With HITECH making physician acceptance of CPOE more important than ever, getting the user interface right is paramount. Unfortunately, most HIS vendors have spent the last few decades optimizing their products to capture transaction and store data. Thus, physicians are often left wanting when trying to navigate green screens using function keys. To address this need, those same HIS vendors have gone back to the drawing board in an effort to make the docs happy. But third-party vendors have also been working to fill the breech, including PatientKeeper. To learn more about how this vendor is making core HIS offerings palatable for physicians, Healthcare Informatics Editor-in-Chief Anthony Guerra recently caught up with CEO Paul Brient.
GUERRA: The timelines for HITECH seem quite aggressive. What are your thoughts?
BRIENT: Well, that’s an interesting question. Certainly, I think from how meaningful use has been described so far — putting aside the timeline — it’s very consistent with where just about every hospital system was going with their automation. And at some level, I think healthcare IT gets a bad rap. People say, “Well, gee, we don’t spend enough money on technology,” so as a technology provider, I can’t help but agree with that, but I’ve been in this industry for 20 years, and there’s been a tremendous amount of automation in hospitals, a little less so on the physician practice side, but I point out that every single practice in the country basically has a practice management system all by themselves. Why? Because they had an ROI. The ROI on ambulatory EMRs been a little questionable so adoption’s been slow. But on the inpatient setting, the core clinicals are all automated, people are doing bar code administration, and PACS is almost 80 percent penetrated. So a lot of work is already done, and everyone knew that eventually we would do CPOE and we do physician documentation.
So, at a conceptual level, I think meaningful use is very congruent with the direction the industry was already heading. The timing, obviously — and the point of stimulus is to change things — is very different than where people were going. CPOE was very much on the “later” category. Almost every one of our customers were saying, “Hey, we know we have to do it, but that’s not even next year’s project, that’s down the road.”
The question is how far forward do we bring it? If they put it out too far away, everyone’s going to just keep ignoring it, and no one wants to do that. If they make it, “Hey, you’ve got to have it all in next October,” which they’ve kind of threatened to do a little bit, that’s just too soon. It’s taken them almost a year to come up with a definition of meaningful use. It’s not reasonable to say, “In six months, you’re going to have to implement it.”
GUERRA: That’s a good point.
BRIENT: I think, just from discussions I’ve had, they’ll recognize that. So there’s a balance there. You’ve got to make it urgent and yet you’ve got to make it somewhat doable. My general view is that one of the disconnects is CPOE has largely not worked in the community setting. In the academic settings, yes, in places where you own your doctors, okay, but in the traditional community setting where there are no residents and only the admitting physicians, it has not been successful. We’ve got a lot of clients that have tried to deploy it and have failed.
So just saying, “Go do it,” isn’t going to solve that. We’ve got to figure out a different way to do it, and PatientKeeper, as a company, has a very different approach. We’ve got to do it differently in the community setting, and I think that’s the real rub. I don’t have a great solution for it, but what really needs to happen is several rounds of innovation in the community hospital space to get community-based CPOE to work before we can really be guaranteed of success as an industry. I think that’s the rock and the hard place, and if I were king for a day, I’m not sure I would necessarily change the trajectory, but that is a real rock and a hard place situation.
GUERRA: Let’s say they come in on the aggressive side, do you think the greater likelihood is that people will just, as you said, possibly ignore it and say it’s too hard, or do you think there could be instances of trying to do this before people are ready, resulting in some major disasters?
BRIENT: I think there are definitely going to be both, and some of our clients have already explicitly said, “Hey, we’re not going to go try to do the ARRA thing. CPOE is already part of the plan, documentation is already part of the plan, we’re going to keep that plan but we’re not going to change the plan to meet the ARRA deadlines because we don’t want to be in the second category of trying to do this before we’re ready and failing.” The folks writing the legislation are pretty clever, they haven’t said that you have to go try, they’ve said you have to succeed to get the money.
So you could be in a really bad situation where you spend $15 million to put in your CPOE system, have it fail, and not get the ARRA money. Even worse, if you look at the math on hospital revenue, if it goes down by 1 percent, it wipes out all their ARRA money. If you make your doctors angry or just slow them down by a couple percentage points and do less volume, then all of the money you might have gotten from ARRA is eviscerated.
