ve got to forecast what are the strategic demands coming into your organization, and what are your current abilities to support the future.

One of the things I’ve said quite often in team meetings is we have to future-proof IT. We’re not future-proofing it against outside attack; we’re future-proofing it against internal demand. The whole idea is to create an IT organization that is not a constraint to business decisions.

Did the evaluation find that the IT department was underfunded?

Oh, yeah. There were some adjustments made there also. Probably another way to look at it is funding is not in the right places. It was not just underfunded, but the distribution of money and funds — are we spending our money on the most important services and problems?

How much larger did your operational percentage of total budget need to be to meet these standards that were laid out in the evaluation?

Let’s see … what was that percentage increase? I don’t want to guess at it. Suffice it to say that it went up modestly. [laughs]

And you had that commitment going in, knowing that there were things to be accomplished that might cost money, that the folks writing the check would say, “Yes, we’ll buy those recommendations and fund them?”

Right. You have to prepare an organization to accept that. Obviously, marketing the project as goals and describing what it takes to meet those goals helps prepare an organization for an additional cost.

I believe we really did an excellent job on not making those costs burdensome. If you really look at our budget, we have stayed at just about the same expense percent revenue. It has gone up slightly, but not enough to sound alarms. [laughs]

What are you doing to establish relationships with your physicians?

One of the things we’d done is strengthen our governance process. We have a group of physicians that are integral to our governance and decision making to represent physician needs. We’re also looking for better support models for docs. We know service levels required for docs are far different than anybody else in the organization. They don’t have five minutes to hang on on the phone.

We’re looking for easier ways for them to communicate to us that there is an issue. They might want to simply let us know one of the keys is sticking on a keyboard. You’ll never hear about that from them because they’re far too busy to stop and tell you if you don’t make it easy for them to do that. They’re not going to pick up a phone because they don’t like being put on hold.

All those things we’re doing from a clinical perspective. We continue to enhance their portal. We make that their one windowpane to clinical information, or one pane of glass to clinical information is what I’m trying to say. We continue to enhance the speed, we set service level agreements for response time on the full transactions that represent 80% of their work. We are spending a lot of time right now prepping up for computerized physician order entry. That’s going to be a big one for them. Those are the big things.

In summary, the two most important things if you were to ask a doc is that the systems fail a whole lot less, and they run a whole lot faster.

Are you doing anything specific to stimulus funding?

Yeah. CPOE is going to be part of the “meaningful use” definition. We’re working with our physicians not only in the hospital, but with community docs that are affiliated with our hospital, and even extending our reach to all the counties that we serve, and collaborating with other hospitals and their physicians to start talking about health information exchange and how we can better share information, and how we can help them achieve the maximum stimulus dollars available.

What kind of things are you doing with the physician practice EMRs and practice management systems? How are you tooling up to get them prepared and to get your integration strategy with the doctors going?

Boy, I tell you, it’s essential to have a meeting before we talk about that. [laughs] It’s probably one of the more interesting things I get to spend my time on.

Anyway, here’s our strategy in a nutshell: we are going to standardize on one system, one physician EMR that we will recommend, and we will pre-build any necessary interfaces back to our hospital systems. Therefore, if a doc agrees to select that system, and of course we can’t make them do it, but if they agree to select that system they know that they automatically are going to be joined in the information sharing with the hospital.

This is also where HIE comes. We are looking for our own kind of mini-HIE for docs that might not agree to purchase that particular system, and at least provide some way for them to participate in information sharing with the hospitals that they have admitting privileges to.

We’re differentiating very clearly between docs that we employ and docs that we have affiliations with, and trying to provide those two levels of service. We’re really trying to work out the kinks on what is going to be our support model. Are we going to be the ASP, or is there going to be a vendor ASP involved? Might there be a hybrid model? There’s still a lot of unanswered questions, but we are right in the middle of trying to sort all of that out right now.

What would your credibility have been before you did Project S as opposed to now?

They would have run me out of town for real. Don’t you write that. [laughs] They would not have even considered it because our service levels were so abysmal that there was no confidence. There was a crisis of confidence in our physician staff with IT. Rightfully so.

What had happened was the needs of the organization had grown faster than the IT of the organization’s abilities to support those needs. That’s not unusual. That is the reason you have these clearly defined and measurable maturity levels for IT organizations, because you have to match up your IT organization’s capabilities with your internal customer’s demands.

Last question. If you look back at the last couple of years, what are the smartest things you’ve done as CIO?

What a great question. Smartest thing I’ve done as CIO … probably dealing with IS as an internal business. Allowing that perception to govern how I make decisions helps me make the right decisions. That would be one.

Another one would be taking no prisoners when it comes to hiring the best. I’ve got to have a team of people who better and more ideas than I do. I want to be the idea vetter, not the idea creator. Surrounding myself with good people — it takes a while to finally get that figured out, but if you do that right, the rest of the job gets easier.

In terms of information systems, specific or technical things that I’m proud of — I kind of don’t know how to say this, because I don’t know how to say this and make it print right, but I’ve spent time with a particular vendor and greatly influenced their product direction. We use a product here, a bed management system that a particular vendor and I drew on the back of a napkin, and he turned it into a product. So I’m pretty proud of that. I didn’t get a doggone thing out of it, but I’ve got a doggone good system.

Maybe another way to put it is I’ve always worked very hard to match a technology to a problem, and not just push technology.

I’ve got to share this one, too: putting in strong governance. If you want to succeed, have strong IT governance.

I always liked somebody who’s got a really firm vision on what needs to change without getting so wrapped up in the minutiae like hospital folks so often do, so it’s refreshing to have somebody with a plan who actually made it work, especially when you get into stuff like infrastructure and staffing and IT governance, which is usually kind the Vietnam of CIOs. [laughs] You get wrapped up in all the stuff you really can’t get closure on.

That’s so true. I tell you, my boss and I had a long conversation. He said, “Avery, what you’re very good at is the visioning part of being a CIO,” and he said, “I really like that about you, and what you’ve got to do is make sure that you have a structure around you and manage the details.” Because what happens to a lot of CIOs is they get pulled down into details and never get up the 30,000 feet to see what’s going on.

Is that inherent in their background, though, when you’ve got a lot of folks who worked to move their way up through IT, which is the argument of “are you better off with someone who’s risen through the IT ranks”, or better off to get a visionary who just lets other people worry about the nuts and the bolts?

That’s an interesting debate. I’ll just tell you about me: I came up through the technical ranks. I hold an MBA, but more importantly, I have an affinity to business. When people ask me about me and my job, I tell them I’m a business person who just happens to know IT.

I’d like to think that I could run any of the departments in this hospital. A good example is that nobody is surprised when the CFO runs the pharmacy department, or the CFO runs materials management. It should be no big surprise either that the CIO can do the same, or does the same. A very good friend of mine in another hospital — he’s the CIO there — runs the pharmacy down there. Another friend of mine who’s a CIO runs the home care division.

So a chief information officer is not a propeller-head. A good one is a business person. You think like a business person, and you recognize the importance of your specific trained professional discipline, which is IT, but you don’t let it rule you.

I think there are advantages to having a technical background because it does help you understand when your people are talking to you. I’ve seen the other side of the thing where the person did not come up through the technical ranks. It must be horrifying to be a person who has a strong grasp of the business but has no clue about technology, because the language we IT professionals talk on can be scary.

That’s why, frankly, a lot of CEOs are uncomfortable with IT reporting directly to them. If you’re not the kind of CIO who’s a business person, your CEO is not going to take to you. CEOs don’t want to hear about the bits and bytes and stuff.

I’m going to share this with you real quick. One of my crusades is to make my organization think about what we do from the customer perspective. Don’t tell me that the systems are up 99% of the time. Tell me how many hours you were down, because that’s how the customer looks at it. Don’t tell me that the server 214 is down. Tell me how many patients are getting backed up in the ED. Tell me how many fewer registrations I’m going to do per day because of this. Tell me what my impact’s going to be to the bottom line.

Part of our monitoring effort here is to cause our monitor to tell us what’s happening in the business based on what’s happening in IS. You’re not seeing a whole lot of IT leaders thinking that way, and that’s a problem.

I really want to pick up my phone and say, “You can probably expect a two or three percent decrease in collections today because we have some stress on one of the segments on the network that prevented as many bills going out.” That’s a different phone call than if I called my CFO and said to him, “Just wanted to let you know that your people are going to be a little frustrated because systems are running slow today.”

So I think that is really what IT leaders have got to strive for, the user viewpoint, the user view of the services that IT provides.

HIStalk Interviews Janice Newell

 

Janice Newell is CIO at Swedish Medical Center, Seattle, WA.

Do you think the government’s strategy of subsidizing EMR purchases is the best way to improve patient outcomes with technology?

I certainly share their belief. I think the only thing that’s going to push adoption is money. Whether or not their approach is the best way to do that, I haven’t given a lot of thought to. But I don’t think anything’s going to move these docs but money.

Will subsidizing the purchase of EMRs themselves incent usage or will there need to be more steps that follow?

This is the easiest question?

[laughs] The second part got harder.

Well, yes. Certainly, incenting them to adopt it is a necessary first step. Then at the other end of it, there’s this little, minuscule penalty they’ll take if they don’t adopt it. That’s certainly more significant as time goes on, the penalty.

But I think the other thing that’s going to be key is really getting some significant measures of outcomes in performance, and how is this really changing the outcomes and cost, because if it’s not doing all that, why bother? 

Is your strategy any different at the health system based on what the government does or doesn’t do, or are you pretty much down the path that you plan to stay with?

We’re pretty much down the path. We had really made a huge commitment. We’re a relatively small health system, about $1.3 billion. We had already made the commitment that we were going all in with the Epic system, and so committed about, let’s say, $120 million to it over the past four years. We were going there anyway.

When you look back at that investment, would you say it has paid off as you expected four years ago?

I certainly wouldn’t say that it paid off yet, because in fact, we still have pieces that we’re implementing. But yeah, are we starting to achieve the things that we had outlines we were going to achieve? Absolutely.

What kinds of things were you looking for as measurable benefits?

Certainly we were looking for providers in general to have the information that they need as they’re actually caring for patients wherever they are. We’ve certainly achieved that, in that we have it available everywhere.

Also, in terms of improving our quality metrics, I’ll give you just one small example. Pain reassessment is always an area of interest as both a customer satisfier as well as a JCAHO requirement. Our pain reassessment measures were not that good. We made some changes to Epic in terms of what kind of notices the nurses get about pain reassessments being due. It has moved the pain reassessment measures from the low 60s to the mid-90 percent. The nurses are doing the pain reassessment in the timeframes that are required just by changing how the system was supporting them.

So certainly on the quality metrics, we’re starting to get some traction. Also, in the financial arena, we’re getting some traction. It’s a pretty broad swath there. Certainly it has improved the revenue cycle in terms of how long it takes us to get the bill out the door. It’s improved the level of billing we do, more accurate with better documentation.

Also, still in the financial arena, it’s also helping us standardize processes across the organization. One area that’s a biggie for us is the operating room. Before Epic, we had so much variation that it was incredible. The surgeons have taken it upon themselves with Epic to really start the standardization process of what supplies they use, what supplies come into the room, what ones shouldn’t be there at all. So all kinds of good fiscal outcomes.

But a lot of that must have been other than just technology. You must have had a lot of change initiatives to go along with it. How did you package up your implementation and your change management to make this all work?

It terms of actually sitting down and changing wholesale processes in our operations, we actually started out doing that. We quickly abandoned that approach because what we found out is, sure, we can sit down and talk workflow with our folks in operations. They would describe to us what they thought happened and how they thought things worked. But in fact, we found out that it was pretty consistently not happening that way.

We ended up adopting the approach of, let’s use a good model system, get it in, and make the improvements after that. So in fact, many of the process changes are coming afterwards.

It seems that anybody your size and bigger, along with some smaller, are buying Epic. What’s their secret sauce?

A couple of things. One is that they are an integrated system. I don’t even know how many modules they have any more, but they have one system that supports care in the clinics, care in the hospital, in the operating rooms, all of the billing and revenue cycle, pharmacy, lab, home care, you name it. They have modules to support all of the different functions.

Instead of us going on in a best-of-breed world, where we add two dozen different systems, each individual system, we now just have Epic. It is much more effective from both a user experience and an IT experience to have the same data, the same application be available wherever you are. If you think about healthcare as just a continuum of care, it just happens in different places, either the clinic or the hospital or the ED, it really supports that kind of a model if the organization itself thinks it’s a system. So that’s one reason.

The other big reason is that the Epic implementations are successful. They’ve done this enough. I think they provide very good support for organizations to actually have a successful implementation. I’m not sure I can say of all their competitors that their implementations go relatively smoothly.

How does that work when basically they are young people trained usually from scratch with no industry experience? What are other vendors doing wrong that they can’t do what Epic does?

Certainly the young people without the industry experience has some downside to it. Frequently they’re great technicians without the industry expertise. And if something goes wrong, that could cause some problems. But in terms of the process for actually going about with kind of a project, they have been doing it long enough in documenting what the process is.

Just insisting that their customers go through this process, sure, we all have some variation in how we do it. But Epic is pretty clear in the way they want you to do things. And so we all do things in a somewhat similar manner in implementing Epic.

They are there the whole time. No matter what, you’re going to have an Epic team with you through the implementation.

Meditech and Epic seem to have a similar approach that, right or wrong, they genuinely believe they know better than the customer and protect them from doing things that don’t make sense. Do you think other vendors are too catering to their customers instead of saying, we know the product, just do it our way and it will work?

I think so. Yeah. And the other ones are run by a bunch of marketing people. Meditech and Epic are the only ones that are run by software people. The other ones have a huge marketing influence, sales and marketing.

You have to deal with the idiosyncrasies of Epic, but at the end of the day, if it works, it’s OK.

You’ve said that federal stimulus money must be carefully managed or it will go down a rat hole. Did you have something specific in mind or was that just a general comment?

[laughs] Yes, actually, I did have something very specific in mind. What I had in mind is that there is so much variety in the systems that people have now, and these are just the organizations who could afford to be moderately early adopters.

I mean, if you think about the hundreds of systems that are already in the marketplace, and then you think about multiplying that by some factor as every Tom, Dick, and Harry sees an opportunity in the marketplace and comes up with the $99 EMR, I think it’s scary.

And then you have these little offices who really don’t know that much about technology or how to really use it in their practice, or what can go wrong with that technology in your practice — you know, 99 bucks and I’m going to be able to get $44,000 from the government, how could I go wrong?

So while we already have the data exchange issue in healthcare, some of it because not many of us have much electronic data in front of it because there’s so much variety, but if you multiply that by whatever factor is appropriate with people going out and doing every Tom, Dick, and Harry system, it just seems that there’s a lot of opportunity for that to turn bad.

I think what the government is trying to achieve wouldn’t be achieved if we just end up with, instead of three million islands of information, now we have 23 million islands of information.

Do you think that the certification process as well as the “meaningful use” criteria are going to make that less likely to occur?

No. Say we double the number of EMRs in the marketplace so that people have on their plate trying to exchange data. They’ll not all pass certification, but it’s still going to be a data exchange challenge.

I read your local newspaper’s article that said, hey, what an irony, we’ve got three of the best hospitals in Washington that are basically almost in the same neighborhood, and they can’t exchange information. How do we address this issue of everybody’s being their own silo?

At the end, at making it Epic-specific — with our Epic system, we are actually in the middle of a project to bring our largest affiliated group, about 150 docs, on to our Epic system. So they will be using Epic in their clinics, their own service area. All they have to do is share clinical data with Swedish, and they’re using our Epic system.

