With its carrot-like incentives, HITECH has placed severe demands on healthcare providers throughout the country to adopt electronic medical records and computerized physician order entry. And while paying for such systems is difficult, inducing clinicians, especially independent physicians, to use them can be the highest hurdle in the race to leave paper behind. One institution grappling with these challenges is Northern Inyo Hospital, a 25-bed critical access not-for-profit district hospital in Bishop, Calif. Recently HCI Editor-in-Chief Anthony Guerra had a chance to talk with IT Manager Adam Taylor & HIS Manager Linda Goodwin about how HITECH has effected their plans.

GUERRA: Tell me a little bit about the hospital: how many beds do you have; what is the patient mix in terms of Medicare and Medicaid?

GOODWIN: We’re a critical access hospital with 25 beds. We have a high mix of Medicare and MediCal. I can’t give you any percentages; we’d have to get that from fiscal, but I know we have a lot. We’re a retirement community, actually.

GUERRA: Are any physicians on staff or are they all independent?

GOODWIN: They’re pretty much independent.

TAYLOR: We have one doctor on staff who is the head physician in our rural health clinic, otherwise all physicians are independent.

GUERRA: Approximately how many physicians refer patients to the hospital?

TAYLOR: I would say 20 to 25.

GUERRA: And the IT staff is just the two of you?

TAYLOR: No, Linda is focused exclusively on the hospital information application, the one main one. As far as staffing goes, we’ve got three helpdesk technicians – me, the manager, and two who we call infrastructure people (dealing with networking systems).

GUERRA: Linda, do you report to Adam?

GOODWIN: No, I report to the CEO.

GUERRA: Adam, who do you report to?

TAYLOR: I report to the CEO.

GUERRA: Some organizations have people in your position reporting to the CFO, but you report to the CEO.

TAYLOR: Actually, the person I report to is CEO/CFO.

GUERRA: Tell me about your IT environment.

TAYLOR: For a while now our feeling has been that QuadraMed is not a good fit for our small environment, their Affinity product. When you also consider that they are going through some major changes right now, we wanted to be aware of other options, feeling that the changes involved with Affinity were going to be about as painful as switching to another hospital information system anyway.

Linda and I attended a vendor/buyer seminar in Las Vegas last year, and we really felt that H.I.S. Professionals (a consulting firm) could offer us a good value to come in and look at how we’re using QuadraMed, look at how we’re using Affinity, and help us decide if that was a good path to stay on, or if they can make recommendations for a different way to go. In addition, they came and looked at our IT environment in general and produced a report for us that, as far as hospital information systems go, they pretty much recommended QuadraMed was probably not the best way for us to go.

Our CEO/CFO John Halfen recently attended a leadership conference put together by McKesson. He was impressed with them. I think he is starting to feel like we need to get rolling on this, based on the availability of HITECH funding. Before that, we had our HIS review on the backburner, primarily because we’re in the middle of a big construction project. But now we’re kicking off our search for a replacement.

GUERRA: Did the opening come because QuadraMed was doing a conversion from one main product to another, and you were going to have to switch anyway?

TAYLOR: That was the initial portion, but I have to stress that we’re in the middle of a major building construction project. Basically we demolished about half the hospital and are building up a brand new two-story facility. We were concerned about money, that maybe we shouldn’t do this until after the construction project is complete, but I think the availability of the stimulus funds has moved it forward.

But I would agree with you, with all the major changes at QuadraMed, we felt the pain was going to be about the same as moving to a new product anyway, so we might as well open up our vision to other things.

GUERRA: What’s the name of the new product they were trying to switch you to?

GOODWIN: QCPR.

GUERRA: So you had no choice in the matter?

TAYLOR: I think they’re sun-setting quite a bit of their products, so they’re not giving us an option to stay with the old stuff.

GUERRA: Have you decided on McKesson?

GOODWIN: No. We’re going to look at several. We love McKesson (Paragon), but that’s a pretty high dollar amount and we are in the middle of that big building project, so we are going to look at others.

GUERRA: Can you tell me any other finalists?

TAYLOR: It has been recommended that we also look at CPSI, HealthLand and HMS. At a higher level, we were directed to Meditech in addition to McKesson. At this point, I’ve asked Vince (Ciotti) to provide me with a proposal whereby his company will help us with the RFP, help us with selection; and help us with contract negotiations.

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?

GOODWIN: I would think so. I worked as a nurse here for eight years. I was their applications coordinator, and I worked on the floors and worked with the doctors, so I know a lot of their personalities. I think initially that we should grab the ones that would welcome it and concentrate on them, because they’re going to be our best spokespeople. After that, we’ll work one-on-one with the physicians that need it.

TAYLOR: I don’t think we need to one-on-one them. Most will adopt, but then we’ll have to put the screws to the guys who aren’t adopting. You don’t just approach them as an IT department or nursing; you get doctors on their own to appreciate it. I don’t like to use negative reinforcement, but there’s going to be some level of shaming going into it.

GUERRA: A small facility has challenges, but you also have the benefit of knowing these physicians individually.

GOODWIN: Exactly. I did work with them quite a bit, so I can approach them. One of my goals is to work one-on-one with some of the more difficult physicians.

GUERRA: Will you ask the physician champion to do a formal presentation for his or her colleagues?

GOODWIN: That could be an idea.

TAYLOR: Again, we are a hospital district here in California, so we have an elected board of directors, and I think we could do that. I think we could have the board of directors sign some type of initiative or some type of request for the local physicians. “Please come do this.” Regarding high-level nursing; we could just bring all of our pressure to bear from the different groups and just try to get them in. I think if you can get them in a room and have somebody they know and respect show them how this is going to benefit them, most of them will eventually take it up.

GUERRA: Is there anything else you want to touch on?

TAYLOR: The stimulus funding has realigned our priorities a bit. It will be interesting to see how many people who were going to put IT projects off, suddenly aren’t.

GUERRA: Well, if anything, it gets the CEO/CFO types to really champion this a little more because the dollars are there.

TAYLOR: The moment you put a dollar sign in front of it, things change

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