EXECUTIVE SUMMARY
Hospital and health system CIOs are working intensively to help physicians achieve meaningful use; but, given limited resources and the foreshortened timeframes involved, most are putting the bulk of their focus on their employed physicians. Still, some CIOs are also finding creative ways to engage their affiliated physicians and move forward on several fronts at once.
Thomas Smith, CIO of NorthShore University HealthSystem (formerly Evanston-Northwestern Health System), based in the Chicago suburb of Evanston, Ill., is very clear about what to do to help his physicians achieve meaningful use: He is going all-out to implement core electronic medical records (EMR) and computerized physician order entry (CPOE) systems for the four-hospital, 916-bed health system's 675 salaried physicians, while providing training and support for its remaining 2,000 affiliated, non-salaried physicians. And his strategy is typical of those of most CIOs right now.
When it comes to employed physicians, Smith says, “We're essentially implementing the current copy of the EMR we have in the hospitals,” which is the core EMR from the Verona, Wis.-based Epic Systems Corp. As for non-salaried physicians, “We're offering them the Epic EMR and Epic registration and billing, and about 25 affiliated physician offices are live today” on those systems. For both groups, he says, “We're going through the meaningful use rules right now and trying to figure out what we need to do.”
The core difference has to do with the level of detail and coordination of effort involved. Smith and his colleagues in corporate IT are working very closely with NorthShore's employed physicians on every detail of implementation and meaningful use compliance. But because the affiliated physicians are not employees of the health system, there is naturally a greater detachment involved, he says.
“Let's say we offer help on medication reconciliation; one of the standards is you have to meet that standard 80 percent of the time. So we offer training, encouragement, and reports that tell them what their status is, and expect to continue to help them until the date when they'll make an application. We basically are looking at our analysis of whether we're compliant, in terms of our own functionality and ability to meet clinicians’ needs,” Smith explains. The affiliated physicians can then turn to NorthShore for advice and tips, but will have to follow through on their own in terms of the details of implementation.
This is pretty much the pattern being played out nationwide, as CIOs prioritize their levels of involvement with salaried and non-salaried physicians in their organizations’ orbits. Like Smith, most CIOs are caught between and among competing priorities. These are the need to optimize their own internal hospital processes, the desire to help both types of physicians, and the complex politics of working with independent-and independent-minded-non-salaried physicians.
WE OFFER TRAINING, ENCOURAGEMENT, AND REPORTS THAT TELL THEM WHAT THEIR STATUS IS, AND EXPECT TO CONTINUE TO HELP THEM UNTIL THE DATE WHEN THEY'LL MAKE AN APPLICATION.-THOMAS SMITH
NEW APPROACHES
Having to focus and prioritize is especially important for organizations like the three-hospital, integrated Sinai Health System in Chicago, which with large Medicaid and uncompensated care populations, is always short on resources. At Sinai, vice president and CIO Peter Ingram is working intensely right now to get both the hospital and medical group of the health system qualified for meaningful use in 2011.
The flagship 320-bed Mt. Sinai Hospital is live on the Meditech Magic system from the Westwood, Mass.-based Meditech. Ingram and his staff of 55 are working diligently to go live with the Horsham, Pa.-based NextGen EMR at the 200-doctor Sinai Medical Group. Given his small staff and limited resources, Ingram says, “It's going reasonably smoothly, but we're also putting in an enterprise master patient index [MPI] at the same time. The MPI will be the traffic cop between Meditech and NextGen here,” he says.
For that capability, he and his colleagues have chosen the Chicago-based Initiate Systems (now an IBM company). In fact, such moving forward on the roll-out of their MPI has compelled Ingram and his colleagues at Sinai to scrub the MPI of the health system; “We have four or five FTEs in the health information management area currently scrubbing our MPI,” he reports. The initial go-live was scheduled for this month. Ingram is also working far more loosely with two medical groups affiliated with Sinai Health System, but whose physicians are not salaried employees. In that case, one of the complications is that those two groups have a different EMR vendor and their own CIO.
Other CIOs are working through equally complex situations. In the case of the 450-bed Mercy Medical Center in Cedar Rapids Iowa, senior vice president and CIO Jeff Cash is working with an affiliated group of 90 physicians to help them achieve meaningful use, while also beginning to plan a bridge to modernization of the hospital's Meditech Magic inpatient EMR and CPOE systems.
Given the complexities of the situation, Cash and his colleagues have gone live with a physician portal solution supported by the Newton, Mass.-based PatientKeeper Inc., in order to facilitate physician documentation. Using PatientKeeper, the affiliated physicians can now log in, view results, create new notes, and, will soon be able to order through CPOE, all via PatientKeeper.