Instead of just having a system that supports follow-up functions within Swedish, we now have a system that supports all of the patients in our largest affiliated group, too, that we cross over thousands of patients every year. Our intent is to do that with a lot more of our affiliated groups where they can create their own little space within Epic. They can have their own service area.

It’ll be like they have their own system, except that it will be our Epic system and we will all share clinical data. We won’t share financial data, but we’ll share clinical data.

Another piece, once again at the risk of being Epic-specific, Epic actually has a capability where there are a number of us now around Puget Sound that have Epic. We have it, MultiCare has it — that’s another billion-plus organization — Everett Clinic up north. Epic actually has a feature where in fairly short order, we can have the Epic systems exchange data with each other.

Was that something that led you to choose Epic initially?

At the time, no. It was more the integrated feature that let us choose Epic initially.

How about MyChart? Is that an important part of your strategy to get closer to patients?

Absolutely. It has the ability for them to get at their information without us being the guards at the gate. Sure.

If you look at where you are and where you need to be, what do you say are your most important priorities and your biggest challenges right now?

We still have a few big pieces that we haven’t implemented yet. Two of them happen to be billing. So we need to do those other two big pieces for the professional billing and hospital billing. We’ve actually started that.

The tail end of the spectrum that we haven’t done yet is home care. So we still need to do that. Also included in that is getting it out to our affiliates. So that’s one bundle of work, which is implementing it in more places, more functions.

The other priority is a combination of improving the systems that’s been installed and actually continuing to work out how we’re going to get value out of it. So using the system to be a facilitator for our standardization efforts or workflow improvement efforts. Those are big items for us.

Improving the system itself, making the system simpler, I should say, and using it to improve our work processes.

HIStalk Interviews Frank Clark

Frank Clark, PhD is vice president for information technology and chief information officer of Medical University of South Carolina, Charleston, SC.

How is the IT world at MUSC?

I think it’s going well. We have about 1,200 physicians that are our own employees — we have a closed staff model. We started deploying McKesson’s Practice Partner, an ambulatory product we acquired a couple of years ago. It’s been in here a long time. We started in 2004 and we finished it up in 2006. We have it in all of the departments and it’s being used pretty well. I think we still need to do some work with some of the sub-specialists and some of their templates, but that’s going well.

We started rolling out the e-prescribing module. It’s part of that package. We hope to have all of that done by the end of the calendar year. As far as catching clinical data in the outpatient setting, we’re doing a pretty good job.

On the inpatient side, we started in 2006 putting in some clinical documentation and meds administration and CPOE. We’ve got two of the four hospitals finished; two adult hospitals are done. We’re starting on the children’s hospital and we’ll do the psych hospital last. But we’re aggregating all of that data into the Oacis or Emergis Clinical Data Repository and Viewer, which our caregivers really like.

Our strategy is to create an enterprise-wide EMR and not separate the outpatient setting from the inpatient setting, to try to give the caregivers an environment in which they can operate regardless of the care setting, and all the patient information is in one place. They can do it, trend it, look at it, all in one.

I think that the nice thing about the Oacis toolkit is that it gives us the opportunity to make changes and cater things to the caregivers’ liking, unlike some other more fixed systems.

So that’s where we are. We have Telus working on meds reconciliation. We’ll do that out of the Repository/Viewer environment. We’ll do discharge summary and inpatient notes, and they’re working on those pieces as we speak.

So on the McKesson side, you’ve got Horizon Expert Orders, I assume, going to Meds Manager, and then you’ve got Horizon Expert Documentation.

Yes, that’s done. So we have that closed-loop medication process. If you look at our clinical IT environment, I guess the center of the universe is the Oacis Repository and Viewer. We’re using a number of the McKesson products. We use Cerner lab. We use IDX radiology, and of course the Practice Partner functionality, which is a McKesson product. We try to pick and choose fast, specific functionality to capture data in the various care settings, and we aggregate that into the repository.

So that’s all of our strategy. The Oacis toolkit gives us a good bit of flexibility to fill in the gaps with the discharge summary, meds reconciliation, and physician inpatient notes.

How does Oacis tie in with the McKesson parts?

We tried to identify certain pieces of functionality that are appropriate in certain care settings, certain areas like the nursing or clinical documentation. Anywhere nurses deliver care with that service, we want to capture that data electronically, and we’re using McKesson’s clinical documentation to do that. The same thing is true for meds administration — we’re using the McKesson piece — and also CPOE.

The key pieces of the closed-loop medication process come from McKesson, but as far as gathering that data and making it available for caregivers, we’re using the Oacis Repository and clinical results viewer. Given that it is a toolkit, that it is an open system technology, we have quite a bit of expertise, so we can go in and tailor those views.

We just did a really nice view for the ICU, what we call the Critical Care Viewer. It’s a view of data that the ICU docs need to look at. We’re pulling all of that data that’s captured with this task-specific functionality into the viewer. We looked at the Portal, but our caregivers said, “That is a step back.” What we have is much more advanced, much more flexible than McKesson Physician Portal.

I implemented the Portal in 2001 or 2002 when I was in a community-based hospital organization. And those physicians, independent contractors, thought the portal was great. But when you come into an academic medical setting in a closed-staff situation, our physicians said, “What we have is much more advanced.”

You had mentioned to me before that both Duke and Vanderbilt are using their own separate versions of a repository and viewer. Would you say that’s a good compromise between not trying to go off building your own clinical systems and yet having the presentation and data retrieval flexibility that you can get from having this third-party tool?

Absolutely. We don’t have the resources that Duke or Vanderbilt have. It’s kind of ironic. We’re going to spend all day with Bill Stead and his people, trying to fill in some gaps, because our strategy is very similar to that of Vanderbilt’s and also Duke’s. You are right — they use their own home-grown repositories, respectively, but they both are using a number of McKesson products in those task-specific areas. We talk to Vanderbilt probably at least two to three times a week trying to understand how they did some things with the clinical documentation.

You know, I think this would be true of any big vendor. It’s been difficult for McKesson to fully appreciate what we’re trying to do because they are used to the community-based setting where an organization just buys all of their products, like I did when I was in Covenant in Knoxville.

But academic medicine is, as you know, a little different. We were saying, “We don’t need all the functionality of what you might have in clinical documentation or meds administration. We want to pick and choose those pieces that we feel would fit nicely into our setting.” It’s been really difficult for them to understand that.

Of late, we’ve been able to work a McKesson individual who works with both Duke and Vanderbilt, so he understands what it is we are trying to do. Finally, it took us a while to get around to getting McKesson to understand that, but I think we are on track now.

We want to get away from buying these complete systems. Vendors want to sell you a standalone ambulatory electronic medical record. Well, we don’t want it to stand alone — we’re trying to bring two care settings together, because many of our physicians see patients in their clinics, and then of course there’s those patients in the hospital. So we want them to have a longitudinal view of their patients’ data regardless of the care setting. 

That’s our strategy. So far, it seems to be working out OK. It’s difficult for the McKessons and I’m sure it would be for the Cerners and the Siemens, too, because they just want to sell you their stand-alone systems.

The same thing is true in the emergency room. They all have an emergency room product, but it turns out that a lot of that functionality you already bought when you bought the outpatient system or the inpatient system. They just want you to buy a lot of their functionality over and over again.

Meditech is on the low end and Epic on the top end, but people seem to like them for the same reason — they have everything. The territory in the middle is up for grabs.

You’re right. When I look at the big vendors to see who is probably most attractive to closed-staff model organizations like Cleveland Clinic or Mayo and most of the academic centers, it would be Epic, because they do have a repository strategy. A lot of the others don’t. They’re struggling because the relaxation of the Stark provision and the anti-kickback in this pending healthcare reform — I think independent physicians are going to bind themselves more to hospital organizations.

Hospital organizations can offer these independent physicians more systems, some kind of ASP subscriber model electronic medical record, and they can come together on the data-sharing agreements that hospitals will house the physician office clinical data in a single repository.

I think the people like Epic probably have a product that’s appealing if you don’t want to try to fit it together like we’re doing, piece it together like Duke and Vanderbilt, and also there may be some academic centers that’s pursuing the same strategy. But most of the big vendors — you’re correct, they’re kind of struggling because they don’t have that single repository strategy. They’ve got a separate electronic medical record for the outpatient, one for the inpatient, so it’s kind of bifurcated. But I think those two worlds are coming together.

Do you think you’re well positioned with the core clinicals from McKesson, plus Practice Partner, plus the Oacis Portal that would be the equivalent of MyChart, to do what the Epic folks are able to do?

Yes, I think so. I think it would compare very favorably. We’re really pushing McKesson on the Practice Partner side, because in order to do the kinds of things that I mentioned earlier, we’ve got to have their cooperation. I don’t know how much you know about Practice Partner, but we are really pushing them because of the size. We probably have 2,500 users, and when Andy here developed that product, it was designed more for smaller practices.

We’ve really pushed them to try to make it robust. We’ve gone to the Oracle database. We’ve moved on to Unix servers, both for database and application. But in order for us to do meds reconciliation within the Oacis environment, we have to have a bidirectional interface between Oacis and Practice Partner. So we were really challenging them to kind of open up and let us get down into the details of that system to make it work for us.

I would think that they’re open to understanding what you need, knowing that there are potential other sales just like you out there.

I think so. In my understanding, it was one of the biggest selling products in 2008. They have a competing product, it’s called Horizon Ambulatory Care, and maybe they’ve already made the decision, but they have to decide which of those two products they are going to fully integrate into their enterprise release strategy. I think they’ve made the decision, as best as we can discern, that Horizon Ambulatory Care will be the product they will integrate fully into their enterprise releases.

That was disappointing to us because that would have made it a lot easier for us, I think, as we try to do things, trying to closely knit the two care settings together. But in the absence of that, we’re really working with them to try to let us open up the architecture, because in order to do meds reconciliation through Oacis, we have to have that bidirectional interface.

There’s so many legacy products out there that the architecture of the framework doesn’t really lend itself to interoperability. That’s huge. 

Do you think the market’s going to pressure vendors to talk to each other’s systems so that you’re not stuck in your own vendor’s silo? 

I think so. If we’re going to achieve any modicum of success as far as HIEs and exchanging data, it’s got to. But it’s going to be a tough, long battle, I think. When you look at “meaningful use”, wherever that will end up, they can’t set the bar too high, because if they do, nobody is going to be qualified in October 2010 to get any of this in use.

Is HITECH something you’re looking forward to and planning around, or is it just “if it happens, it happens” but it’s not really going to be part of the strategy?

It’s part of our strategy. We’ve been thinking about it since the beginning of the year. We’ve been planning, trying to anticipate what will be the final requirements or the initial requirements for October 2010. I think we will be well positioned. I mentioned we’ll have meds reconciliation, discharge summary, and inpatient notes. We’ll have that done in months, all of those. We’re already doing CPOE, we’re doing outcomes reporting, we’re doing health registries, so I think we’ll qualify both for the physicians and the hospitals for that first round of funding starting in October 2010.

When I talk to a lot of colleagues across the country, both in big hospitals and small hospitals, not that many that are doing physician order entry for the closed-loop medication things.

Have you calculated what’s on the table for you if you qualify for all the HITECH requirements?

The finance people have been doing that. The hospital side doesn’t seem to be that much money in the scheme of things. On the physician side, it looks pretty good. For a physician, I guess they’ll have to choose between the Medicaid and the Medicare; they can’t do both. Hospitals can.

So they’re doing the numbers, and we’ve already made the investments, so it’s not that we’ve got to come up with a bolus of money because we’ve already invested heavily starting in 2004.

Other than those three pieces I’ve mentioned a while ago — meds reconciliation, discharge summary and patient notes — we have all the functionality that we’ll need. Going forward, we’ll continue to design it. But I think that’s the nice thing about Oacis, that it gives us the flexibility to fine tune and do some things that otherwise you’d have to ask the vendor to do. It just takes a long time for them to do things as opposed to having the ability to do some things on your own.

Going back to your question a moment ago, we don’t have the resources that Duke and Vanderbilt have, so we’ve had to do it on the cheap, so to speak, or do it in a less expensive way. We’ve had to buy more pieces and parts, whereas Vanderbilt could probably write their own meds reconciliation functionality. And they’ve done their inpatient notes piece, whereas we would have to contract with Telus Health and Emergis to do that.

If you look down at where your time and energy and concern is going to be placed in the next three to five years, what do you think is going to be important?

We need to finish the inpatient functionality, the children’s hospital and the psych. We’ve got closed-loop medication in all of our inpatient facilities. We’ve got to make a determination if the functionality inherent in the Practice Partner piece is going to be flexible enough long term to fit into our enterprise-wide clinical IT strategy, because as you know, 95% of the care is delivered not in the hospitals, but in the clinics.

We want to be as efficient and as effective in the outpatient setting. For instance, like charge capture — right now, that’s manual. We’re doing charge slips; caregivers are writing out the charge slips. We need to be capturing that electronically. So that’s something we will do over this period that you’ve just alluded to.

We’ve got to be as effective and as efficient in delivering care in the outpatient setting to be competitive. Again, we’ll have to make that determination if the functionality that we’re using out of Practice Partner is flexible enough and robust enough to serve us well long term. That’s going to be a primary focus going forward. Does that make sense?

It makes perfect sense, yes. You never know why vendors acquire ambulatory systems — do they really plan to integrate them, or do they just want to latch on to the trend of the moment? Vendors have to figure out how badly they really want to get in the business of tying in and I guess it’s up to the customers to push them.

I’m not sure if they’re any different from some of the other vendors, with the exception of Epic. I think Epic seems to be well positioned as care settings come together and organizations look at acquiring a clinical strategy or solution that scales across both care settings, and Epic is really attractive.

Most hospital organizations are not going to do what we’re doing, and that is trying to knit it together to some degree, or they don’t have any development capability; it’s all commercial off-the-shelf. I know Pam Pure and her leadership team, right after they acquired Practice Partner, came down to spend a full day looking at how we were using it. And I think at the time they were trying to decide which of those two horses to ride. Should they continue with the development of Horizon Ambulatory Care or should they look at trying to integrate the Practice Partner product into their enterprise strategy? I don’t know, maybe that’s why Pam’s not there any more. I’m not privy to all the details, but they’re not unlike some of the other big spenders; they’re trying, through a lot of acquired systems, to coalesce and integrate them into a common framework, a common platform. This is a slow process.

Anything else you want to share or mention?

These are exciting times in healthcare. I can’t tell you how many calls I get from vendors trying to sell stuff and there’s just so much money out there around healthcare. It’s like flies around honey. There’s just so much money, so many opportunities out there for vendors, particularly in the health information exchange market.

We’ve got a project here that we’re trying to link eight emergency rooms in the Charleston area across four organizations. We call it the ER Alert System. When a patient presents in one of the EDs, a caregiver can query the other hospital organizations to see if there’s any clinical data about that patient. You know, some people are shocked, they just go to the ER to get drugs. We hope that it will cut down in procedures, if somebody’s already done a CT scan or MRI at one of the other facilities, they can access that, or if they have any labs or meds or anything like that.

So we’re looking at technologies for that sort of health information exchange, trying to decide on which technology to use. We’re looking at Oacis technology, but also this Vanderbilt-developed product that Informatics Corporation of America spun off. It seems a lot of businesses, a lot of companies say they have a product that will do that. I think we’ll see a lot more of those health exchanges. I think that the reform of ONC will push to try to make that happen.

HIStalk Interviews Ross Koppel

Ross Koppel, PhD is on the faculty of the Sociology Department, the School of Medicine, and the Graduate School of Medicine of the University of Pennsylvania.

 

You’re a sociologist. What would you say is the major sociology at work among vendors, doctors, and CIOs?

