SMALL HOSPITAL SPOTLIGHT: One-on-One With Northern Inyo Hospital IT Manager Adam Taylor & HIS Manager Linda Goodwin

GUERRA: What’s your budget for a new system?

GOODWIN: We don’t have one yet. Our CEO just got back two weeks ago, and he’s been really against us getting something until the building was completed, which is going to be in two or three years. But once he came back, he said we need to start actively looking. So I don’t think we’ve come to a dollar amount yet.

GUERRA: Without HITECH, you would probably still have this on the backburner because of the construction project.

GOODWIN: Yes, exactly.

TAYLOR: I’d agree with that.

GUERRA: You mentioned the doctors – have you involved them yet, do you plan on involving any of the physicians that refer patients to your facility in the HIS selection process?

TAYLOR: Our goal is to start off with a doctor who we know is open-minded about tech stuff. We have an aging physician population here who tend to be a little bit averse to change. So our goal is to involve Dr. Brown who is the head of the Rural Health Clinic. He, of course, is too busy to be involved in all the day-to-day meetings, but we intend to involve him at the high-level meetings, get his buy in and, hopefully, use that as the kernel of acceptance that will spread out. If we’ve got a doctor talking up our new system, I think that will help. I think they have to be involved or else it will just be a failure.

GUERRA: Are you optimistic you will be able to get the independent physicians to embrace this?

GOODWIN: I think nurses will embrace it. I think we have a few younger physicians that will embrace it. I think that we’re going to do okay. Initially, it’s going to be painful for the older ones, but we’re going to get buy-in from the younger ones. I have no doubt about that.

GUERRA: Do you think a hospital of your size has specific challenges that you’d want the people involved in fine tuning the legislation to know about? There’s a concern that the small hospitals could be overwhelmed by what they’re being asked to do.

TAYLOR: I don’t feel that – the dynamic here is good at our hospital, so it’s tough for me to speak for other hospitals. We have a CEO/CFO who is very receptive and understanding about technology; who does not give us too many budgetary restrictions.

My concern with the legislation is that, in reality, rural hospitals are really at the beck-and-call of physicians. We cannot dictate things to them. It’s just not possible. We spend all of our time and all of our effort in recruiting doctors to come here and so it’s really tough to say, “Yes, come here and we’re going to make you work this way.” So we have to spend a lot of our efforts convincing them to use it. Larger hospitals may have a little bit more sway over their physicians in forcing their hands, but we don’t. So requiring a high percentage of CPOE is going to hurt small hospitals who really have no bargaining power with their physicians at all.

GUERRA: IT is certainly not the biggest challenge in this project.

TAYLOR: I think the biggest challenge is changing culture and cultural issues within the workplace. In the end, installing software is really easy. Changing culture is tough to measure. It’s tough to force people to change their ways.

GUERRA: Not to mention that physicians are extremely independent in nature.

ADAM/GOODWIN: I agree.

GUERRA: You mentioned that you’re employing a super-user strategy, where you get a physician champion who then influences his or her colleagues?

TAYLOR: I would agree with that. I don’t think we’ve got any way to incentivize this for them. We cannot do any type of a punishment system; it pretty much has to be, “Here are all the benefits for you; here are the benefits for your patients.” We’re not going to be doing anything like taking away privileges. I can’t imagine that would happen if they don’t use CPOE.

GUERRA: I would imagine many physicians will just tell the nurses to put the orders into the system for them.

GOODWIN: That’s exactly what will happen.

GUERRA: So what do you do to support your nurses and give them the confidence to say, “No, I can’t do that”?

TAYLOR: Well, we need to do this in such a way that it will be tough for a physician to argue that it’s easier just to tell a nurse to put in the order. We want to make it so simple for them to do that it would be ridiculous for them to scribble a note or tell someone else to do it. So we’re going to support our nurses by really making it easy for the physicians to use.

GUERRA: And I suppose you’ll want to make it clear that if they tell someone else to put in the order, they’re adding an extra step where a medication error can happen.

TAYLOR: I agree with that. I imagine that part of demonstrating meaningful use will be to prove that your physicians are actually using the system and not ordering a nurse to do so.

GUERRA: Are you going to target the physicians one at a time? Would that be the best approach when you’ve only got 25 to deal with?