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"Whom Doth the Grail Serve"

September 8, 2009
by Pam Arlotto
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For years, hospitals have focused on CPOE as the Holy Grail of HIT. In recent days, articles and blog posts abound about the new Holy Grail “meaningful use” (MU). Many legends exist about the Holy Grail – from the middle ages to recent adaptations by Monty Python and Dan Brown. Regardless of the time in history, the message is clear – the Holy Grail is the ultimate goal, elusive, requiring a quest. On their quest to find the Holy Grail, the Knights of the Round Table would only achieve enlightenment if they asked the right question of the chalice: "Whom doth the Grail Serve?"

With CPOE, many quests have failed because this simple question has not been asked.

§ Hospital IT Departments have implemented CPOE without the proper due diligence of understanding the impact to patients, physicians and staff

§ Vendors have provide modular applications rather than clinical information systems that drive integrated workflow

§ Physicians have focused on the time inefficiency of CPOE and have often delegated its use, separating themselves from the ordering process

§ Hospital Boards and C-Suites have deemed CPOE an IT initiative, rather than a physician alignment strategy

As consultants we have been asked in recent months to evaluate health system readiness for ARRA and HITECH stimulus funding. Remarkably, we find most hospital CEOs unaware of the vastness of the MU quest ahead of them and many CIOs still focused on implementing CPOE. If the new Holy grail is MU (ie., interoperability, standards, quality measurement and ultimately care coordination), then where does CPOE fit in?

CPOE is an essential component of the organization’s Physician Alignment Strategy rather than the purpose of the quest. Emerging payment models such as pay for performance, bundled episodic reimbursement and physician directed coordinated payment coupled with changing physician demographics and new technologies such as e-visits and telemedicine will redefine the hospital—physician relationship. Most hospitals are experiencing the tip of the iceberg with increasing numbers of physicians seeking employment. CIOs have seen evidence of this when asked to deploy a physician practice EHR for employed physicians.

We suggest to our clients that they take it several steps further. First, health system leadership must embrace their role in automating the ambulatory environment. Visibility into community physician practice EHR deployment or lack thereof is essential.

Segmenting physicians according to technology adoption culture along with their attitude regarding:

§ IT services currently provided by the hospital

§ The value of EHR and other advanced clinical technologies such as health information exchange

§ Implementation of an electronic health record within their practice

§ Their needs, requirements and barriers to deployment of an electronic health record

§ The role of the hospital in EHR selection, deployment and maintenance

Combine this assessment with an inventory of existing technologies, intelligence regarding competitor activity and RHIO/HIE activity in your local area, state or regional, will provide the basic building blocks to begin strategy development.

Strategies vary quiet frequently from community to community based on a number of factors including historic physician-hospital relationships, leadership of physician champions, current payment environment, etc. Some hospitals we work with have slowed down CPOE based on their findings and have pushed to automate practices first, others have done the opposite. Regardless, the key is that the focus must be on improvement of quality of care through more effective access and use of information. Strategy, followed by technology enabled process redesign and effective communication will provide more insight regarding the sequencing, speed and investment required to ultimately achieve MU. There are many who believe there is no chalice - that the Holy Grail is the quest itself; and that it is the quest, rather than the cup, which brings the gift of ultimate enlightenment. So rather than focusing on MU or CPOE its in all of our best interest to ask "who doth the grail serve", and I think we all know the answer to that question.
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Comments

Pam and Robert, I think you both touch on a fundamental mistake hospitals are making in this process. They are afraid of involving physicians in the EMR/CPOE process because it is hard work. Involving them means they there will be more "cooks" making the soup, and it's easier just to present it to them once all is said and done, then figure out how to get their buy-in. This is obviously a fundamental mistake. Physicians must be embraced sooner or later in the process. Sooner will be easier and offer success, while later will result in failure most of the time.

Fantastic post. As I travel around the country doing executive presentations in front of large audiences of various health care organizations looking to transform themselves I am shocked by the limited number of physicians engaged in the process.

I've been in rooms with CEO's, CIO's, CNO's, pharmacy directors, compliance officers, CTO's, medical records directors and the list goes on. If I'm lucky I get maybe one dotor out of a staff of hundreds. This failure of communication, collaboration and planning is just shocking to me when an organization is preparing to shell out millions of dollars on an information system that requires physician adoption.

Hospital boards and management teams have to spend considerable time informing, educating, and yes cajoling hospital and community physicians to grasp the technology. Without it organizations will have the proverbial saying "herding cats" reverberating throughout their hallways. Failed implementations will happen but don't blame the physicians.

Pam Arlotto

President and CEO, Maestro Strategies

Pam Arlotto’s blog focuses on the business and clinical value of the healthcare industry’s...