A bit of context may help understand my research on the sociology of HIT. My first love was sociology of work. The use of technology in the workplace came next. About 10 years ago, I was working with some physicians to try to understand medication errors by young docs due to workplace issues like fatigue, inconsistent supervision, and dealing with life and death issues for the first time in their lives. And, remember, hospitals are workplaces.

With colleagues at the Penn Med school, we got a grant to study stressors in the hospital workplace. In response to my questions, the residents always insisted on showing me the remarkably lousy CPOE system. It was generating errors — some horrible, most easily fixed, but not fixed.

If you think about it, my looking at these issues is not all that odd. I’d been studying work, workplaces, technology, and sociology of medicine for 34 years. Also, the 2005 JAMA article combined sociological skills in ways that not many others had at their disposal: focus groups, expert interviews, shadowing docs and nurses, an extensive survey of 90% of the residents, intensive interviews, and observations on the floor. I’ve been teaching research methods at Penn for 17 years. I should have learned something.

Now, to your question directly. The physicians want to get their work done, ideally with greater safety and in less time. The vendors want to sell their wares and capture market share. The hospital CMIOs don’t want the software to crash catastrophically on their watch. None of them want to hurt patients, but the combination of forces is often counter-productive. 

Vendors seek market penetration ASAP because user implementation costs prevent reconsideration of other options once a hospital or even medical practice is committed. But vendor product cycles do not allow the ongoing feedback and adjustments that allow rapid improvements. The vendors are eager to roll out new iterations while the industry structure does not encourage patient safety or the actual needs of hospitals and clinicians. 

Also, hospitals want to show how wise are their investments, so few benefit from discussing errors. And many contracts prohibit open discussion of problems. Added to this is the reality HIT only works when it is embedded in complex organizations with other HIT systems. And that’s darn near impossible to test a priori. So even if the software had viable user interfaces and transparent coding, we could never be sure it is safe and functional until we can examine it in situ, which is both difficult and expensive.

Last, we must remember that most of these systems are built on back office programs from the 1980s with interfaces that are state of the art from the 1990s. There are structural issues that are difficult to surmount.

You got a lot of reactions to the 2005 article you wrote about CPOE. Which of them made you really mad?

The ones that misquoted or never read. The University of Pennsylvania wrote a reasonable press release. JAMA wrote more of an incendiary press release. A lot of people never actually read the article, so the things that pissed me off the most were those that were saying, “He only did the three focus groups,” when in fact I had a 90% sample of all of the residents and I had complete logs of every order put in.

There were all kinds of mythologies that were developed that bore no relationship to what I did. That was irritating as hell. I think there were some fair criticisms that the system that I studied was, in fact, an old one, and in fact I have a new study based on a brand new system that’s not been yet published. 

It was the misquoting and the misrepresentation that most pissed me off. I mean, I’m an academic. I’m used to people commenting on my studies. I’m not used to vendors creating a whole mythology from what I said when I never said it.

Was it surprising that HIMSS jumped out and wrote a disclaiming memo of their own when they were not even really directly involved?

Well, HIMSS is a sales agent of the industry, so no, it’s not surprising at all.

The vendors would say, at least based on some of your writings, that you will always find the anti-IT angle to every issue. Is that fair?

No. They should read some of my other writings. I have an article published in JAMIA that speaks very much in favor of CPOE as a patient safety device and develops a whole algorithm to use that. A lot of the work that I did with Michael Harrison — there are two publications there — talk about unintended consequences that focus mainly on the role of hospitals and healthcare organizations in creating errors. In the most recent JAMA article, half of the article, or certainly 40%, is devoted to protecting vendors from unfair attacks by incompetent or misguided or maltrained or otherwise inadvertent errors introduced by hospitals and other healthcare organizations.

I view myself as deeply in favor of HIT. The problem is, some of the HIT vendors and some supporters have some sort of a siege mentality. They see my critiquing some of the problems of the HIT as an attack on the HIT. But that’s like saying that the guys who wanted American car makers to build more fuel-efficient cars are trying to destroy the industry, when in fact, they were trying to save it, maybe not just to save the industry but also for more noble social purposes.

But I see the vendors who misread or mischaracterize my work as being incredibly myopic on their part. I am a lover of HIT. I think it’s going to eventually produce some of the stuff that we all want it to. I think prematurely putting out HIT that’s primitive, that the user interfaces are barbaric, doesn’t do themselves any good.

Ever since that 2005 article — actually, I presented examples of it earlier — I’ve received about 10 or 20 e-mails a day from physicians who say, “Stop me before I kill again” and they send me illegal screenshots and the like. I have a whole battery of material that would scare the hell out of HIT vendors that I’ve never ever, ever, ever shown to anyone … which they know about, because it gets reported to them, but physicians and others are not allowed to discuss it among themselves because of the non-disclosure clause.

So what responsibility does the hospital and the CIO have? They bought the stuff and they’re the ones who signed on to use it.

What a great question. Yes; first of all, they are responsible for some of the errors. If they insist on a blue background because it’s a hospital color or something, and the warning notices come in blue, then how can the vendor know that a priori? They can’t know that in advance. They should be doing more due diligence.

But let’s talk about this. I talked to a CMIO the other day in the New York City area and they wanted to see examples of XYZ vendor software. They were given a hospital in Texas and a hospital somewhere else to go to, and the guys — you know, it’s not like the CMIOs don’t know who they are in a city, and we’re talking major hospitals — they said, “What about X, or Y, or Z two subway stops away, or M fifteen minutes away, or whatever?” And the vendor said, “No, we don’t want you to go there.”

So they shipped them off to their – you know what a Potemkin village is? [note – they were fake village facades constructed to fool Russian Empress Catherine II in 1787] Potemkin hospital 2,000 miles away, and even then, when they asked to see something, they started to say, “No, no, no, you can’t see that screen!” and they covered it with a sheet, claiming HIPAA protective law, which, by the way, is psychotic — I mean, one of the people in the team was a lawyer for the hospital who said, “No, all he has to do is sign a release. We all have HIPAA certification. Three of us are CMIO types or CIO types with medical training.”

I think vendors go out of their way to sell — I’m trying to avoid the word vaporware — I think vendors go out of the way to put a best foot forward in ways that really are more of a marketing effort than an information effort.

But it works, the free market. People are buying their stuff. They’re delivering their promise to the free market to provide what the customers want.

No, it’s different. If you buy a bad toaster and you realize you screwed up, you’ll eventually throw away the toaster. If you’ve spent a hundred million bucks on a whole system-wide software, and then 600 million installing the thing and training all of your staff — you know, hospitals cannot say to people in — pick a neighborhood: northwestern Wisconsin — “Nobody’s allowed to get sick for the next six months while we bring this thing up live.” You can’t do that.

The training and cross-cover for hospitals is an awesome responsibility. I’m not making those numbers up, right? And you know that. The installation, implementation, and then you’ve got to get it working with other systems already in place. That’s a non-trivial task. You just can’t say, “We screwed up; we got Sunrise but we should have gotten Epic,” or “We got Epic and we should have gotten Sunrise.” You’re married. It’s worse than really expensive divorce.

So do CMIOs and CIOs have a responsibility? Yes. But there are all kinds of pressures on them, including the most recent ARRA thing, to buy this stuff. I think the pressure should be removed until they can have software that’s really worthy of the promise that we’re getting.

That does not mean that I don’t think they should buy software. I think that what it does is wonderful. I would much rather be in a hospital with an EMR and a CPOE and an eMAR than one that’s based on paper, but from the reports that I get and my own research, I can tell you some of those interfaces are nightmarishly bad. I mean, if it takes four screens and seven scrolls to find both systolic and diastolic on the same patient, we have to open trap doors to find the lab report you’re seeking that should be right there. This is primitive. You’re in this business. You know the reality of some of those bad interfaces.

But the worst reality is that none are clearly so much better that the ones that aren’t suffer from it.

From what I’ve seen of eClinical Works, it’s significantly better, but that’s just an impression.

Yes, it’s probably more dramatic on the physician practice side. I’m more of a hospital guy, but …

Most of my research is hospital. Although hospitals are moving into — I don’t know what to call it, “eClinical Works Turbocharged” or something — but yeah, you’re right. But on the other hand, they have different faults. One has a reasonable lab reporting system, the other has a reasonable medication list display or whatever. But yeah, there’s an awful lot of mediocre software out there.

Why would the industry take critiques about it as an attack when I desperately love this stuff? I want to see it better so that they can make even more sales with it. This is like selling a really mediocre, unsafe car and insisting that if you point out that it’s unsafe, that somehow you’re doing the car industry a failure. It’s ridiculous.

Nobody seems to correlate the fact that the utilization isn’t very good among doctors and nurses, which may be directly related to poor usability in software design.

No, they blame doctors for being troglodytic, for being technophobes, none of which is true. Doctors may have an unfortunate taste in golf attire, but they’re not morons and they really want to do what’s right.

I’ve been through the training sessions. I’ve watched the software. I’ve watched allergy indications almost impossible to update. I’ve watched patient information disappear or appear, require seven clicks and twelve scrolls to see two pieces of information that should be contiguous. A 12-year-old programmer would say, “So you want these together, right?”

So why are people still buying? Why doesn’t that move some vendor to say, “Well, I’ll be the usability king and I’ll make a ton of money”?

That’s a great question, and there are a couple of reasons. One, remember back when we were young, they used to say something like “God could create the world in six days and then rest,” and then “Why can’t we have a software program?” And the line was, “God didn’t have to deal with an installed base.”

Some of that is that the software is incredibly complex. When they fiddle with one thing, it screws up the finance department linkage or something like that. Some of it is that they prefer the mythology of blaming doctors for being idiots. Some of it is that when they hire doctors to work with them, the doctors go native.

You know that reference to anthropology? You send out an anthropologist to study some tribe somewhere and he’s supposed to write a perfectly accurate and scientific ethnography of this tribe. Finally you go search for him because you haven’t gotten any reports, and there he is with a bone through his nose and war paint and strutting around. You say, “Doctor Whatever, you’ve gone native! You were supposed to write … ”

When I work with doctors who have been working on these things and I say, “I know we’re deeply concerned about the inability of the physician to see the current medication on one screen,” they go, “Yeah, but look, we’re dealing with pixel X, and with bandwidth problems, and with…” And I’m going, “Wait a second, you did not go to medical school to give me lectures about bandwidth and utilization rates and the time…” There’s got to be a way in which somebody is protecting patient safety and clinician safety. That goes by the wayside all too frequently.

There’s another issue. Given what we’ve said before about trying to capture the market, because once they’ve got you, they’ve got you, right? They are rushing versions to market. They want to grab market share, and grabbing market share often gets in the way of making the product what we really want and know we can achieve. So it’s sort of a structural problem within the industry.

You’ve written about vendors who know about software defects and yet prohibit, in one way or another, customers from saying anything about it to other customers.

The non-disclosure clause. It’s a massive problem because it perpetuates exactly the kind of thing that you were asking about. It perpetuates the slow responsiveness.

So the vendor gets 2,000 complaints. Let’s say — I’m making this number up — 500 are ridiculous, it’s just the guy didn’t know how to plug something in. But of the remaining 1,500, the vendor then picks and chooses on the basis of what has to be immediately fixed to avoid being shown lethal versus what can come in the next upgrade, and what can come in the upgrade again, and then the upgrade later, and how many complaints did they get about this.

And so the vendor picks and chooses on the basis of a market model and a marketing strategy, not on the basis of what is greatest for the greatest number of patients and clinicians. Now, if that were transparent and we could see that there are, of the 1,500 complaints, there have been 10,000 dealing with — those are categories of complaints — I don’t know, the impossibility of entering allergies, or when you enter an allergy, it wipes out the previous allergy. So if the first allergy was anaphylactic shock and the second was a mild rash to latex, anaphylaxis dies, disappears, and you get the mild rash to latex coming up.

If you saw there were 10,000 complaints about that bug, there would be no way in hell a vendor could ignore that for the next iteration. But with the vendor having complete control over the listing, and clinicians being unable to see it and to talk with each other about this except sub rosa, not being able to send screenshots, it just perpetuates the economic self-serving model which does not serve patient safety or clinicians.

Now, why do clinicians accept this? It’s because they didn’t go to law school. And by the way, I’m speaking very soon to a group of healthcare lawyers and the like. The CMIOs come to me and say, “Look at this, we bought this and now we can’t address this,” and the lawyers for the hospitals say, “Schmuck. People come to me with a $5,000 contract to make sure it’s passing muster. You signed a $100-million contract, and now you come to me now that you’re stuck.”

But if we were talking about any other industry that didn’t involve patients, what vendors do would just be considered admirable business — they do what it takes to make a profit and keep shareholders happy. Is it inherently impossible to have a for-profit, publicly traded vendor model and expect them to really care beyond what is in their obligation to deliver? How do you make their interests align with those of their customers?

Exellent question. I think you can make their interests align because, ultimately, they have to be concerned about patient safety, because some of this stuff is going to come out. 

In the most recent JAMA article, March 25th, we did a lot of research. We found that the vendors, when they settle with the hospital and with clinicians and with patients, that’s settled with a closed case, right? And nobody’s allowed to disclose the terms of settlement. It’s not in the hospital’s interest, because the hospital doesn’t want to say, “We screwed up, Mrs. Jones, even though it wasn’t our fault, it was XYZ software’s.” The doctor doesn’t want to say, “I screwed up the patient, but it wasn’t my fault; it was XYZ software’s.” And the patient or the patient’s widow is told that if they want the $1.2 million, they have to stay quiet. So nobody exposes that.

So we know that there are a lot of subverts. If there was openness about the problems because of the patient safety issue, then that avenue of hiding stuff would not be available.

In terms of your attack on capitalism, no, I don’t agree. I think that it is possible to be vigilant about patient safety to produce the best imaginable software and nevertheless to produce profit. I think that the fact that there are well-made, very safe cars on the road is proof that there can be pressures equated to safety, and nevertheless profitability. This is the wrong time of the economic cycle to make this argument, but nevertheless, I still defend capitalism that way.

I think what the vendors have been so frightened of in the 13 years since they held that meeting where everyone — except the AMA, for some reason — agreed that they must do everything in their power to avoid federal regulation. I think that they have put themselves in the position where increasingly, regulation is a possibility.

And by the way, in my article, I argued that there were about 12 steps that they could do before regulation and I laid them out. There could be professional oversight — in other words, the physicians in the hospital associations would say, “We will not accept contracts with non-disclosure, period,” it would end the problem. The lawyers’ association for the hospital could simply say that. The IT industry itself could say that. “We, from this day forward, will not include that.” AMIA could say that.

That said, let’s see what happened two days ago, or four days ago, in JAMA. There was a letter — including my letter, then a rebuttal — that said, “Guess what? The Joint Commission rules state specifically that a hospital and its clinicians are prohibited from not talking about patient safety-related errors in the HIT.” So every single hospital in America, theoretically, that’s involved with HIT would be in non-compliance, would lose accreditation if they follow the rules of the current HIT vendor contract. 

Has anyone contacted the Joint Commission or has the Joint Commission read the letter in JAMA? And the answer is yes. Not me — I didn’t contact them. But it turns out that the Joint Commission reads JAMA, and I have been contacted by them, and they said, wow!

So the Joint Commission may simply say, “There can be no non-disclosure anymore if you want to stay accredited.”

Last question. If you were healthcare IT king for a day, what would you do?

I would say to the vendors, “The solution to your marketing problem is to create really good software, not to abuse people who study it and find problems, not to place the blame on ‘moron doctors’ or ‘idiot CIOs’, but to make really good software.”

And good software includes superb usability. I would say that there are excellent models out there of good usability. For God’s sake, look at Google, look at Google Maps, look at some of the people who are doing really innovative work out there. I would not shunt them away, but rather I would choose them as models.