And so there are a lot of hospitals out there looking at it and saying, “That’s just too big a risk. I want to avoid the penalties, so let’s make sure we get this in eventually, but we’re not going to change the timeframe that we had. Maybe we’ll move it up a year or two, but we’re not going to try to do a ‘pull out all the stops sprint’ to make it work.” I think that’s a very real possibility for a lot of organizations around the country.
GUERRA: I interviewed a CIO who said, “If it’s between blowing up my surgery business or losing some HITECH money, I’ll lose the HITECH money.”
BRIENT: Absolutely. I mean, when you look at the steps that hospitals take around revenue-producing physicians, I mean they go to great lengths to make them productive and happy and successful, and if this goes in the face of that, well, that’s a real problem.
I do think, though, that the program is having a very high level of the desired effect. CPOE was not part of the dialogue a year ago. Now it is very much part of the dialogue. So they’ve achieved that, frankly, without spending a single dollar of taxpayer money — yet.
GUERRA: Let’s talk a little bit about the core HIS vendors. How dependent is your success on those companies playing nice with PatientKeeper, and do some play nicer with you than others?
BRIENT: Very interesting question. So the other part of the discussion in the healthcare IT world is there’s no interoperability, and the more interoperable systems are, the less anyone needs to play nice with anyone else because they just communicate. The reality, of course, is that the major HIS systems go out of their way to not be interoperable, despite what they might say in public. We have developed expertise and knowledge around each one of those systems and we know the nuances of them, we know what works well with them, we know what doesn’t work well with them, we know how to get the data out of them, and how to get the data into them. In some cases, we do that with pretty amazing cooperation and support from the vendors, in some cases, begrudging support and, in some cases, active hostility and no support.
At the end of the day, it’s more about the technology than the support necessarily. Our preference would be to work closely with them. I think our customers don’t view us as competitive with the HIS systems, our customers very much view us as helping solve a problem that they have which the HIS systems have not. We really view them as a necessary party. If the HIS system wasn’t there, our software wouldn’t work.
You must have all this automated, and our strategy on order entry is we’re the physician part of physician order entry. We’ve got to be able to send that work to a departmental system that can do all the complex processing which the core HIS vendors do really well. So we need them and our customers need them, and our stance is that we love to partner with and work with all of them, but each one has a different view and stance towards us.
GUERRA: So you’re still able to go into a hospital that’s using a “hostile” HIS and do you what need to do to be successful?
BRIENT: Absolutely, and we’ve already developed the integrations to every one of the major ones and several of the minor ones, including some homegrown ones.
GUERRA: If you have a company with proprietary software, and they’re not interested in working with you, how do you integrate with their software?
BRIENT: Well, remember that the software is, for the most part, installed in a customer site. Their customers have deep knowledge of those systems. There’s a whole infrastructure of people who will do the integration work who know the systems well, and we either employ those people or we leverage the expertise of our customers. Most systems have ways of getting some of the data out pretty nicely, and you get a lab feed out of every one of those systems pretty easily. When you get to some of these advanced clinicals and stuff like that, it’s a little different. The systems need to communicate with other systems. So it’s not completely proprietary, but in the case of the most proprietary system out there — MEDITECH Magic — we hired people who know the Magic programming language. We wrote Magic software to pull data out of MEDITECH Magic, and now we can do that.
The McKesson systems have a very nice set of HL7 interfaces that we leverage. Cerner; we partner with on a thing called Millennium Objects and pull their data out to their published APIs and Web service. We partner with them very closely. So for every HIS system, we have a story and a lot of experience and, you know, a lot of bruises for the most part. We can walk into the hospital and it’s not a science project anymore. Six years ago or seven years ago, it was.
GUERRA: What is the main thing you’re hearing from CIOs?
BRIENT: Well, the side effect of the stimulus program has not been great for CIOs. So every CIO in the country is being asked by their CEO, “How am I going to get the whatever millions of dollars I’m eligible for from HITECH.” They’re all trying to deal with that within their own organizations either saying, “We’re going to go aggressive into this,” or, “It doesn’t make sense to do this,” but that is a very big theme on every CIO’s mind. Most of them, by now, have sorted this out, but it’s a board-level kind of discussion.
The second thing that’s on their minds is resurrecting plans that were put on hold during the recession. That is being done in the context of making sure they’re driving revenue to the hospitals because, at the end of the day, that’s what it’s all about. They have to figure out how you do that in this new context, and how don’t you let the ARRA stuff get in the way of that. So I think it is probably the most challenging time to be a hospital CIO there has ever been. I don’t envy many of my clients, but there are some great CIOs out there doing some really cool stuff.