California-based Memorial Healthcare is a four-IPA organization that includes a 35,000-visit-a-year urgent care clinic and a disease management center. The four IPAs represent 220 primary care doctors and 400 specialists – across North Orange County, Anaheim and Long Beach – centered around four hospitals. Primarily handling at-risk contracting with health plans, the IPA has begun working to bring EHRs to its providers. Recently, HCI Editor-in-Chief Anthony Guerra talked with CEO Patty Page LaPenn to learn just want IPAs want, and don’t want, from hospitals.

(Part I, Part II)

GUERRA: Are you working to integrate with any inpatient EMRs so you don’t have to print, scan and upload?

LaPENN: As soon as they can, I told them to give it to me any way they can. We will work out the interface on our side.

GUERRA: And what about certification, are you getting your own product certified?

LaPENN: We’re heading down that road. We’re coupling the eligibility piece that we have with a kiosk. So it’s like when you go to the airport. The patient can register, and if it’s one of our managed care patients, or a fee for service patient who is in their practice management system, it then sends that down to SureScripts. SureScripts works great. Then we get the prescriptions up from Surescripts so that it populates the EMR. That way, you don’t have duplicate data entry. Entering the drugs on a patient takes an awful lot of time, and it’s a huge source of errors. So getting that working is great.

When we get anything from the hospital, our goal is to attach metadata to it and run it like a Google search. We’ve got our lab data working that way, and it works great. So if a doctor wants to see lab results on a patient, they can just go to their screen and put in their first name, the plus sign (+), and the last name – just like you can in Google – and all the lab work for that patient shows up, sorted by test, by the type of test, and then by date. So that works great.

So doctors love using any sortable data. That makes their life easier. If you have 10 doctors in a room, they’re going to have 10 different ways they want to do a visit because they’re different people.

GUERRA: How many hospitals do your physicians send patients to?

LaPENN: For my management company, it’s probably a hundred, but 80 percent of the admits go to five main hospitals.

GUERRA: What’s your relationship like with those five CIOs?

LaPENN: Well, they have their own business strategy. Hospitals basically feel that anchoring doctors to their EMR anchors that doctor to them. That’s part of what they want to do. They want us all on their EMR. They don’t want to make it easy for us not to be on their EMR. Doctors will change their hospital affiliation based on ease of access to data and – in my opinion, and only in my opinion – doctors need rapid access to their own data. It needs to work like Google.

If a doctor was taking care of you, and he was trying to do your refills for your cholesterol medication, if he could go in and put in your name and cholesterol, and bam, all of your cholesterol meds and cholesterol drugs showed up, that makes his life easier, and it makes your healthcare better. But the rigid structure of the way these systems are, the doctor has got to navigate through this fixed-format application.

For example, if a patient is discharged on a Friday and the doctor is out on Monday, that patient may get an appointment on Tuesday. The patient could walk in and the doctor has no idea why that patient was hospitalized. And so it would be very nice if they could go to some interface where they could type in a minimum amount of information and see that data, but we’re not there yet. It’s about the indexing of the information so that doctors can easily find stuff. That’s not working well.

GUERRA: Doctors want to see the hospital data, but are they willing to let the hospital see their data?

LaPENN: They don’t need to see into the ambulatory system to know what medications they are on. They need to go to SureScripts.

GUERRA: Well, what about beyond medications, what about other treatments that are documented in an ambulatory EMR? Doctors don’t want to give access up to their data so ER docs can see it, do they?

LaPENN: No, that’s not it at all. Do you know what’s always in the back of the mind of an ER doctor? At any moment, there could be an accident five blocks away from here where there’s five people coming in immediately, so they’re thinking, “Get this patient off this unit.” They want to admit him. If someone comes in with difficulty breathing or someone is in respiratory failure, they want to intubate that patient and get them up to the floor.

The ER is a very special place. It’s a hot place, and if a patient shows up in respiratory failure or if a patient shows up in a really acute life-threatening situation, they want to stabilize them and get them into a unit where they have nurses who can just focus on that patient, where you can get another internist involved who’s going to get all that information on the patient and get them taken care of. That’s what happens in an ER.

In my experience, ER docs being able to see the ambulatory record will have some benefit but it doesn’t necessarily change what they do.

The hospital that just rolled out the new EMR has only seen a 7 percent reduction in lab costs. So it’s decreased a little bit of lab usage. Where is the data that shows this saves money? Where is the data that installing an EMR decreases costs for Medicare? Does Medicare have evidence? Medicare should provide that to us. They should be able to say, “This hospital during this time period before they went on the EMR, their average cost was this and after they went on the EMR their costs went down to this.” There should be either a level trend when others are going up or it should be a downward trend. I want to see that it saves money. And if you’re saying it just improves care, I want to see that data too.

You can get the drug information at SureScripts better than anywhere else. Surescripts works.

GUERRA: Why does it work?

LaPENN: Well, first of all it’s nominal data. It’s not qualitative data. There are specific names of drugs with specific doses. It’s not like when you read an MRI, the doctors don’t say normal or abnormal. They describe. It’s not nominal data. It’s not something where you can say it’s positive or negative. There’s nothing like that on most of the data that you get from the medical system. Lab data is the right kind of data, pharmacy data is the right kind of data, but radiology, you can’t do it with radiology, you can’t do it with heart procedures, and you can’t do it with surgeries, because it’s not the same thing.

GUERRA: The bottom line seems to be hospitals want tight integration to lock in patient flow but physicians want to maintain some level of independence. How do you see it?

LaPENN: I am with the independent physicians. What independent physicians want is a portal with a quick search where they can get their information. They do not want to change 90 percent of what they do to get access to that data. For the hospital, it’s mainly the ER that needs rapid access to information out of the ambulatory model. That’s where I think the biggest problem is. Do you have a portal where they could get rapid access of information? It doesn’t have to be pretty. Just put some metadata on it so you know where the patient is, what the date of the admit is, make it a diagnosis.

We need some standard metadata, attach it to a file and send it. Let’s do it like Google, rather than trying to structure it, because it’s not there yet. It feels like a Commodore computer in the early ’80 s. That’s what EMRs look like to me. It looks to me like when ATMs came out, that was really easy to do because a dollar is either plus or minus and you have an account number. That’s a real easy technology shift to me. A cholesterol level of 120 means one thing if it’s coming up from 90, but it means quite another if it’s coming down from 300. Doctors love technology, but they can’t adopt things that make it harder for them to do their job.