I would develop a system of openness wherein we could really compare and test, not these Potemkin hospitals where you send potential purchasers, and really seek to improve on a real basis what is best. I mean, do the manufacturers of Epic really think that nobody from Sunrise ever sees their software or the like? There should be a real, open — call it a bake-off, wherein people can see what’s happening, and they’re not selling vaporware.

I went to one hospital the other day where they gave the top vendors a scenario then said, “I want you to do this, and then you get interrupted, and then you have to have a lab report to comment on, and then you’re going to wait for another drug information, and you have to do this live.” They did a real test. Most of the vendors either refused or failed. One vendor who I don’t particularly love passed.

Why did it have to be this one hospital CMIO type to call this test? This should be standard. There shouldn’t be hiding about this stuff. Patients’ lives are on the line and physicians’ reputations are on the line. Hospital bottom lines are on the line. Nobody benefits from having mediocre software, except maybe the salespeople of mediocre software. We can do so much better.

HIStalk Interviews Bert Reese

Bert Reese is senior vice president and CIO of Sentara Healthcare of Norfolk, VA.

You’ve been at Sentara forever. What’s the secret to CIO longevity?

I think the secret is to make sure that the technology is aligned with the enterprise, both the clinical and business initiatives that the company is addressing. So the closer the IT is aligned to the business and the more you are able to deliver on that, the more successful a CIO would be.

Sentara was mentioned recently for developing its own interface from Epic to Picis LYNX. Tell me a little bit about that project.

We were a Picis LYNX customer before we did Epic. The problem that we were trying to solve with LYNX was our inability to code properly in the ED, and therefore, our billings were inaccurate.

What the Picis LYNX software did for us, prior to Epic, was give us the ability to properly code the patient during the visit. We saw that in the old world, prior to LYNX, that we were under-coding, which actually meant that we were understating our revenue potentials from the ED, and from a clinical perspective, not really indicating the proper problem that the patient was being treated for. With the LYNX software, since it’s a logical part of work in ED, it was more convenient for the nurses to code as part of the care process, so it’s worked out very well for us.

We went to Epic, and we wanted to preserve the capability of LYNX, so we developed an interface between LYNX and Epic to allow us to move information from Epic down to LYNX so that they could continue to use the coding software in a convenient way. One of the issues that you have is that nurses and caregivers don’t see coding as value-added to the care process; it’s more an administrative function. So when you want them to do something like that, if you can make it a byproduct of how you treat the patient. Then it’s a lot more convenient and they’ll do it. That’s what we did. It’s pretty straightforward; that’s the real secret sauce is in the Picis LYNX software.

Your EMR project is said to have cost $237 million. How will you measure its benefits?

That’s a great question. So it’s $270 million over ten years. The first thing was we set an expectation that a project of this magnitude goes out over an extended period of time and that you have to set the expectations of the company that they will be spending this kind of money for awhile.

The second piece of it is that when we started the project, we identified 18 major clinical processes that drive about a $35 million-a-year annual return of investment. We have identified those, we have four of our eight hospitals up, and we have seen benefits this year – `09 – at around $16.7 million.

So we know from a dollars-and-cents perspective that electronic medical records do create economic value. If you take that $35 million over the $270 million investment, that’s like an internal rate of return of about 12.3%. That’s a good return of your investment.

The other part of it relates to clinical quality indicators. If you follow the clinical quality indicators and see some level of improvement in clinical quality activity — that is, you see the patients are being better cared for under electronic medical record — then there is that benefit as well.

We have seen great clinical quality. I’ll give you an example of one. In the old world, it would take 137 minutes for the doctor to enter a medication in the hospital before it was administered to the patient. Now, it’s less than five. And there’s tons of stuff on turnaround time and length of stay and things like that.

The key to this — in looking at the return of investment, you look for where there is hunting and gathering of information, i.e., you’re looking for the old paper chart and/or whether there will be hand-offs between one care partner to another care partner. That is where the opportunities are for both economic and clinical quality savings. 

What are your overall impressions of the Epic system and its implementation?

First of all, in the way of background, I’ve got experience with Cerner, Eclipsys, Epic and GE’s IDX/Centricity, so I’ve seen a lot of them. I will tell you coming out of the chute that you can have the best software in the world, but if you do a sloppy install where you support it in an inappropriate way, you’re going to have a failure.

Part of the secret sauce is in the quality of the software. I would say the other part of the secret sauce is in the quality of the local IT staff. Then, the culture of the company who’s adopting the technology.

In the case of Epic, Epic is a superb piece of software. It’s not buggy. It comes very, very clean. They’re a very collaborative company. That makes it easier. It’s less mysterious on the IT side about what it is you’re going to get and what you’re trying to do with the software when you get it fixed, or an upgrade or something like that.

But I will tell you that the responsibility, ultimately, is at the hospital or health system level. They need to make sure they made the right investment in order to have a varsity team to be able to support an application, either in the Cerner, Eclipsys, or an Epic type of venue.

Did you use outsourcing for the implementation?

I used it in an unusual way. In the old world, I was converting from a TDS 7000 to Epic and I had a choice: I could either bring in new staff, or outsource staff to help me with Epic, or I could take my Eclipsys support and give it to an outsourcer — it will move my old staff to learn Epic. 

I elected to do the latter. We hired Perot Systems to commit and run our Eclipsys environment for us while we took our old medical systems team, retooled them on the Epic toolset, and had them support the implementations. Perot is still with us today because we have a couple more hospitals to do on the Eclipsys side, and so they’ve been with me for about five years or so. They do a great job.

How have your IT strategies changed, or have they changed, with the economic climate?

First of all, I want to make a comment. What we’re doing is not about electronic medical records. In our view, in our culture, an electronic medical record — when you have it implemented, most organizations will become a technology-driven company, and our advice is: skate to where the puck is.

The puck is not being a technology-driven company. The puck is going to be when you are a data-driven company, meaning that in order to use the data, a prerequisite is to have the electronic medical record.

When you have the data, the advantage will go not to the organization that has the EMR. It will go to the organization who can convert data to information, to knowledge, to action the quickest both business-wise and clinically.

I’ll give you an example. In the old paper world, I could tell whether you had been in the hospital, whether you had pneumonia, and whether you had an antibiotic administered; but, I couldn’t tell you when I gave you the antibiotic. I can’t tell you the outcome. The outcome would manifest itself. Does it shorten the length of your stay? Did you have more doctors’ office visits at the end of your hospital episode? Because I couldn’t see across the continuum of care.

Now we know when we study the data that when you present with pneumonia in the doctor’s office or in the ED, and the doctor concludes that it’s serious enough that he wants to have you admitted, to onboard the antibiotic as soon as possible. So if I know you’re in the practice or in the ED, and I’m going to send you to the hospital, I’m going to give the antibiotic immediately, because we know that getting the antibiotic onboard will start the curative process, will shorten the length of stay, and shorten the subsequent doctor office visits that are required.

That improves the care for that patient and reduces the cost. You can’t do that without having the data. You can’t do that without having electronic medical record, so that when you decide to tell the care delivery team if you’ve got a diagnosis of pneumonia, "Give the antibiotic now," because you can communicate it electronically to all sites — you can’t do it without that.

So the electronic medical record in our view is, "Welcome to the starting line." It’s going to revolutionarily change healthcare. As it relates to my current level of investment given the current economics, they’re giving us more money. They believe in what I just stated. They believe it’s all about data and the new information that will be created.

So if I was going to summarize it for you: electronic medical records improve quality and make money and they position you for extraordinary opportunities that you’ve never imagined.

You have to have administration that supports that concept?

Yes, absolutely. I think what the role of IT is in the future is that a lot of times, our customers are a rearview mirror. They’re not a guide to the future. So a customer, perhaps, would have never invented the television set, the microwave, the iPhone. It was technologists who invented those technologies and innovations, right?

And so it is the role of technology in the enterprise or in the health system to create a new reality for the company based on the technologies that are available. That’s a big statement. I don’t wait for my administrative staff to create a new reality. I, because I understand the technology, create a new reality on their behalf.

Back to your first question about how it is that you last so long as a CIO in the organization, it’s because I’ve been able to innovate in front of the company to improve what it is that they wanted to do.

Tell me about your internal work with standardization.

You’re right on point. That is part of the secret sauce. If you’re going to report on data, that means that you have to call the same thing the same thing across the enterprise. So a chest bilateral is a chest bilateral, not a chest x-ray. And, more importantly, you have to have the same lab normal values across the enterprise. One pathologist may say with a CBC, "This is a normal value," and another pathologist may say, "That is a different value from the normal limit."

One of the discussions you have to have early on is — what are you going to call things? What will be the standard of practice within the enterprise? So from the Sentara perspective, we are heavily standardized. We took a page out of the banking business back in the late 80s, early 90s where bank mergers took place and went through a heavy standardization. You’ve seen it with stimulus packages and banking consolidations. We took a page out of how they did their conversions and we decided to go that way.

When we affiliate with a new hospital or a doctor’s group, we bring them onto our standards suite with their application. In the case of my eight hospitals, there are no Norfolk General status set screens, there are no Sentara Careplex status screens; there are only Sentara Healthcare status screens. All those hospitals collaborate in what those screen flips look like, which means heavy dialogue, heavy participation, great collaboration, and a lot of fun.

How important are mobile devices for your clinical projects?

Not so much. The biggest extent of mobile devices we have are WOWs, workstations on wheels. Medical staff is not pushed to move them to phones or tablets or anything like that. At the doctor practice level, inside the practices, we experimented with mobile devices and we found, based on the workflow, that the fixed workstation worked best.

Let me describe that for you. If you’re a patient going to one of our doctors and you go into the exam room, you’re normally accompanied by the doctor’s nurse, who then logs on to the system and then enters your problem, enters any of your vital signs, any of your current meds, any changes in your physiology, and brings everything up to date. She then locks the workstation; she bookmarks where she is on your record, and locks it. When the doctor comes in to see you, he logs right on, right where the nurse picked up. So he doesn’t have to reacquire you as a patient, doesn’t have to ask any additional questions. He’s right where she left off, right where his workflow starts.

If he was walking from exam room to exam room with a mobile device, he’d have to log on every time and reacquire the patient. I wade through all the patients I’m going to see that day. And so we found it to be faster if the nurse does her work like she normally would, locks the workstation — he comes in, logs on, and he just picks up right where her summary of the information is and carries on the conversation with the patient. So mobile devices have been interesting for us, but that’s where we are right now.

Anything else that you want to add?

The only other thing I would say around community physicians and electronic medical record — there’s stimulus money out there for doctors that go up on electronic medical record. I would say to the hospitals and the health systems that they have a responsibility to guide that conversation in their communities that they reside on behalf of their community-based physicians. They should become the rallying point, they should become the center of truth, and to help the doctors with the decisions they have to make on the electronic medical record, because they have the capability of doing it.

What I don’t want to have happen is I don’t want a doctor, because he’s anxious about the stimulus money or losing Medicare funding, to make a knee-jerk reaction to a decision. I believe in the theme of better together, and I’d like to have my community doctors as close to us as possible so we can all go there together. And that if we make a mistake, well, we’d all make it together, and hopefully we’d have the power of crowds, maybe we’ll learn from each other.

I would encourage everybody to take on the responsibility of helping to guide the community physicians as to what they should do with the electronic medical record. There is certainly benefit for the hospital, but there’s also certainly a benefit for the patient. If you control the conversation or help guide the conversation, you’ll probably minimize the number of technologies that you have in your community. That means we can start to solve the interoperability problem when you have to hand the data off from a primary care doctor who’s on the XYZ system to a specialist who’s on another system, that the chances of that being done successfully and clinically correct is improved.

So I think the patient benefits, and then ultimately the hospital and the caregivers, because they’re able to have more information in order to care for the patient better. Ultimately, it’s all about the patient.

HIStalk Interviews William Hersh, MD

William Hersh, MD is professor and chair of biomedical informatics at Oregon Health & Science University, Portland, OR.

How many informatics people is it going to take to support projects launched due to HITECH?

I’ve actually not sat down and penciled that out. I published some research last year using the HIMSS Analytics database, which is an admittedly imperfect source of information, that moving everyone to Stage 4, which was CPOE and clinical decision support, would require another 40,000 people on top of the 109,000 or so that are presumably already working in health IT if you extrapolate.

One of the big questions, though, is the role of people who do informatics. The HIMSS Analytics database focuses more on IT. There’s a growing recognition of people who work in informatics, who work at that intersection between IT and healthcare, and are working with IT but in more of an informatics role, a focus on information. The estimates there vary. Chuck Friedman, who is now David Blumenthal’s deputy, came up with a back-of-the-envelope calculation of about 13,000. Don Detmer, the former president of AMIA, said it’s probably more like 50 to 70,000, but probably somewhere in that ballpark for the informatics people.

We’ve got a lot of people in the industry who learned on the job when there wasn’t any formal training available. What results will we get by using the formally trained people?

There are many ways to learn things. I don’t have a degree in informatics myself. A lot of fields begin with people who blaze a trail. They pick things up, learn things on the job. That’s probably, when we’re talking about industrial scale health IT, not practical. Plus, there is a growing base of knowledge that many of those trailblazers learn.

I think the world is changing and there’s going to be more of a need, just for efficiency reasons, to train people, to give them the knowledge and skills. The old-timers kind of learn that through the college of hard knocks, but to really scale things up is going to take more formal training.

There are so many ways to get training — ANCC certification for nurses, 10×10, graduate certificate programs, full-fledged undergraduate degrees, and graduate degrees. What are the disadvantages and advantages of all of those credentials compared to what the market needs?

I think the market will probably sort itself out. People ask me, “Will I need to have a credential to work?” And at least in this point in time, the answer is no, but that could change in the future, just like anything in our economic system. The value will be what people put in it.

There may be a time in the future when people go to apply for a job and potential employers might look at a group of resumes where one person has some formal knowledge that’s been validated by some sort of certification process, as opposed to someone who has just learned things on the job, and that may tip the scales.

If the people are otherwise equal, if the person has been in the job for 20 years, that may tip the scales the other way. So I think it will sort itself out over time.

Informatics is a profession but with different roles, such as a nurse who sits in front of a screen and builds order sets all day all the way up to a physician who is an architect for an entire system, yet each could call themselves an informatician. Is there a need for more granularity in what people are doing with their credentials rather than which credentials they have?

Yes there is. The reality is, in some ways the informatics field has some similarities with an MBA. People typically don’t come into an MBA program with a business degree. They come from all walks of life. I know of a couple of physicians who have MBAs who’ve gone on to management jobs in healthcare.

What I always tell people is that informatics is a very heterogeneous field. There are many different kinds of things and there are many heterogeneous pathways into the field. There are many heterogeneous pathways into jobs, although usually the job that you do is somewhat a function of your background. So for example, it’s pretty unusual to see a CMIO who’s not a physician, or at least who’s not a clinician, but typically a CMIO is a physician.

But there are other jobs, such as managing an EHR implementation, that are more suited for someone who has knowledge of healthcare but who isn’t necessarily a clinician. And it’s also a jobs-in-between, like the nurse who creates order sets or order entry screens and things like that, like you mentioned.

A physician colleague I know was in the OHSU graduate certificate program and said it was hard, with a lot of statistics and epidemiology. Is there a presumption that there is a base set of knowledge that would be more typically found in a physician?

I’m actually kind of surprised to hear that. In our graduate certificate program, they don’t — for example, like they have to for our master’s program — take a statistics course. I guess it depends on how you’re defining statistics and epidemiology.

Our certificate program, and I think in a lot that are forming, is focused on giving people the knowledge of informatics in terms of what you do with information to improve healthcare, to improve its quality, safety, etc., and then how you go about implementing systems to be able to capture and use that kind of information.

