One-on-One With Texas Health CIO Ed Marx and CMIO Ferdinand Velasco, M.D., Part II

MARX: We have two in our market. One is on the Fort Worth side, it’s about 1,000 physicians and they have a sub-entity where they try and do a lot of the information exchange. We are probably their primary health system, and they share a significant amount of information with us today. So that’s a relationship that has been around and alive for a couple of years.

On the Dallas side, there’s another organization, another IPA. It’s about 1,500 docs and their desire is emulating that same strategies. Today, we don’t formally exchange information, but we are in discussions with them, just as they are with many other health system, I’m sure, about exchanging information.

We all desire to exchange information primarily for the clinical benefit of the people in the community that we serve. Certainly, everyone wants to have good relationships with IPAs for business reasons as well. Those are the drivers.

GUERRA: Any advice on how IPAs want to be engaged?

MARX: I think one way is to build a bridge across the organization’s business and clinical leadership, and talk about your vision of the relationship, particularly regarding the exchange of information. That way, everyone understands from the beginning where you’re trying to go. So begin with the end in mind. It’s basic business 101, but it’s funny how often basic business 101 is overlooked, and then you’re playing catch up and doing damage control, those sort of things.

There are three things that you can do. (#1) Include business and clinical operations. This is not an IT thing. (#2), once you bring all the key stakeholders together, talk about what you’re trying to accomplish; and then (#3) would be to have routine meetings with those same individuals, the same leadership on the business and clinical side.

GUERRA: Let’s talk about your CPOE success. You’ve got about 80 percent CPOE now. So my first question is, not to diminish the 80 percent by any means, but what about that last 20 percent? What are the challenges in getting that last 20 percent done?

VELASCO: First of all, it’s actually 85. Actually, the reality is that it’s actually 100 percent.

GUERRA: We just went from 80 percent, to 85 percent, to 100 percent (laughing).

VELASCO: My explanation for that is there are some artifacts in the process that prevent us from getting to 100 percent as a practical number. We essentially have universal adoption of CPOE. What prevents us from having a perfect score, if you will, is that there are situations where a physician needs to admit a patient, or write admission orders for a patient, who is not yet in the system. In that context, we certainly allow the physician to go ahead and write those admission orders, and by the time that patient arrives at the hospital, they are in the system. So those orders are transcribed into the system.

Another artifact, if you will, that accounts for 15 percent is there are times when the pharmacist needs to adjust a physician’s order. The physician electronically enters a medication order, perhaps it’s a non-formulary med and some adjustment needs to be made by the pharmacist. The reentry of that medication order counts against our CPOE numerator because it is a pharmacist-entered order.

So, in essence, we actually are now at a point where we have universal adoption of CPOE wherever it’s available. There are always going to be verbal orders and that sort of thing, but it’s not a case where we still have some stragglers, if you will, that are sneaking around the system and writing things down.

GUERRA: Talk to me about standardized order sets, and the overall importance of order sets. We’ve heard how important it is to work on those before you roll out CPOE, to make sure you’ve got them right. You made the point that 50 percent of your CPOE orders are standardized order sets. So that means 50 percent are not. What is the difference between the standardized order and the non-standardized order, and why is it important to get people towards these standardized orders?

VELASCO: Order sets are critical to CPOE’s success, and that’s why I think we are achieving the adoption we have. You just cannot pull this off without order sets. Prior to coming over to THR to become the CMIO here, we actually implemented a very early version of Eclipsys at New York Presbyterian, and I know you’ve had interactions with Aurelia. We didn’t have order sets back then. I can’t imagine trying to do CPOE without order sets. They’re so essential; they make CPOE acceptable.

Now, beyond just that aspect of it, they obviously are a vehicle for facilitating adherence to evidence-based practice, and we are very conscious about incorporating that into this design, into the content of order sets.

Prior to the implementation of Epic and CPOE at THR, we collected all the preprinted order forms that existed in the system and analyzed them. First of all, there were no system‑wide order sets or preprinted order forms before the advent of Epic. So each hospital had its own pneumonia admission order set, its own heart failure admission order set, etc., and within each hospital, there was great variation in terms of accommodation and individual physician-specific orders for postop knee, pacemaker insertion, you name it.