The interoperability that Cash and his colleagues have created falls somewhere between true EMR and a kind of quasi-health information exchange. It sounds complicated, but, says Cash, given the need for the hospital to update its core EMR system at the same time that it creates CPOE, physician documentation, and other capabilities for the physicians, this is an approach he feels he can live with.
“This allows me to give my physicians and clinicians the systems they need, without having to do a complete replacement of my current healthcare IS. Otherwise, we might be forcing ourselves into a timeline that we might have difficulty with, and our vendor might also have difficulty,” Cash explains. “Thus, we're using a niche vendor who can come in and give us some capabilities as a layer on top of our existing systems, and provides needed capabilities to our physicians. This could also give me the flexibility to migrate away from Meditech if necessary, though I'm comfortable with them and with moving towards their new system.”
THE DOCTOR IN THE ONE- OR TWO-DOC PRACTICE DOESN'T WANT TO HANDLE ALL THE COMPLEX TECHNOLOGY CHALLENGES, DOESN'T WANT TO HIRE AN IT PERSON FOR SUCH A SMALL PRACTICE, AND DOESN'T NECESSARILY WANT TO BECOME PART OF A BIG ACADEMIC MEDICAL CENTER'S EMR SYSTEM.-GEORGE BRENCKLE
Meanwhile, at the seven-campus, 1,100-bed UMass Memorial Health Care in Worcester, Mass., George Brenckle, Ph.D., senior vice president and CIO, has found yet another way to tackle the multiple challenges. Like NorthShore's Smith and Sinai's Ingram, Brenckle is working very closely with UMass Memorial's employed physicians on meaningful use. And when it comes to the system's affiliated physicians, Brenckle reports that his team has “developed a community model for this.”
Working with the Chicago-based Allscripts, he and his colleagues have created a subscription-based model for connecting with the core Allscripts EMR via the company's MyWay product. “The doctor in the one- or two-doc practice doesn't want to handle all the complex technology challenges, doesn't want to hire an IT person for such a small practice, and doesn't necessarily want to become part of a big academic medical center's EMR system,” he says. “So instead, for $600 and with no capital upfront, except for the computer terminals you put in your exam room, you can establish connectivity to the Internet, and make use of our secure communications to a data center and use a hosted, supported application, with only a 12-week implementation. This includes practice management as well as EMR, and includes electronic submission and remittance,” Brenckle notes. And though the program had just begun as of press time, he believes it will be very popular with affiliated physicians.
WE'RE VERY FORTUNATE. THE MUIR PHYSICIANS IN THIS COMMUNITY ARE QUITE AMENABLE TO CHANGE; INDEED, THEY'RE ADVOCATES FOR CHANGE.-TINA BUOP
GETTING GRANULAR
If there's any setting in which the rubber really meets the road, it is in the complex, resource-spare medical group environment. At the 600-physician Muir Medical Group IPA, based in the San Francisco Bay Area community of Walnut Creek, CIO Tina Buop has been working through a welter of issues, and plowing through the group's meaningful use gap analysis and interface analysis phases. A major focus for the fourth quarter of this year, Buop notes, is following up those intensive analyses with IS upgrades (Muir Medical Group's vendor is NextGen).
When one gets down to some of the specifics of meaningful use for physicians, things get very granular very fast, Buop says. Among the many areas in which the organization's EHR clinical gap analysis has already led to care quality and workflow improvements: diabetes utilization, immunization and patient plans; mammograms and colorectal exams; hypertension and coronary artery disease; congestive heart failure and attention deficit hyperactivity disorder; and patient summaries. What's more, she says, “We have to make sure that the physicians are using the right application; that they're clicking and not dictating when required to do so; that they're using the correct lab interface, and so on-in other words, that they're using the best practices.”
Fortunately, Buop reports, all the work to improve processes and to help move the doctors forward on meaningful use “has been well-received. The physicians just want to know how to do it right,” she says. “And we're very fortunate. The Muir physicians in this community are quite amenable to change; indeed, they're advocates for change.”
The countervailing challenge remains “the time to train them, because everybody's trying to see more patients in order to maintain their reimbursement levels.” She wonders, though, about all the solo physicians who “don't have someone to help them as our doctors do, will have to become a lab interface expert, a radiology results expert, a privacy and security expert,” in order to master meaningful use and not see Medicare payment cuts after 2015.
And though most hospitals, health systems, and medical groups are still focusing on the physicians with whom they have the tightest relationships-in many cases, primarily their employed physicians. In the long run, all the CIOs interviewed for this article say they recognize that, just as a pebble tossed into a pond leads to ever-broadening ripples of water, they will ultimately need to reach out to their more loosely affiliated doctors over time. With limited resources and tight timeframes, though, all are working most closely right now with those doctors with whom they are most closely bonded, even as the timetable towards 2015 moves inexorably forward.
Healthcare Informatics 2010 September;27(9):20-22