There’s not a massive amount of statistics and epidemiology in our certificate program. I don’t have the exact numbers in front of me, but about 50% in our program are physicians. Of the remaining 50%, about 25% are in healthcare professions like nursing and pharmacy. The other 25% are from everything else, with probably the majority of which is IT. We do get a fair amount of people with IT backgrounds who want to learn more about healthcare to be able to apply it.

Going back to your other question, “Do people need to be trained?” We actually have a lot of people who are already in CMIO kinds of jobs and then realize that they need to learn more informatics and enroll in our program. I chuckle about it sometimes because that’s not usually the way you go learning about a field — after you’ve gotten your job. You wouldn’t send a surgeon off to residency after they started doing operations.

If you’re reporting to a hospital executive, they probably don’t know anything about informatics enough to say, “Yes, I want my person to have a certificate, if not a degree”?

Yes, it’s true. This is still a new field that is sorting itself out. Another problem related to what you’re describing is that HR departments know very little about it, although spending time talking to more and more forward-looking healthcare organizations, the HR departments are starting to learn about the value of this.

There’s a local hospital here in Portland, Providence Health Systems, and they are doing a lot of effort, mostly internal development, but more appropriate, like sending people off to learn more, but also developing internally an informatics cadre, if you will.

It seems like the ideal appetizer for the training would be the 10×10 program, which you were involved in that early on. How does that fit in now and is it going to meet the goal of 10,000 people by 2010?

The 10×10 program was started when AMIA was looking to have some kind of e-learning option. They had talked to some vendors and it would have been prohibitively expensive. We actually already had a broad-based course in our program here.

So I suggested to the AMIA people, “Why don’t we just take this course? We can repackage it as more of a continuing education course.” That’s how it came about. AMIA turned it into a sort of a program that let other universities offer 10×10 courses and so forth.

We won’t hit 10,000 people. In fact, there have been 750 people who have done the 10×10 course. But the main reason why we won’t hit the 10,000 people is that 10,000 people haven’t come forward and said, “We want to do this.” But about 750 have, and we have some published data saying that people find the experience worthwhile.

The way we’ve structured the 10×10 course here is that since it is essentially equivalent to our introductory course. People who do the 10×10 course can then get credit for the introductory course in any of our graduate programs, even all the way up to our PhD program. The graduate certificate program consists of eight courses, one of which is that course, so then they have to take seven more.

10×10 is a broad-based and intensive but introductory experience to informatics. I don’t know if anyone will become a high-end informatician unless they have loads of experience just with that one course.

The tough thing about establishing a credential is that you’ve got to market it to employers. Do you think vendors, given their emphasis on “just get stuff in and installed”, maybe don’t really care too much about the theoretical nature of informatics and are never really going to embrace a credential?

We’ve had vendors who have sent some of their folks. Some of the big vendors have sent a few of their folks to learn about it. I agree, vendors are focused on getting your systems up and running.

I wouldn’t call 10×10 a theoretical course because it’s pretty practical, these issues with implementation, with standards, with quality measures, and things like that. I mean it’s definitely an academic course, but it’s actually not highly theoretical.

We don’t know for sure, but at least half the people get their tuition paid by their employers. Typically, hospitals will send people, sometimes universities, and again, we have had a number of vendors who have sent some of their staff.

I think it would be a great course – obviously, I’m biased — for vendors to just get a bigger sense of the marketplace. With all the expectations of the stimulus package, the vendors are going to have to be a little — you probably know this as well as I do — more cognizant about standards and interoperability, because it’s going to be expected of them, whether they really deep down want to do it or not.

What do you think HITECH is going to do in terms of innovation?

I think that if we define Meaningful Use at a reasonably good level, a level that most people can hit, and we make interoperability a big part of it, that will drive the vendors in a way — I mean, I remember 15 years ago when people were saying, “Should I demand of my vendor that they speak HL7 Version 2?” It was really customers that drove that, and I think it’ll be the same way. 

It’ll be customers and the Meaningful Use guidelines, at least around things like interoperability, that vendors say, “If I want customers to be able to meaningfully use my EHR system, we’re going to have to do this interoperability thing whether we deep down want to do it or not.” I think it’s important for people to know what the issues are around interoperability standards and so forth which are the kinds of things that we teach in courses like this.

Maybe that’s part of the reason programs haven’t picked up — vendors aren’t really developing a lot of new products. Are people with all this formal training going to be disappointed when they go to work for a vendor and realize they won’t get to design a lot of fun new stuff and re-architect systems that have been on the market for 20 years?

That’s actually hard to know. We have about 250 alumni already in our program. That’s not 10×10; those are actually certificate or master’s program. A small number of them work for vendors.

I think they probably have mixed feelings about their job. It probably varies from vendor to vendor in terms of what things people get to do. Of course, you might get a job with an innovative vendor, but you might get stuck on some project that you really don’t want to do anyway.

But I think one of the good things — maybe I’m a little idealistic about this — but if we come up with good, achievable definitions of Meaningful Use, that we can get the vendors or companies … I’ve never worked in the private sector but I certainly know a lot of people in the private sector, and at the end of the day, you’ve got to make a profit. But if we set the motivations for the vendors right, then hopefully we can make them do the right thing and keep their feet to the fire, just like some of the hospitals and physicians will have to be kept to the fire, too, in terms of implementing things that are Meaningful Use.

You were involved with clinical data sharing before it was a hip thing to do. What’s your vision of where it should go?

I think we need to be realistic about it. We need to recognize, for example, that the kinds of things we can do with clinical data sharing, when we have good, quality data to do it — quality measurement, for example — is a great thing. I don’t think anyone is opposed to it in principle, but the question is, can we get good enough data and meaningful quality measures and act on them?

I think that a lot of times people think that just because data is in electronic form that that means that you can do anything with it, like it’s the gospel. The reality is that, for clinicians in the trenches, high quality data is not their top priority. Usually their documentation is what stands between them and their getting home for the day.

I think we need to focus on trying to develop ways to help clinicians to get the best data in the systems so we can do things with it like quality measurements and health information exchange, all the kinds of stuff we talked a lot about now, but all that depends on as good a quality of data as possible. I also think we need to be realistic in what we can and cannot do.

Is it skewed toward having physicians input their own information to create all this quality data that someone else gets to use?

Speaking as a physician, although I actually don’t do patient care these days, I sympathize with a physician when someone ends up imposing an extra hour onto their day in terms of entering data.

This is where I think the research comes in. How can we find ways to get the highest quality data and not increase the cost of getting it? If it truly takes an extra hour a day of physician time, ultimately we’re going to pay for that, and I’m not sure if the healthcare system or the payors are willing to do that.

I think we need to find ways of getting as good a quality of data as possible, but I think physicians are going to have to change their ways a little bit, too, and recognize that they can’t just scribble things, that we need a certain standard of quality for data. I think this could be a role for physician specialty societies — groups like ACP, AAFP that have initiatives — looking at these sorts of questions, like how do we get the best data without taking an inordinate amount of time?

Is it the right step to shoot the government’s wad on putting out electronic medical record systems that didn’t take advantage of any of that research and say, “Look: type or use a mouse, it’s up to you, but that’s how it goes in”?

There’s definitely a risk in what we’re doing. On the other hand, we need to be bold and make it happen, just like healthcare reform. There’s going to be no perfect healthcare reform because we have so many different competing interests, but I think we’ve got to do something because the status quo is not acceptable.

The same thing is true when it comes to information. We need to be bold, but again, I know there’s been a lot of arguments about what should and should not be in Meaningful Use, but I think that it’s a good bar that most people with the right amount of effort can hit. That’s what we ought to aim for.

What technologies that aren’t necessarily mainstream now that can make a difference?

You know, it’s funny, because when I talk about informatics, I often times say, “We can’t be too focused on technology; we need to be focused on information.” I think it would be technologies that help people enter high-quality data, so maybe there will be some kind of role for some things like speech recognition with real-time transcription, or data entry interfaces that have structured interfaces but don’t completely box you into choosing this checkbox or that checkbox.

Whether that’s going to be handheld devices — they’re obviously portable and convenient, and they’re wireless now. On the other hand, they have tiny screens, and things like typing on them are very difficult.

So it’s hard to predict which technology — again, I think the focus should really be on what we want to do. To me, the most important issues in informatics are getting high-quality, standardized, interoperable — I’m actually less concerned about interoperable applications. Those will come if you have interoperable data.

We really need to accelerate trying to standardize clinical data and obviously make it available with obviously all the security protections and so forth, but across applications. The rest of the interoperability, and also things like health information exchange and quality measurements, will come from that. 

My last question, elicited from your previous answer — and this is an A or B answer only, there is no “all of the above” — is informatics about technology, or is it about people and organizations?

Unhesitatingly about people and organizations. That’s an easy one. [laughs] I mean, it’s what you do with the technology. You can’t be ignorant of the technology; you have to understand it and be facile with it, but informatics is about people and organizations, basically improving healthcare and improving people’s health.

And your programs focus on it in that way rather than about technology?

Absolutely. You can come here or online or whatever, and learn a lot about technology and get involved in projects that do a lot with technology, but at the end of the day, it has to have some value to health or healthcare, making people’s lives better. We emphasize that. I think that most informatics programs emphasize that point of view.

I think one thing that’s happened in the last few years is that the informatics field has kind of matured a little bit and recognized its role. Again, I don’t want to say that technology’s unimportant, because it’s very important, but it’s what you do with it that’s more important. I think that informatics has kind of recognized its role in that realm.

Any other comments?

Obviously I have a little bit of a bias toward the academic/education side of the field, but I do think that there is growing knowledge in this field and that people benefit from knowing it. That’s one of the roles that academic programs are going to play. I actually believe that informatics will mature as a profession as a result of that knowledge.

No matter what happens with ARRA, the trajectory was already to increase the use of health IT and I think that will continue, probably accelerated through ARRA.

HIStalk Interviews Loren Leidheiser DO, Chairman & Director, Department of Emergency Medicine, Mount Carmel St. Ann’s Hospital, Westerville, OH

What made you decide to use speech recognition instead of the usual mouse and keyboard? 

I think speech recognition offers a lot of efficiency both financially and also in time savings. The accuracy is outstanding. It allows you to perform chart documentation and navigation through an electronic medical record much more effectively than without it. That is so much better than point and click with a mouse and a traditional keyboard.

What did you use before? 

I’m an emergency physician. We would document 100% of our charts with traditional dictation. That was a very, very costly process. It cost us probably close to half a million dollars a year for an emergency department that saw about 70,000 patient visits. 

The accuracy wasn’t all that good. Our traditional dictation would be farmed out to transcriptionists over in India. When it came back, it really needed to be cleaned up.

We went with the Allscripts emergency medicine product, which was a dynamite electronic medical record. The problem we had was that even the best-in-breed still left a lot to be desired with being able to capture the unique elements of the history in physical examination. And really, the point-and-click, drop-down menus were clunky at best in terms of telling the story. Even the navigation through the software was somewhat cumbersome.

Speech recognition was a natural solution to a lot of the shortcomings of electronic medical records and also with traditional dictation. Your startup costs are reasonable. The training time is very short. Even physicians, allied health professionals, nursing staff — the training time and complexity is so minimal that it’s certainly not a barrier. The cost savings once the initial costs are incurred — really, your investment just pays off over and over and over.

How hard was it to get Dragon to work with the Allscripts product and to get the accuracy up to par?

The Dragon product runs in the background and then it populates data elements right into the electronic medical record. I can tell you, from day one, we’ve had great success using Dragon with Allscripts.

We started back with Dragon 6.0, which was really a product that needed a lot of improvement. That improvement has been seen. In other words, right now, the 10.0 version is absolutely dynamite, for lack of a better way to put it.

Allscripts recognized how good Dragon was and actually started incorporating it with their software, making some special considerations with regard to being able to use speech recognition to navigate through their software, and actually started marketing the Allscripts product with Dragon as a bundled offering to hospitals’ emergency departments.

The onset of the roaming feature, which allows a group of people to save their voice files on a central server and then pull them into any application that you’re using in a given geographical area, has been huge. What a wonderful addition. That has worked well with the Allscripts product as well.

What would you say the main benefits have been and what were some of the drawbacks?

I think one of the main benefits is that you can tell the main story uniquely in terms of documenting a history and physical examination, review of systems, medical decision-making. All those functions that are key, absolutely essential to a physician and an allied health professional, and by that I mean a nurse practitioner or a physician’s assistant.

Dragon offers a way to do that that is so much more efficient and accurate than drop-down menus and with traditional typing. You just can’t achieve the level of accuracy by other means. So I think the cost savings is huge.

The drawback I see is that there have been criticisms about the accuracy, but as I said, what I’ve seen is that the accuracy just keeps getting better and the ability to meet the end user’s expectations has been a commitment that has been a work in process that has been achieved. I’ve used the product for many years, and I put on the headset — I’m a traditional headset user — and for me, it’s just part of the process of being a physician, just like putting a stethoscope on, a normal part of my evaluation of a patient.

I think some people have found that there have been occasional problems with recognition, but there have been problems with traditional dictation being transcribed when it came back with errors. You have to look at it and skim it to make sure it’s OK.

The speed is not a downside. The speed and accuracy actually improve as you talk faster. The recognition is actually improved when you do that. If you slow down, then there are problems.

So I wonder if some of the criticisms is that people don’t know how to use the product. In our institution, we’ve got about 25 physicians that use the product and probably about 15 or 18 mid-level providers. Part of what I do is say, "OK, let’s sit down together and let me show you how I use it." The macro feature where you can store a letter or a pre-set amount of text, then simply use a voice command to spit out, let’s say, a normal physical examination, is huge. That has been a wonderful feature as well. It’s all those little shortcuts that you can really use to improve things. 

These things are easy to use. To navigate through software is very easy. It’s very intuitive. Nuance just continues to make it better and more logical. 

What do you think benefits are, if any, to patients?

I think the benefit to the patients is that it more accurately reflects the medical encounter with the patient. I can be more efficient in my order entry in the medical record. I can do that much more quickly with Dragon. I can document more accurately the historical elements of what’s going on. In other words, tell the story better.

I can reflect what has actually happened in the emergency department by very efficiently using voice recognition to capture a decision or discussion of the risks, benefits, and alternatives with the patient. I can do it at a lower cost as a result of voice recognition compared to traditional dictation, or as a consequence of the increased cost that I incur spending 14 to 18 cents a line for traditional dictation.

Do you feel that, in all the meaningful use discussion, that the use of speech recognition is going to be a help or a hindrance?

I’m very biased on that and I’ve said this for years. When I first started using Dragon back long ago, I thought traditional dictation is going to go away. As much as I hate to see automation taking human jobs, I just don’t think we can surpass the accuracy and efficiency of voice recognition.

I think it’s only going to become more pervasive, in at least the healthcare industry, as we need to have short turnaround times on the documentation in a hospital setting. Now maybe an office setting is different, but the healthcare industry changes and evolving. Already, if you look at what’s going on in the government, we’re trying to cut costs and trying to take money out of the budget for healthcare, in Medicaid and Medicare. This is going to be yet another way we can be more efficient in how we operate.

It’s not going to be just healthcare, either. I think you’re already seeing that with the phone lines, where continued use and development of voice recognition just makes sense. I don’t think it’s going to go away, I can tell you that.

So why do you think so few hospital-based doctors use speech recognition?

You know, I wonder the same thing, because I’ve been using it for probably eight years. I think I’ve been patient with it, I believe in it, and I’ve seen it work. I see it in my own practice.

