AG: What were your impressions of the HIMSS conference? I know you’re connected to the show, but what did you notice?
DG: I work there too, but I’ve been going to the HIMSS conference since, I think, ’91. It seemed to flow smoother than any one I’ve been to in the past, and maybe that’s because I was paying attention to that. And I was really paying attention to that because I wanted to make sure that it was a good experience for everybody. We have had issues in the past, from what I understand, with things not working right. This year, I thought the exhibit floor was heavily populated. I think there were considerably more CIOs there this year and they stayed longer. We had more representatives from critical access hospitals there than we’ve ever had in the past, which is a good thing because those people are in the market for application software that haven't been before because they haven't had the money and they haven't had the impetus to do it. There was some special attention paid to that.
AG: What about major trends — anything that you heard people talking about that indicated certain directions the industry was moving in?
DG: I think there is still a bunch of confusion about what interoperability means. I’m seeing more rubber hitting the road on that kind of stuff. In the standards arena, people were pleased and were starting to actually codify some of the great ideas that people have had, especially the continuity of care document stuff. So I saw and heard some very positive stuff about that. I think the industry is in a stage … there are multiple stages and it depends on how far down the road you are and which stage you're in, but there are a lot of organizations out there that have spent a lot of money implementing technology and haven't gotten commensurate value for it. I think there is a recognition on the part of the organizations who haven't gone down that road yet, ‘Wait a minute, we need to factor that into the equipment right at the beginning rather than think about it after the fact.’ So I saw quite a bit of that kind of conversation going on. I don’t think there was any real breaking news.
AG: Did your organization conduct the HIMSS Leadership survey? There seemed to be some major questions about the results in the press luncheon we were both at.
DG: Yes, we did the Leadership Survey, but HIMSS Analytics also did surveying of its own. We’ve been doing the leadership survey for years for HIMSS. In the comparisons that we’ve done in Analytics, we’re showing that about 43 percent of the healthcare organizations increasing their spending, 22 percent are decreasing their spending, and there is not much change in the remainder (35 percent). Most healthcare organizations are increasing their spending; they have to. And it depends on what stage you're in. If you haven't spent the money yet on an enterprise vendor coming in with a bunch of clinical apps — which is the situation for a lot of critical access hospitals and the hospitals under 150 beds — they're going to spending a lot more going forward because they’ve got to spend, not only capital to buy the systems, but they’ve also got to spend in operations to be able to support it. So their budgets are going to go up.
If you’ve already spent the money and you’re already starting down the road, your operating budget is going to go up because you have to have more people to support the more advanced clinical apps, and you're starting to depreciate the capital you spent. That hits your operating budget as well. If you have already got everything implemented and you're not done, but you're way down the road, your operating budgets are still higher because you need a large IS staff and the support of IT to your organization is going to be greater.
It may not be the IS organization. Your organization may have a whole bunch of nurse informaticists that report into the nursing organization, but the total spend on IT in an organization from an operating perspective is going to be greater because you have to support the apps, they don’t support themselves, and you're going to be depreciating the capital.
So I don’t see any way that spending isn't going to go up. I just don’t. The stuff that we have projected through the next five years is showing them going up on the operating side, as well as the capital side. It won’t go up at the same level on the capital side in our view because we’re heading into a recession. We think people will be a bit more careful about their spending on the capital side, but the operating side, I don’t know how that number doesn’t do anything but continue to go up.
AG: Let’s talk about your EMR adoption model with its eight stages. How can our readers use that model to help them?
DG: That’s a good question. When we first invented our model in 2005, it was just looking at whether organizations had an application implemented or not, as opposed to how they were using it. Rob Kolodner made that comment a couple of times in the presentations he was giving, that it was not enough to know just whether you have an application implemented or not, it’s that you also need to know how it’s being utilized. And he’s right, but if he looks at the percentages on our EMRAM (electronic medical records adoption model) even if you assume that it’s just for whether or not an application is installed, the story is not very positive. What it’s showing is that there is not a huge amount of implementation of some of the advanced analytical systems because people aren’t very far along.
What we did is, once we implemented and we built the algorithms that go into the database and find out where people are and do the scoring, we decided that we needed to add some questions to the survey instrument on the qualitative stuff — ‘How are you using it, nursing documentation, how many units have you got it on and what are they doing with the nursing documentations, CPOE, what kind of orders are your docs using CPOE for; is it just tests, is it just lab, is it pharmacy — what is it, and what percentage of the docs are actually doing it?’ that sort of thing.
So we got a whole lot more qualitative and put that information into the model and built algorithms to look at that as well. What the model essentially says for stage 0/stage 1 is do you have the three core ancillary systems? That’s all that is. We originally thought that everybody would have the three ancillary systems because they're just foundation elements. They're not electronic medical records, but it’s pretty hard to have one without them. So we said this is kind of the infrastructure you’ve got to have. You’ve got to have networks and you’ve got to have PCs and you’ve got to have servers, but you also have to have the three ancillary systems. And then what we found was there were a bunch of healthcare organizations in the U.S. that didn’t have all three of them. That’s when we added stage 0 and it became an eight-stage model, instead of a seven-stage model.
So those are pretty rudimentary stages. But if you look at the percentages of organizations that are in those stages, that’s not a very positive statement about where acute care American healthcare organizations are.
Then Stage 2 says okay, we also think this is a foundation element, but it’s the foundation of the EMR. Do you have a clinical data repository, do you have a database where you store all the information and data goes into it and results come out of it? That’s standard stuff. Most hospitals in the United States have this repository and have had it for years.
We add in some components to it, but we are not penalizing people if they don’t have those components implemented; we’re just making assumptions that they do have them implemented and we’re giving everybody the benefit of the doubt. That’s controlled medical vocabulary — some sort of decision-support system that will allow them to build rules. In the model, we’re simply building the various components in the order that most healthcare organizations implement them. If they don’t implement them in that order, that’s okay, we give them credit for the different ways that a healthcare organization can go about an implementation. But these are the basic components of an electronic medical record, and it shows where everybody is, relative to their peers in the benchmarking stuff that we give healthcare organizations.
What we’re finding is that people really want to know what their score is, and we had a bunch of people come to our booth in Orlando saying, ‘We don’t want this to be wrong. We want our data to be right because we want to know what our score is and we want to know what our score is compared to peer organizations.’ And there are lots of reasons they want to know it. They either want to prove that they're not spending enough money to their boards, or that they don’t have enough. They may want to say, ‘We’re in the top 15 percent of healthcare organizations and yet if you look at our staffing compared to peers, we’re not there.’ CIOs are using the model in any number of ways to help rationalize their strategies, get more staffing, get more budget, move in a certain area.
If we’re talking about closed-loop medication administration, for example, and there were a lot of people doing it and they weren’t doing it, then they could say, ‘Wait a minute, we’re missing the boat here.’ It’s just another tool for CIOs.
AG: Are there other ways CIOs can leverage the information?