Leaders at Bronx-Lebanon Hospital Center Health System in New York City are working on hundreds of projects with an IT element to them, in a hospital facility that sees more than one million patients a year. Robert Leviton, M.D., the hospital’s CMIO and physician advisor, who has been in his position since May 2010, is helping to lead a host of informatics-facilitated initiatives there. Leviton began at Bronx Lebanon in May 2010, and leads a combined team of 12 informaticists onsite in New York, and five based in Pune, India, giving the team the capability of addressing issues around the clock.
Leviton and his colleagues at Bronx Lebanon have been working closely with professionals from the Chicago-based Allscripts to help them realize their vision of a more effective clinical organization.
Leviton spoke recently with HCI Editor-in-Chief Mark Hagland regarding some of his organization’s recent advances. Below are excerpts from that interview.
What are some of the key priorities right now for you and your team at Bronx-Lebanon?
Our number-one focus right now is the ICD-10 transition, with a go-live by October 1. We’ve been live for about two weeks with an ICD-10 solution. I’ve been rolling it out by department, but it was overwhelmingly accepted by everyone, it’s very easy to use: two or three clicks and you’re done; so we’re rolling it out to everyone. It involves an ICD-10 calculator. I’m an AHIMA-certified trainer [certified by the American Health Information Management Association], studying ICD-10 since 2012. [The switch from ICD-9 coding to ICD-10 coding] involves 10 clinical modifiers: laterality (left-right), acuity, encounter (initial, subsequent, delayed), anatomic site (eyes, ears, nose), so when you think about these clinical modifiers, you think of clinical modification columns.
So ICD-10 is a very specific kind of tool to get to the granular level of the diagnosis. For example, congestive heart failure could be either acute or chronic; so that’s one column. And someone could have a left or right metatarsal fracture; or left or right, or bi, so that’s an example of laterality. A stroke could have an etiology; a thrombotic event could be a strombolic event. Pneumonia could be due to different bacterial agents. So these columns are clinical modifiers that take the broad categories and reduce them to a single diagnosis in two to three clicks. Most of us work in venues where the diseases don’t change a whole lot. The Bronx has a lot of heart failure, diabetes, obesity. So we’ve created favorite calculations, and once you’ve calculated, you save to favorites.
So most of the diagnoses will be taken care of by this solution?
All of them will be, yes. They love it. Everyone has been hearing the hype, so when I get up in front of everyone and show them the solution, you see mouths drop, It’s so easy. This is a Y2K event.
What are some of the initiatives you’ll be working on next?
Core measures will be a big focus for us. CMS [the federal Centers for Medicare & Medicaid Services] has a series of core measures under value-based purchasing. So what we’re doing, and why I really enjoy working with Allscripts as a solution, is that we’ve created a workflow that’s absolutely brilliant. As the doctor is working through the DVT [deep vein thrombosis] risk assessment calculator, it comes up with a risk score, and that risk score crosswalks to an order set, and all the doctor does is click initiate my DVT risk order set, and that order set is right there, and they click and save, and the orders get sent automatically.
That involves just a few clicks?
It’s a few more, but not more than that. You click on the patient’s risk based on age, calculates from 1-6. And then you indicate whether there are contraindications for medical treatment, or for mechanical treatment, mechanical prophylaxis, like an elastic stocking, and then, high risk for bleeding; and then it recommends one of nine different order sets. If you have varicose veins, you may not be a candidate for elastic stockings.
Both of these solutions are completely embedded in the EHR?
As you’re rolling out solutions, what criteria are you following to prioritize your work?
That’s a great question. We’ve developed an administrative structure with a core leadership team, an MIS steering committee, and reporting to that are an acute-care team, an ambulatory care team, a behavioral care team, an emergency care team, and an allied healthcare team (nursing, social work, etc.). Each team is responsible for identifying the key projects they want completed. They ten present to the MIS steering committee, which decides on the funds and the timing.
When did this governance structure get set up?
About a year ago.
And how is it working?
It has its fits and starts, like anything else. You know, the issue of, hey, Robert, can you do this for me real quick? That doesn’t work any longer when you’re trying o build an integrated process for the whole organization. We ask that everyone take into account all stakeholders… all clinical stakeholder groups, risk management, everyone else.
What are the biggest challenges and opportunities for you as a CMIO, right now?
It’s QWERTY, your keyboard. Doctors are busy taking care of patients, they don’t like keyboarding. Imagine if you were a doctor, trying to keyboard. And then your computer mouse is the second impediment. It’s the same analogy. What we’re asking doctors to do is to get information into a structure that is not pen or paper, so that we can collect that information and then make use of it to drive care to successful outcomes on increasingly fewer dollars. So the shift is what’s important to collect through an electronic health record versus what we used to do with pen and paper. And then there’s education: why is it to capture this into an electronic health record, and why, Dr. CMIO, are you making me do this?
So when we design EHR solutions, we have to keep in mind what outcomes we want. If the outcome is care-oriented, we have to make sure that the capture does not impede doctors getting their work done. The VDT risk assessment, that’s something they have to do, and by presenting the calculations in line with their notes so they don’t have to go into a separate solution, that’s great. You take the ICD-10 calculator, and show the doctor the easy solution and get the “aha” moment, that’s what a CMIO should be doing. So showing the doctors solutions and educating them in how the solutions should be used, that’s my core set of challenges. It’s not a Word document, and it’s not lie shopping on Amazon. It’s my work tool. We spend a lot of money training doctors in using surgical devices and medical equipment; why aren’t we spending that money on helping doctors to sue the electronic health record? It’s as much a critical tool as a stethoscope is. That’s my mantra. And we’ve just provided a very successful module with core EHR education; and now we’re building a customized workflow solution. It’s all right there.
What do you see as your greatest opportunity as CMIO in the next couple of years?
The greatest opportunity will be to leverage data analytics to understand what is working for our community, what drives our community to seek care, and how we’re going to drive analytics around this to improve care delivery. They talk about the second-generation CMIO being the analytics CMIO; we hear that more and more. We develop a CHF care plan. Is that care plan really improving outcomes, helping patients to lead healthier lifestyles? Are the care managers helping fulfill the requirements of the health plans? That’s the next level of this.
Is there anything else you’d like to add?
I just want to tip my hat to everyone in healthcare who's using the electronic health record. I think we’re at a very important tipping point. We just need to stick with this. Voice recognition will become more and more important and better; Tablets will be recognition-based. I use a Bluetooth headset with Dragon, and an electronic pen on a tablet—it’s moving towards touch-and-talk. I think there will be less keyboarding in the future, because people are asking for it [less keyboarding]. We struggle every day to type 40-50 words a minute. Most people don’t type that rapidly; yet if I see 30-40 patients a day, how do I get that information into my record? Your doctor is sitting across from you with his pad on his lap, jotting notes. But why is he or she doing that? We’re beginning to experiment with bidirectional voice tagging right now. There are many possibilities.