I don’t know if it’s an issue where doctors just don’t have the energy, or maybe they define themselves as needing to focus on having to diagnose appendicitis, but think they don’t have to focus on the things that are more business-related. I don’t know. I’m in Columbus Ohio, and I’ve talked actually to several other practices who had an initial bad experience with voice recognition, then abandoned the idea and never came back to it.

But I think it’s like most things that we see. With time, the technology improves, the accuracy improves, and all of a sudden you find that the product is now one that really works. And maybe it’s just that I’ve been patient and also persistent. But I also thought that it was going to allow us as a group to reduce our cost of doing business and be more efficient and that has been the case.

Frankly, I think in large part that voice recognition has allowed us to pay for electronic medical record in two and a half years, based on the cost savings that we’ve achieved by eliminating traditional dictation, because half a million dollars a year was eliminated as a result of two things: voice recognition and the electronic medical record. That just continues to accrue year after year after year.

But in terms of why other people haven’t seen the success? I don’t know. Maybe we have, where I practice, a very wonderful support system in the IT department, and a very open-minded, progressive hospital administration that says, "Hey, we have the same vision that you have, and we see that this is going to work and we appreciate the fact that you’re going down this road to develop this."

So we’ve had a lot of support. And when it came to me saying, "Hey, I’d like to upgrade Dragon to the next level," they said, "OK, here’s the money, we’ll make that happen."

Our sister group wanted to have $300 handheld microphones, with a built-in mouse and everything, whereas I was happy with a plug-in headset that cost $15. And I think I get better speech recognition than they get for the $300 handheld mic. But the fact is, we’ve had support from administration who says, "Yeah, go ahead, we’ll support both. You can use the $300 handheld mic and we’ll also pay for the $15 headset." 

Maybe it is that doctors don’t want to wear headsets. You look like air traffic control person. But you know what, if it gives me the desired results better, then I’m going to wear the headset, because it frees up my hands to use the keyboard and the mouse. You know it’s not easy.

I think we want instant gratification. We want a product that, boom, just works out the box. But the fact is that the effort and the time is not that great, and really, if they give it a little bit of time they find that this really is everything that it’s said to be.

HIStalk Interviews Chuck Podesta, SVP/CIO, Fletcher Allen Health Care

You’ve been on the job for a year now. What were some of the high and low points?

The high points actually started with the interview process. I was very impressed with the organization. I was very excited about the EHR the project with Epic. A lot of the heavy lifting had already been done around project organization, budget, and resources. I was excited from that standpoint. I was starting at a time when the project was kicking off, which is an exciting time as opposed to all that pre-planning stuff that you have to do.

Any low points?

No, I really can’t see any. Burlington, Vermont is a beautiful city. It was the first career move I’ve ever made that had a boost, not only from a job perspective, but from a quality of life as well. 

You’ve just gone live with some early parts of PRISM and Epic. What’s next?

We’re into Phase II right now. We’ve gone live with the ED, the electronic health record, which included CPOE, bedside medication, and of course all the nursing functions and charting. We’ve also got the monitors linked in to the flowsheets as well. We completed that on June 6. It’s going very well.

We have CPOE, with 92% of all orders being entered by physicians after just a few weeks of going live. That’s extremely successful for us.

Phase II is our first ambulatory site. We have a large faculty practice, so we’re rolling it out in the outpatient area. That goes live in November. In the rest of 2010, we’ll be implementing our ambulatory sites. Along with that, we are also implementing Beacon Oncology for Phase II — that’s December of 2009 — along with MyChart, the patient portal. 

December 2010 will be our last ambulatory practice and the Cadence scheduling system. That finishes up the three phases of the project.

In conjunction to that, too, we have the opportunity to offer the Epic licensing to other community hospitals in the state and in the ambulatory sites as well. Our project is called PRISM — Patient Record Information System Management — and the extension of our PRISM project is called PRISM Regional. That’s a hosted group purchase solution. We’re working closely with Epic on that.

How will you be using MyChart?

Actually we just fired that up. We’ve got a team in place and we’re working closely with marketing to put together a plan to market that to the community. Two options that we’re looking at right now since we have the inpatient up — we can roll it out from that, but we’re thinking that the biggest bang for the buck is on the ambulatory site. So there’s the decision that we have to make: do we roll it out in December for the inpatients in our first practice and then just continue on with the practices, or, do we wait until we have all the ambulatory sites up and roll it out after that?

My guess is we’ll probably implement the inpatient side of it and then we’ll add on each ambulatory practice as it comes up. So the practice will have to work with their patient population to get them signed up to use it. But we’re still in the early stages of that right now.

Have you changed the project scope or timeline due to economic conditions?

No, we really did not. We were not part of a bond or anything like that. The money was basically money in the bank, so it wasn’t an issue that we were running into bond covenants or anything like that, or we would have to stop and conserve cash or anything along those lines. We were lucky that we got all that done before the market started to tank. So the investments were there. We met all of our deadlines.

What is the expectation for return on investment?

We’ve got a benefit utilization group. We came up with some of the different benefits. We’re also convening the group now that we’re live, actually going in and start to measure those. But a lot of the standard ones that you would see: measuring medication errors, some types of quality patient safety.

But what we see as the biggest bang for the buck is utilizing the system to help us drive towards a best practice. For example, if we have an initiative to reduce nosocomial infection rates, how can we use the system to prompt the clinicians to protocols that drive that number down? That’s what we’re really focused on right now. With Epic, with the Clarity database, which we have as well, which is the clinical decision support database of the Epic system — we’re going to utilize that heavily to start looking at where we can impact the care process.

Any specific timeline for being able to show those metrics?

I think once we deal with the initiatives we have right now, like medication errors, by the end of summer we’ll have some good data on those. We did calculate the "before" picture prior to going live. We were collecting data probably for a year before we went live on certain measures. Once we get over the learning curve, we’re going to go back and see how we’ve impacted those. By the end of the summer, beginning in the fall, we should be able to do that.

How are you engaging physicians?

To me that’s been a real success here. We’ve got an orthopedic surgeon who’s about half-time on the project. He has been instrumental. He knows the system inside out and has been instrumental in working with physicians.

We also have a physician advisory committee that’s very strong, providing physician leadership. The chairs have gone along on with them, so that’s working well. Our CEO is a physician, so that definitely helps with pushing the adoption. The physician leadership actually voted in the bylaw that, to be credentialed to practice at Fletcher Allen Healthcare, you have to use the system, including CPOE. That’s part of our success in driving that percentage up as well.

That was key and also our education process. It’s one thing to have a policy, but another thing is to implement a procedure that works. We did a lot of work with pilot groups. We took a pilot group of 10 physicians and ran them through the standard eight hours of training. With their feedback, we were able to design a training program that worked for physicians which was a combination of the e-learning modules and didactic classroom training. 

We let the physicians decide which learning environment they wanted to do, e-learning or didactic training. But in all cases, when it came to the certification process, that was in the classroom. So we let them learn the way they wanted to learn, but we made sure we certified them and there was a standard way to do that. That worked out very well and was very well received because you could do the e-learning modules offsite on the weekends and such.

The other thing that was unique with Fletcher Allen is that this whole project — the PRISM project — reported up through operations, not to IS. The two executive sponsors were the senior vice president for patient care services and the president of faculty practice. As the CIO, I had operational responsibility but not executive responsibility, which showed the organization that this is not a technology project but a process redesign. It was a change to the way that we deliver healthcare. I think that was a good way to go.

I understand you’re on the board of the VITL?

Yes, Vermont Information Technology Leaders. That’s the HIE.

How will you participate in the HIE and what’s going to be your involvement technically as you move forward?

We will actually link up with the exchange based in Vermont. We have an opt-in process, so the consumer — the patient — has to opt in for the records to be shared. By the end of the summer, we should have those links in place.

We’re starting with lab results and orders, but then we’ll move rapidly to bi-directional continuity of care documents with VITL. The power of that is going to be that if we have other hospitals run Epic in our a single database, they’ll be automatically connected to the VITL exchange. That will be very powerful.

Is it tough being an Epic shop in the epicenter of GE-IDX?

Yes. I came from Massachusetts, so I don’t have the Vermont history here, but I do understand it was probably more of a tense situation back in 2003, 2004, and 2005 when the selection process was going on. I got here after that was all complete.

We do still have the revenue cycle for IDX. We also have ImageCast, the radiology system. So, we still have a relationship with GE-IDX. If we had gone with everything Epic and not had any GE here at all, it probably would have been a different issue. 

We meet with them on a regular basis. We’re actually in the process of potentially doing an upgrade of the IDX system as well, so the relationship seems to be good. GE is also the vendor that’s doing the exchange for VITL, so there’s plenty to do for everybody.

I understand Fletcher Allen gave the ACLU an advisory committee seat. Is the way you’re addressing privacy a lot different than where you worked previously?

Yes. If you look it at the HIPAA rules, opt-in is not a federal law. It does not come into any of the HIPAA guidelines. I think Minnesota is the only state that has actual legislation and made opt-in a law. But in my mind, it is the gold standard, and probably with the new ARRA privacy regs will probably be standardized in most places. So we decided at VITL to adopt that ahead of time knowing that it was coming, and then as part of PRISM and PRISM Regional we’re following those guidelines as well. We had a subgroup which I was on that is part of VITL; we did a lot of work in that area, and not only the policies themselves, but the procedures to implement.

What lessons learned can you share with other CIOs about your PRISM project?

I’ve been through a few of these with different vendors. I’ve done MEDITECH and SMS before Siemens. I’ve been doing this for about 30 years now and each one’s a little bit different; I always learned something new on each one. 

For go-live support, we had about 185 people with yellow shirts on, including the vendor, consultants, the IS team, the PRISM team, super users — it was just a sea of yellow out on the units and in ED. It really gave people comfort, even if they didn’t have a question, to look up and see four or five people in yellow shirts on. We had a lot of positive feedback on that, knowing that if they did have a question there was somebody there to answer.

We put in a best practice service center and spent a lot of time doing 24/7 with our service center. We ended up answering 9,000 calls in about an eight-day period. It was only about a four percent abandon rate. We trained those in the service center. We actually put them through the same training that the nurses went through. On the front end they had a lot of knowledge on the Epic system.

Senior leadership visibility. As senior leaders, we all had the yellow shirts on as well. We were here 24/7 doing different shifts, just being visible more as cheerleaders and support. Our management team delivered food. These seem like little things that are huge. When you’ve got a nursing unit in there struggling from the standpoint of learning a new system in patient care and all of a sudden the manager wheels a cart up in there with all kinds of food on it, it just means a whole lot to them that we were all in this together.

So those were the keys, and I think what I mentioned earlier: if you want to drive your CPOE adoption rate up, you really have to focus on that with good physician leadership. Also, potentially changing the bylaws, and the training, and support.

Also, one tip that I’ll give. If you are an academic medical center, if you have access to medical students within an urban area, use them to support the physicians. It worked out great. We paid them a small stipend. Typically they’re broke, they’re happy to get a little bit of money, and they’re young, they’re doing the Twitter stuff already so they just take to this stuff. They were tremendous. I think we ended up with about 20 medical students that supported the physicians. They were a great help as well.

But to me, what I learned on this one was really that the go-live support, the command center, the service center, and the people we had there — to me, that was the key. A lot of organizations may short-change that a little based on cost, but I think it’s key to getting past the go-live hump and then moving into a support model.

Last question: in your opinion, what are the biggest threats and opportunities across healthcare IT today?

The biggest opportunity is with the ARRA money. I think the threat is also with the ARRA money, depending on how meaningful use and certified EHRs develop and are identified. The HHS is leaving some of that open for public comment.

I think the biggest threat is that some of these vendors might not be ready. For the ones that do have the product, the line to get that product could be out the door. So from a timing perspective, it’s going to be difficult.

I think there needs to be some new models that are created for implementation across the country, because if you look at HIMSS’ eight phases of adoption, you’ll see how many are not even near meaningful use. The vendors don’t have the capacity and there are not a lot of educated resources on implementing EHRs. Those individuals that are educated are going to be snapped up by the consulting companies, then, charged back at three hundred bucks an hour.

So I think workforce development and the implementation itself is a threat, based on ARRA. That’s why I’m seeing some of these community hospitals going to their local large-hospital academic medical center and saying, "Can you help us?"

I think the model that we’re creating here with PRISM Regional — I’m starting to see with other Epic sites across the country — Geisinger, Cleveland Clinic – -some of the others where they’re actually looking at putting the system in and helping these community hospitals get to that meaningful use. So that’s where I see the opportunities are, but the threats as well.

An HIT Moment with … Mr. HIStalk

Let the record show that I didn’t want to do this since (a) it looks like a vanity piece even though I resisted and am intensely uncomfortable with the idea of featuring myself; (b) I don’t really have much to say that I don’t say every couple of days; and (c) HIStalk is about news and opinion, not about me. However, Dr. Gregg Alexander was persistent, and since he writes for HIStalk Practice, I felt bad after saying “no” the first handful of times. So, I’m disclaiming all responsibility and turning it over to Gregg. This is my first and last interview.

An HIT Moment with … is usually a quick interview with someone “we” find interesting. Today, I have been granted the unusual and tremendous honor of turning the tables upon Mr. HIStalk, HIS-self. As you know, Mr. H is founder and chief organizer of HIStalk.

You are a humble guy, but even you must admit the breadth of HIT industry folks who read HIStalk on a regular basis is pretty impressive. What’s your take on the not insignificant impact HIStalk continues to have upon this multi-billion dollar industry?

It’s hard for me to say. I just sit alone in an empty room and type onto an empty screen. I’ve never heard anyone at my job mention HIStalk. Nobody there knows I do it. I could count on one hand, probably, the number of people I’ve heard say the word HIStalk to me directly. That’s fine since it’s kind of creepy for me to hear people talking about it. It’s a private activity for me. As you know, I didn’t want to do this interview and tried to ignore your request until you asked a second time. I figured I owed you since you write some fine articles for HIStalk Practice, but otherwise, I probably wouldn’t have done it. I’ve turned down quite a few people before.

I know a fair number of people read HIStalk and I’m really happy about that, but in terms of impact I really don’t know. The only reaction I get is the occasional e-mail. I’m like the guy who throws the morning paper in your driveway. I don’t really know what you do with it, why you read it, or what affect it has had on you. I just keep doing my job and hope you find it useful enough to keep reading. If so, I’m happy to keep right on doing it.

I hope it has been fun for the people who read it. I hope it provides a virtual industry water cooler to chat around since so many of us are far-flung and maybe on the road most of the time. I hope it has educated a few industry newcomers. Most of all, I hope it has provided a dialogue, not just my monologue, on what a cross-section of industry savvy readers think about new developments and concepts that affect healthcare IT and, ultimately, patients.

Just keeping up with all you and Inga write is challenging enough, so how do you manage to work a regular day job, keep current with all the diverse news you gather, find time to write about the news you find of note (and include some insight and humor,) plus still have a family life? (I’ve heard you are actually 5 people; it would make more sense.)

It helps that I work in the industry in a non-profit hospital. Most healthcare IT writers don’t, so they don’t really know what’s important, what’s BS, and how it all fits together. They are good at crafting clever sentences, but they don’t know what they should contain. I’m pretty efficient at bringing all the information I have together and hopefully presenting it in a concise and entertaining way. There’s nothing phony or contrived about the way I write, so it’s just me, no different than what it was six years ago, so I can crank it out pretty fast. Readers help me immensely by e-mailing when they hear something new or have an opinion to share and I value that a lot. I spend hours putting together something that looks like a quick, easy read. The longer I work, the easier it looks.

I’ve gotten pretty organized at how and when I write HIStalk, but it’s still a time crunch sometimes. I’m out at least 10 hours a day at work. When I get home, we eat dinner and I head off to the computer. I’m there every evening for at least three hours, sometimes more than five. It takes a lot of time to read and reply to e-mail, to do the primitive recordkeeping I do for sponsorships and all that, and to do the actual writing. I spend a bigger chunk of time on Saturday and Sunday, sometimes more than eight hours each. Luckily, nothing invigorates me more – even after six years and many millions of words written – than sitting down fresh and starting off on another HIStalk.

Thank goodness I got Inga to help me awhile back with the writing, the research, and working with our sponsors. I was getting pretty frazzled, especially right around HIMSS time when it all comes to a head. She keeps me sane. We worked together for almost a year before we ever met in person, having decided after a five-minute phone call that we were a good match. She made it fun again.

I hope I don’t ignore my family in doing HIStalk. I worry about that. Will I look back someday and wish I’d spent more time doing something more profound? Is it really worthwhile or just a comforting distraction from reality? Or, should I be some kind of astute businessperson and make it bigger or better even though I know next to nothing about starting or running a business and I’m chronically lazy? Until I figure those things out, I’ll just keep doing what I’ve been doing.

Speaking of keeping up, there’s so much HIT hubbub these days with ARRA, HITECH, CCHIT, evidenced-based, meaningful use, etc. As you keep a pretty tight finger on the pulse of the goings on in HIT, I’d be curious to hear what your take is on the overall state of the industry.

The government wanted IT activity in healthcare and it’s getting it, albeit at a high price. Based on recent activity with the banks and auto industry, I think this administration expects to be an active partner in healthcare, not just a quiet financier of IT systems. IT will give it a way to collect information and develop policies around it. Good or bad, Uncle Sam is the biggest customer of many or most hospitals and doctors and he’s not happy about the value received, so opening the healthcare kimono via IT should be interesting.

I would be more excited about using billions of taxpayer dollars if there were at least incentives for vendors to develop new products. It’s mostly the same old systems and same old potential customers, only with federal money forcing their awkward introduction. I hope vendors use some of their new revenue to create new systems based on paradigms and technologies from this millennium instead of just patching up the old ones. I worry that all systems are starting to look and work alike since vendors keep swapping former employees with each other, ensuring cross-pollination instead of innovation. CIOs hate IT risk, though, so maybe everybody will just keep running what they always have except for some of the more exciting niche systems and technology platforms like the iPhone.

When it comes to physician practices, I’m not convinced that most of them will take the bait after comparing the potential rewards with the perceived effort required. The government hasn’t been all that reliable and supportive of a partner when it’s tried doctor programs like that before. Doctors know that everybody gets value from EMRs, but they’re the ones on the hook to actually use them. They have nothing to sell but time, so if EMRs are perceived to take more of it, I don’t think the incentives will be enough – except maybe for the small practices that have to count every penny. I would have preferred a rewards system based on sharing patient data, where you get paid extra for making your lab results, prescriptions, and notes available electronically to other providers. Then, let the providers choose whatever tools they want to support that. The final definition of "meaningful use" will most likely include that, so it will probably be fine.

All the rewards require a very short time frame for implementation and productive use, which I worry is more than either vendors or providers are ready to tackle. Resources may be an issue. We’re dealing with patient systems, so let’s hope we don’t see unintended consequences from quick and dirty implementations.

Some vendors, especially those with marketing machines that can capture the attention of prospects in the small window in which they’ll be buying products, will do very well. Those not so fortunate will have a tough time since HITECH will front-load a lot of sales that would have taken years, so those that don’t succeed in that small time window will find the pickings slim for years afterward. I think a lot of second- and third-tier vendors will scale back, close down, or sell out as a result. There’s a big wave coming, but the trough right behind it could be ugly.

We’ll get our critical mass of EMRs, at least assuming everyone gets implemented. The real job is to do something useful with them. That requires focus and change management capabilities, qualities that are hard to come by in many organizations. Without quality reporting, data interchange, and some element of practice standardization, we won’t have gained much by planting all those EMRs. They don’t provide enough efficiency benefit for that alone to be the driver. That could create a new demand for analytics, add-on tools, and formally trained informatics people who can do more than just flip the go-live switch. EMRs might eventually become a commodity as CCHIT, or whatever certifying body is named, expands their functionality checklists to become what could be a full set of specs for an EMR. Maybe you don’t need dozens or hundreds of vendors if they all meet the same basic requirements.

Overall then, I would say everybody’s going to be busy for the next five years at least. We’ll probably see mini-Gartner Hype Cycles as new customers buy systems, find them disappointing for one reason or another, but eventually gain benefits they wouldn’t have expected. Way down the road, the power will be in the connection, not the tool used to connect, so EMRs may be as unexciting as buying a PC today — just a generic tool you need do real work by connecting with everybody else on the Internet.

Your newest “offspring,” HIStalkPractice…what prompted your address of the physician practice world?

Inga came from the physician practice side of the industry, but I was a hospital guy. I knew we weren’t covering everything in HIStalk, but I wasn’t sure that audience was really interested in what was happening with practice management systems, EHRs, CCHIT, and all that kind of detailed discussion. I also knew there were a lot of potentially influential voices that weren’t being heard, such as yours, and I wanted to see if we could cultivate an audience interested in the usual HIStalk style news recap and opinion for that somewhat different market, along with more interviews and guest articles. It has been slow going, but nothing like the years it took to get a few readers of HIStalk.

Inga does pretty much all the writing for it other than what our guest authors put together, now that I’ve convinced her she has the knowledge and the ability without me looking over her shoulder. I do nitpick about how she punctuates and structures her sentences sometimes and I know she’s just neurotic enough to let that bother her, so I try to leave her alone.

On the “About HIStalk” page, you give a fairly complete background on why you started HIStalk and of your general operating standards. Pretty straightforward about your approach and principles. However, you have a sardonic wit and are often quite blunt about your opinions. Both of these traits make for a great read, but from what you do post from readers, you are often also slammed for your perspective. Do you receive more pointed or insultatory jabs for your writing that don’t make it onto the printed screen?

I run most of the e-mails I get on HIStalk if they would interest readers. I do get the occasional viciously nasty and insulting comments, usually for something silly, like years ago when I mentioned some notoriously phony schools where healthcare people were sporting MBAs and PhDs from. I got some threats over that more than once. Those were the only truly angry comments. Sometimes someone complains that I’ve been unfair to a company, have sold out to sponsors, or think I know it all. I do a little self-analysis to see if they have a point that I can learn from, then move on one way or another.

I really do try to be fair. I encourage comments that disagree with my opinions. If I rip a company one day, I try to remember to say something nice about them another day. I see my job as being a moderator who introduces a topic, maybe throws out some controversial statements to get the discussions going, and then makes sure everyone plays nice together as they debate. I like it when people get along, but I understand that some of the most valuable stuff comes from heated discussion.

I’ve heard a buzz that you and the lovely Inga might be unmasked at the HIStalk reception during HIMSS in Atlanta next year. Just wishful rumor mongering or is there any such possibility?

You never know. Inga is a lot more of a schmoozer than me. Sometimes I think she’s about to burst trying to keep the secret that she’s Inga. Unlike me, I think she would probably bask in whatever limelight there is and readers would like her even more than they do now. So, maybe we will arrange her coming out in some fashion at HIMSS. She’s probably already shopping for new shoes.

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.

HIStalk Interviews Ferdinand Velasco MD, Chief Medical Information Officer, Texas Health Resources

What are the most important projects you are working on at Texas Health Resources?

The project is our EHR deployment. We’re an Epic customer. We’re in the middle of deploying the EHR. We’re live now with probably close to three-quarters of our beds. We’re a 14-hospital health system.

We’re very busy with the implementation, but we’ve been live at our earliest hospitals for some time. The focus there is more on optimization, really leveraging the EHR for things like patient safety, quality, and core measures reporting.

With some of our newer sites and sites where we’ve yet to go live, it’s still obviously very much in the early implementation focus — getting physicians on board, that kind of stuff. We’ve had the whole spectrum of the maturity of the implementation even within our health system.

You’ve done a lot of work with first-generation systems. Do you find it easier to work with something like Epic or are the challenges similar?

There are similar challenges. Certainly when I worked at New York Presbyterian we were rolling out Eclipsys. Back then, it was definitely very first generation. The systems have matured, so we don’t run into the same kinds of technical obstacles than we did with those first-generation systems.

Largely, what we run into now is more of the cultural adoption issues, overcoming physician skepticism with respect to health information technology and the workflow issues. I think now what’s different compared to the 90s is that there’s a higher expectation for what these things can do. It’s not enough to just be able to deploy systems and get the physicians on board using it. There are expectations for medication reconciliation and core measures that really didn’t exist in the early days of EHR systems. The bar has been raised higher.

As you know from the meaningful use discussion, the bar will continue to be raised, so there are expectations for barcode medication verification and the whole closed loop process and real-time clinical surveillance. Those are the kinds of things we’re keeping an eye on because we don’t have that yet, but we are certainly gearing up to have those things implemented in time for the expectation for meaningful use.

What are the endpoints needed to be to justify the expense and the effort?

They are always moving. [laughs]. Initially, just getting it installed and getting the docs to use it, but now there’s the expectation that it has to meet the Joint Commission requirements and help us with pay-for-performance. The endpoint now is satisfying meaningful use. The bar keeps going up. We’re just trying to stay ahead and chug away. It’s all of those things.

Where we are today is still implementing the system safely and not killing patients, but we want to go beyond that and realize benefits in terms of reduction of ADEs and improvement in operational efficiency. Our challenge is managing the expectation because that doesn’t happen Day 1. It takes time, there’s a learning curve.

Part of our problem is our own success. The more successful we are, the higher the expectation. That’s a bit of a challenge.

You mentioned the tentative definition of meaningful use. What are your thoughts on what HHS has put together?

From our perspective as an organization that has been on this journey for some time, what I like about the meaningful use is that it gives us a framework. It helps us prioritize those things that we may not have yet planned for or that we don’t have in our timeline. Things like automated surveillance, closed loop medication management including the barcode piece, and medical device integration. That helps us argue for funding those initiatives and putting the plans into place so we can get that implemented on top of our existing implementation. That’s helpful.

It’s helpful for us to use that as a yet another lever with our physicians who are not yet live with the system so that we can say, “Here’s yet another message that this is a mandate and we need to be compliant with this stuff.”

On the ambulatory side, the THR, like many health systems, is providing and making available ambulatory EHR solutions, the Epic solution, as a subsidized offering. Many of our physician practices are too small to be able to buy Epic, so we are providing Epic as a sort of ASP model. This is another sell, if you will, for that offering, this moving meaningful use intended and ultimately the stick that’s the penalty for not having an EHR system by after 2015. That’s how we’re looking at it.

Are they helping you justify what you wanted to do anyway or are they taking you in direction you didn’t want to go?

I think there’s a lot of alignment there. We were very fortunate to get on board with investing in HIT early on and defining what our vision should be. There’s a lot of alignment with what came out in that initial draft and the matrix. We’re pretty pleased — I am, anyway — with that initial draft.

Obviously it’s very aggressive and ambitious so all the organizations have come out cautioning about being so aggressive. It will be interesting to see how that shakes out over the course of the next couple of weeks before the next meeting of the HIT Policy Committee. We’re keeping an eye on that, but from our perspective, because we didn’t wait until something like this came out of the Fed, we feel pretty well positioned and, if anything, it helps clarify our future direction.

You’ve worked a lot with CPOE. AMDIS is saying it’s too much to bite off early on in the meaningful use criteria. Where do you think CPOE fits in the overall strategy?

I think it has an important role. A lot of the important benefits of deploying HIT and, more specifically, EHR is dependent on physician participation. A lot of that is based on clinical decision support. The earlier people tackle CPOE, the better positioned they’ll be to realize those benefits.

I can understand AMDIS and others pushing for it to be not quite 2011. Their point of view is that health systems that haven’t yet selected a system, haven’t yet budgeted for it — there’s no way they’re going to be able to be ready for CPOE in 2011. I think that’s where they’re coming from. I think it sends the wrong message to interpret that to mean that you can delay CPOE.

We’re in a market area where our major competitor is deploying an EHR system but not pushing CPOE. They’re deploying basically all the functionality of Eclipsys and then they’re going to go back and do CPOE, which was what David [Muntz] was going to do if he’d stayed here. That was basically the philosophy that we had here, so we had a change in leadership. I think there’s some benefit to that. You can work on the physicians and soften them up while you’re deploying the nursing components and the pharmacy and all that, but you’re not really going to get a lot of bang if you hold off on the physician engagement piece.

Ultimately you’re going to have to do it anyway. That’s how they’re approaching it at Baylor, that’s how we opted not to do it, and if CPOE stays in 2011, they’re going to have to rethink their strategy.

Just before our implementation, I asked our docs how long they thought it would take before we got to universal CPOE, The results fell into a similar distribution as from the recent CHIME survey, with about two-thirds predicting it would take three or more years. The reality is that at our first two hospitals, it took one year, At our third and fourth, 6-9 months. And at the last three, we are achieving universal CPOE within one week of our big bang implementations.

Folks are being paralyzed by a handful of failed implementations when there are scores of successful implementations at community hospitals throughout the country. Healthcare needs to get beyond this fear factor and move forward with meaningful use. Yes, this is challenging, but we can’t afford to sit still.

What are the secrets of implementing CPOE?

Physician leadership. Getting some really influential thought leaders behind the initiative, buying into it, participating in the design process, being early adopters. These are the things we did and I think we’ve been very successful.

All seven of our hospitals that are live have essentially universally adoption of CPOE, including our most recent three hospitals, which basically went mandatory CPOE on their own accord. We didn’t as an IT department or hospital administration really push it. It was the physicians themselves saying dual workflow isn’t going to work, it’s unsafe, let’s get on board early. We basically had that Day 1 with these go-lives.

I couldn’t be more pleased. I’m really quite excited about where we are with getting the physicians on board. Obviously you have to have a good system and a good build, but if you don’t have the physician leadership, all of that is really secondary.

You’ve worked with a lot of technologies such as Microsoft Surface. What of those technologies have the most promise to improve patient outcomes?

The iPhone certainly seems to be the most promising in terms of the handheld platform. It seems to be the best form factor. I’ve done some work with the tablet PC and it’s got some promise, but I really think the iPhone may be the next killer technology for healthcare.

Are you seeing pressure to have applications reconfigured to be optimally used with the iPhone?

Yes. We’re applying that pressure. We’re putting pressure on Epic to do that. Meditech has a nice iPhone client. A few others may have some as well or in development. A lot of physicians have iPhones. There are a number of medical apps for the iPhone. It’s a compelling device for use at the bedside or at the point of care. It’s a ubiquitous kind of thing — you can use it anywhere. I’m very excited about it.

Are you building anything for the iPhone or looking at other applications that physicians want for it?

We have a physician portal that’s Web-based. It’s the access point for Epic and other clinical applications and other hospital-based resources. We definitely are planning to build an iPhone-compatible portal.

We have a couple of applications that we have deployed that are iPhone-based. For instance, our fetal monitoring system. We have several physicians using the iPhone client that allows you to see that wherever you are. We obviously have Epocrates and an assortment of electronic resource that are available through the iPhone.

We have an internal development shop and we’ve done some add-on work on top of Epic, some calculators and other value-add applications that are launched from within the Hyperspace platform. We’re looking to see if we can port some of those applications to the handheld for the iPhone. That’s all future stuff. It’s not live yet.

Let’s say a well-funded startup came to you and said, “We’ve got money, backers, and technology. We’re ready to build applications that the healthcare market needs. What should we build?” What would you tell them?

Since it’s very top of line for me and we’re struggling with it, core measures and the submission of quality data. That’s the 2013 criteria right now for meaningful use. That would probably be something that would be an attractive offering. More generally, just BI tools, analytical tools, something to enhance the value of EHR systems.

Unfortunately, most of the EHR vendors fall short in terms of being able to provide BI tools. On the other end of the spectrum, you’ve got the Oracles and IBMs. There’s a little bit of a gap between the analytical capability of the software vendors on the one end and the ability of the traditional BI technology vendors that could be filled with a niche player or the EHR and BI vendors coming together in the middle.

So you don’t think Amalga is that product?

I don’t known enough about Amalga. Although we’re a strategic partner with Microsoft, we haven’t had conversations with them about Amalga. I’m somewhat familiar with them because I came from New York Presby, but they are really eclectic as far as all the different systems they have in place. They’ve got the Presby hospital, the old New York Hospital, they’ve got faculty practice plans at each of the medical colleges, so definitely you need an Amalga just to put all that together.

We’re moving more toward the integrated approach, so I don’t know that we really need Amalga. That would almost duplicate what we already have with our data warehouse. But it may be that Amalga has some front-end tools that can help us. To be honest, I haven’t evaluated it enough to be knowledgeable, but from what I’ve heard from our experts on the subject, they would say that Amalga is more hype than reality.

I assume you’re doing a lot with how to manage and use all that data you are now collecting by having physicians directly involved.

That’s a supply-demand kind of thing right now. We have a lot of physicians live with the system and using it. Their appetite and thirst for the data is growing. Our ability to keep up with that is going to be a challenge, particularly since we’re still in implementation mode.

The challenge for us now is prioritization — what do we focus on and where do we place our efforts in delivering this kind of analytical capability. It’s on the core measures and those quality measures that the organization has selected as our key initiatives, things like blood management, glycemic management, VTE prevention, and pressure ulcer prevention.

Our challenge is to keep focused on those things and not get too distracted by people that want information just because they’re curious or they have a localized initiative. We want to focus on those things that have broad value across the entire enterprise.

Now that the federal government is driving much of the IT agenda in healthcare, are physicians and patients in the field being asked for enough input?

I would like to think so. Dr. Blumenthal is a practicing physician. Several physicians on the two steering committees, the advisory committees, are physicians. Certainly there is an openness and transparency to the process so far. It has given physicians an opportunity to participate and comment on the process. I feel pretty comfortable about it.

I come from the perspective of a health organization that is very much in the midst of this. I think there may be challenges with physician practices that haven’t invested in IT and are pretty far behind. They might question whether their voice is being heard. I don’t know that answer to that question, but those physicians in our market area are interested in what we can offer to help them. We’re available to help.

Anything else?

No, we’ve covered quite a bit. I appreciate the opportunity to chat with you about what we’re doing and how we’re working to make the most out of health IT. It’s a very exciting time to be in it. Thank you for your Web site, your blog. It’s been a great resource for all of us. Thanks for the opportunity to contribute.

An HIT Moment with … Bill O’Toole

An HIT Moment with ... is a quick interview with someone we find interesting. William O’Toole is the founder of O’Toole Law Group of Duxbury, MA.

The following are my top three suggestions for negotiating HIT software licenses.

Say what you mean and mean what you say

Determine up front what is truly important to your organization. Establish your contract priority list prior to negotiations. Include as much input as possible from the CIO, CFO, CEO, consultant, and legal counsel. The more complete your list is up front, the better the vendor can establish what it must deal with to land this new customer.

Don’t label something a deal breaker if it is not. Many times I gained the upper hand after responding negatively to a supposed deal breaker issue, only to have the prospect roll on it. Do identify your priority list up front. It does not have to be detailed or extensive. Get the message across early and put it on the table for all to see. Refer to it as revisions are turned. If the vendor does not address an item, raise it immediately.

Identify who is driving the bus

On the customer side, it is usually the CIO or CFO. Establish early and keep this person informed and involved. Others may handle conference calls and meetings during negotiations, but having the person in authority identified helps immensely. Have the vendor identify the individual in charge of negotiations, even if that person is not involved in each conference call or meeting. If things get rough on a specific issue, it may be helpful to have the two “drivers” talk directly after being brought up to speed by their respective sides in order to cut out all the dancing and grandstanding and get right to the issue. Marching orders can then be given back to the negotiating teams.

Do not dictate the terms by which you expect the vendor to license you their software

Setting the stage in this manner only creates an adversarial process, which is not what you want. It sets you up to become just another sale where only the money counts. Approach it as a relationship in the making. Know what you want (see above) and present a priority list, but do not dictate terms or you will get far less cooperation and poor results and ultimately be left unhappy with the deal.

Vendors always talk about being partners with their customers. If you were representing the customer in crafting such an agreement, what terms would you consider essential to truly aligning the vendor’s interest with theirs?

This is a really good question. The term “partner” is way, way overused. Unfortunately that really dilutes its importance. The ultimate indicator of partnership is sharing, whether it be capital investment, development effort, or risk. HIT vendors all thank their customers for choosing them as their HIT partner. But are they really partners? If a vendor truly wants you as a partner and not just its next customer, then you should realize real benefit in at least four major areas.

Payment for performance

If establishing a true partnership, then there should be a willingness to include terms reflective of such a position. Progress payments should be tied to measurable or identifiable events. Further, there should be a willingness to delay or forego (in some specific amount) payments if the events are not met.

Exposure

Government regulations, public entity constraints, and potential liability are prime examples of areas in which a partnership can be created as opposed to a strict customer/vendor transaction relationship. How much is the vendor willing to do or risk for its customer? The more the vendor risks, the more of a partner your organization becomes.

Near term and long term costs

Nail down the cost of acquisition and implementation. The customer partner should have absolute comfort in the cost outlay for the project. Not to the dollar, obviously, but certainly a solid figure assuming no significant deviation in the project. Long term costs should be predictable and you should never pay twice for the same product.

Development

The vendor may find your business of such importance that they are willing to offer you the opportunity to be a beta site or to provide input on development of a key area of software functionality. These opportunities can have both good and “not so good” ramifications. Weigh the pros and cons carefully. While this is a very strong indicia of partnership, it can be a tremendous amount of work for the customer.

Some people think putting performance penalties in contracts starts off the vendor relationship on rocky footing, while others say the only way to get a vendor’s attention when problems arise is to hit them in the checkbook. Should software contracts include penalty terms?

With regard to the initial implementation process, there should be no need for penalties if payments are based on attaining measurable milestones during the implementation (see above). This puts a positive spin on the issue. Pay the vendor for work done as planned. You arrive at the same result, but in my scenario, money is due when work is done, rather than the negative approach where money is not due because work was not done. With regard to ongoing support, it gets a little tricky. If you applied my implementation scenario, full payment would be due only if there were no issues in the service period, not a realistic scenario for any vendor.

So it could be argued that penalties make sense in the ongoing support situation. That said, it only adds another layer of work for the customer and the vendor, which is not something a CIO wants. Ultimately the CIO and CFO will withhold payment if things go really bad, so work with that concept. Negotiate the ability to withhold (delay) support payments in good faith if good support is not provided. Put the work on the vendor. If the vendor’s accounts receivable personnel are looking for payment and the customer reports payments are being held due to support issues in accordance with the contract, then those receivables folks will go to the vendor’s support personnel, which will escalate issues on the vendor’s side with little input from the customer.

In short, I believe that with regard to ongoing support payments, the time spent on identifying penalty situations and associated dollar amounts to be credited is better invested in personnel involved in resolving the underlying problems or issues.

Porter Hospital is involved in lawsuits involving the transfer of software rights to an acquiring organization. How often do disputes over legal ownership and transfer rights occur in healthcare and how do vendors look for noncompliance?

Fortunately I did not experience many disputes in this area during the past two decades. I use the word “fortunately” because these situations are fairly straightforward and end up costing the hospital(s) money.

That said, my experiences all demonstrate that the licensees did not do their homework. Transfer restrictions are not complicated and all vendor agreements have some language clearly stating what is permitted and what is not. Most often these matters involved spinning off a single hospital from a multi-facility license, or the acquisition of a hospital operation from a bankruptcy proceeding. I do not want to come across as preaching from on high, but in any divestiture situation it is incumbent on the parties to do a thorough job researching the items to be transferred, and I did intend to use the term “parties”. If I were on the acquiring side, I would absolutely review all the pertinent documents to make sure everything was in order. Time spent up front is far cheaper an investment than time spent in resolving a later conflict.

As for how vendors look for non-compliance, in the case of my former employer, we found that these matters usually have a way of popping up without extensive watchdog action. For site licenses, it is fairly obvious when the customer calls for assistance setting up a new facility or troubleshooting software tied to a formerly unrecognized facility. In situations involving machine licenses, the trigger is often the request for technical support for unauthorized hardware or for an upgrade or addition of hardware. User licenses may be the ones that go unnoticed unless the vendor routinely performs audits.

In my opinion, the licensees in these situations are not (in nearly all cases) maliciously trying to beat the vendor out of a fee, rather they just are not familiar with the restrictions on their systems. Once again, I suggest that being vigilant up front is less costly for the customer.

What’s it like leaving a corporation to set out on your own?

Daunting, yet comfortable. During the past 20 years negotiating HIT agreements as MEDITECH’s Corporate Counsel, I interacted with thousands of healthcare executives, attorneys, and consultants and experienced an amazing array of perspectives from healthcare entities, ministries, and governmental agencies throughout the United States, Canada, and beyond.

As I considered the next 20 years of my life and career, I realized that there are very few individuals with more experience than me in this practice area. Coupling the confidence MEDITECH management had in my work and the authority they gave me with the compliments I received from healthcare executives at the conclusion of countless deals, I realized that the prospect of establishing my own law firm demanded strong consideration.

Although it was difficult to leave MEDITECH after so many years, I decided that I would be successful and would do well for myself and my family by offering my services to the healthcare industry. It was very telling for me that just prior to my departure from MEDITECH (once the word got out that I was leaving) I had several contacts from entities seeking to retain me once I established my practice. So although no reasonable person would be without some concern in my situation, I am carefully confident that I will succeed.

An HIT Moment with … Dave Dyell

An HIT Moment with ... is a quick interview with someone we find interesting. David Dyell is founder and CEO of iSirona of Panama City, FL.

Everybody’s talking about EMRs. Should they be talking more about integrating device data with them?

In a lot of ways the conversation should be one and the same. When you consider the HIMSS EMR Adoption Model, it shows that any Stage 3 hospital or above has implemented electronic nursing documentation. What it doesn’t show is that much of the data, including device data, is still written on paper to be transcribed into that electronic chart later. Meaning that a physician could be looking at physiological data that is 3-4 hours old by the time it is available in the EMR. I believe the latest data shows over 70% of the market has reached Stage 3, yet most facilities we speak with are still writing vitals on paper and transcribing them later.

We believe that part of the EMR adoption model should be to automate as much of the point of care workflow as possible and thereby truly create a paperless EMR. Its also important to note that device integration is not exclusive to the EMR. Many departmental systems have nursing documentation modules and integrating devices to those can provide a similar value proposition to integrating to the EMR. Examples are ED, Critical Care, OR, Anesthesia, OB, etc.

You’ve worked with integration engines for many years. Those tools opened up entirely new product possibilities for hospitals without requiring major internal or external IT resources. How is that like and unlike tools like iSirona’s that integrate devices?

While there is an aspect of what we do that provides interface engine-like functionality, device integration is really about automating the workflow at the point of care. The bits and bytes of managing data from the device and translating to a format needed by the EMR is engine-like, but interface engines never really touched the workflow directly. They were and still are for the most part a back-end, lights-out kind of tool that only interacts with other IT systems.

In order for a device integration solution to truly impact the workflow it must provide integration points to the end user, the clinician. Whether that be positive patient ID functionality to tie the patient to the devices being integrated or an authentication system that allows the caregiver to review all the collected data prior to delivery to the EMR, it must integrate to the workflow.

Let’s say a hospital’s chief medical officer wants 2-3 examples of real-life major care improvements made possible by your products. What examples would you cite?

A great example is the ability to help reduce in-house codes. More accurate and timely information clearly enables the physician to make on-the-spot decisions and better identify those patients trending towards a code. The average length of stay in the ICU to recover from a code is 14 days and the daily cost per patient is over $5,000.

Another example would be supporting fall prevention protocols. By integrating smart beds to nurse call systems, caregivers can be made aware when a patient that should be stationary is attempting to exit the bed. Along the same lines, the bed can tell us when a ventilated patient’s bed has been lowered below the recommend 30-45 degrees, thereby alerting a caregiver to help prevent ventilator-associated pneumonia.

Considering that these types of incidents are being considered for inclusion in the CMS “never-event” list and thereby would not be eligible for reimbursement, this can have a definite impact financially on the organization.

How fast growing is the volume of electronic data sent by medical devices, how can it be used, and what changes should clinical systems vendors be considering to use that information effectively?

Traditionally the amount of data captured by clinicians related to what the devices can actually output was very small. Some of the data is not necessarily clinically relevant, but the larger issue is there is just not enough time for a single person to collect all of the data potentially available from the devices. A single medical device may be capable of generating 300+ pieces of discreet data, while a given EMR flowsheet may only require 8-10 of those to be typed in.

When you remove the manual data entry task, which is so time consuming, you can then expand that data set to something that is much richer and can have a very positive impact on patient care. As the acuity of our patient population has grown, so has the use of medical devices and the sheer amount of data our caregivers are required to capture. A recent study showed nurses having spend an average of 147 minutes per nurse per shift on documentation, much of that from devices.

Many of the EMR and CIS vendors have decision support algorithms that analyze this data to help provide guidance to caregivers. Having that data set automated ensures the accuracy and timeliness of the data and gives the algorithm a richer set of data to work from. Using solutions like ours that provide positive patient ID ensures the data is charted to the correct patient, giving the caregiver comfort that the guidance being provided is for the correct patient. Clinical staff are then better able to predict and prevent adverse outcomes such as in-house codes, sepsis, and ventilator-associated pneumonia. We have multiple clients and other industry experts that tell us repeatedly that one of the problems with failure to rescue or recognize deterioration of patient conditions is poor quality of data.

Over my years of working with interfaces, we watched the laboratory industry push CIS and EMR vendors to the point now that we can see lab results even from outside reference labs back into our systems within seconds of the analysis on the specimen being completed. That gives our physicians great access to the chemistry of their patients. As we have discussed today, much of the physiology is still written down and typed in later, meaning that a physician logging into CPOE is faced with current chemistry, but potentially 3-4 hour old physiology. This forces a call to the floor to request current vitals, etc. and thereby devalues the CPOE experience to the physician. It is important that IS and EMR vendors recognize the workflow around device data capture and ensure their systems support the automation of this important part of the care process.

iSirona is a small company with at least one well-known competitor. How will you differentiate your offerings and compete with an established player?

I am glad you finally asked a sales question. Product, product, product. We built our product with the help of clinicians to ensure that we solved their needs. Just automating a clinical step was only going to bring marginal value to our customers. Automation alone saves time and allows for greater accuracy, but that has to be countered by associating the device to the correct patient to insure data is documented to the correct patient. Also, iSirona was built with a patient’s mobility in mind. iSirona’s system architecture ensures continuous data capture across multiple care environments and even through ‘cold spots’ in the hospital’s wireless network.

Additionally, we want the caregivers, regardless of EMR, to have the ability to view, select, and comment on the data they are charting. Our clients have the choice between using iSirona or the core clinical system for data authentication and charting additional required documentation. For clients choosing to use the core clinical system, iSirona provides and embedded solution for minimal impact to clinical workflow.

Our goal is to assist our clients in simplifying patient data collection while improving the quality of care and patient safely. We will continue to listen to our customers and prospects and ensure that we remain the visionary in this space.