Ed Marx Ferdinand Velasco, M.D.
Texas Health Resources is a 3,700-bed 14 hospital system in the Dallas/Fort Worth Metroplex with more than 18,000 employees. With almost 100 percent of its practicing doctors working as independent community physicians, the organization needs to be nuanced in its push to get EHRs into their offices. Working on that project, in addition to every piece of inpatient IT, is CIO Ed Marx and CMIO Ferdinand Velasco, M.D., along with the 525 FTEs that make up the IT staff. An annual operating budget of over $100 million helps grease the wheels, but that only goes so far with physicians who take their independence very seriously. Recently, HCI Editor-in-Chief Anthony Guerra had a chance to talk with Mark and Velasco (who he linked up with on Twitter @anthony_guerra, @marxists, @ftvelasco) about their plans to connect the acute and ambulatory worlds.
GUERRA: Ferdie (Velasco), you’re a physician, isn’t there a big reluctance to take action off a test if you didn’t do it yourself, if it wasn’t ordered in your practice or at the hospital? Don’t you set yourself up for liability issues if you take clinical action off a test that turns out to be wrong?
VELASCO: It’s certainly true that there is a reluctance to accept information that’s not from a trusted source. On one level, we will eventually need to get over that because retesting contributes significantly to unfettered healthcare costs. But you’re right, there definitely is a discomfort with that.
Getting back to your question of why our information exchange is primarily one way at this point; truthfully the physicians in the community aren’t that interested in sending their data to the hospital at this point, partly because they don’t want the data to get into Texas Health Resources’ (THR’s) hands. Their interest right now is getting their hands on the hospital information. So if the hospital has a pathology report or an operative report and things like that, these things were historically faxed to them or mailed out to them; they’d like to be able to acquire these things electronically and import them into their physician office EMR. That’s where 90 percent of the interest is right now in interoperability and health information exchange. They’re not really that interested right now in being able to upload data from their ambulatory environment into the inpatient hospital EMR.
GUERRA: They may not be, but I would imagine you are, especially in the emergency department. You have patients showing up there, you would really like to see all the data that had been gathered from all their providers in the community so that treatment could be as accurate as possible, based on as much information as possible. So they may not be interested, but I’m sure you are. Does that make sense?
VELASCO: Oh yes, we definitely are. I think the workflows for that kind of interoperability need to be figured out. I think the problem is that people could jump immediately to the long-term vision of semantic interoperability where somebody’s documentation of the patient’s medication list and allergies, and all that stuff, just magically populates the corresponding data fields in our Epic environment. That’s not only not realistic today, it’s not even necessarily desirable given the data integrity concern that Ed shared earlier. What I think would be helpful today, and perhaps for the next few years, is it needs to be in a read-only fashion. That way, people can access and view that data so you don’t have to take a comprehensive history again when that patient shows up in the emergency room setting.
GUERRA: It seems privacy and security issues are sinking a lot of HIE-type projects. What are your thoughts?
VELASCO: Well, I think it’s tricky – trying to find the balance, and I’m just going to echo what John Glaser said recently, he was one of our keynote speakers at the Scottsdale Institute teleconference here that we hosted at THR. There are legitimate arguments from both sides. The folks that have concerns about privacy and the potential misuse of the data represent issues that need to be addressed.
And then there is the other side of the coin, which is if we’re so restricted as to how the data is shared and made accessible, that it’s basically locked up and no one has access, then it can’t be used for secondary things like research and comparative effectiveness.
So it’s going to be an ongoing dialogue between both sides, if you will, and require constant recalibration to find the balance. As John Glaser said, if patients concerns about privacy are not adequately addressed, basically they’re not going to contribute. They’re not going to give you a complete history, a useful history, and so having that data available in the EHR is not going to be useful either. So again, it’s just a balancing act.
GUERRA: Tell me about your work with some of the largest IPAs in the area. How many physicians are in these big IPAs, and how do they want to be approached? What do they want from the health system, and what don’t they want?
MARX: We have two in our market. One is on the Fort Worth side, it’s about 1,000 physicians and they have a sub-entity where they try and do a lot of the information exchange. We are probably their primary health system, and they share a significant amount of information with us today. So that’s a relationship that has been around and alive for a couple of years.
On the Dallas side, there’s another organization, another IPA. It’s about 1,500 docs and their desire is emulating that same strategies. Today, we don’t formally exchange information, but we are in discussions with them, just as they are with many other health system, I’m sure, about exchanging information.
We all desire to exchange information primarily for the clinical benefit of the people in the community that we serve. Certainly, everyone wants to have good relationships with IPAs for business reasons as well. Those are the drivers.
GUERRA: Any advice on how IPAs want to be engaged?
MARX: I think one way is to build a bridge across the organization’s business and clinical leadership, and talk about your vision of the relationship, particularly regarding the exchange of information. That way, everyone understands from the beginning where you’re trying to go. So begin with the end in mind. It’s basic business 101, but it’s funny how often basic business 101 is overlooked, and then you’re playing catch up and doing damage control, those sort of things.
There are three things that you can do. (#1) Include business and clinical operations. This is not an IT thing. (#2), once you bring all the key stakeholders together, talk about what you’re trying to accomplish; and then (#3) would be to have routine meetings with those same individuals, the same leadership on the business and clinical side.
GUERRA: Let’s talk about your CPOE success. You’ve got about 80 percent CPOE now. So my first question is, not to diminish the 80 percent by any means, but what about that last 20 percent? What are the challenges in getting that last 20 percent done?
VELASCO: First of all, it’s actually 85. Actually, the reality is that it’s actually 100 percent.
GUERRA: We just went from 80 percent, to 85 percent, to 100 percent (laughing).
VELASCO: My explanation for that is there are some artifacts in the process that prevent us from getting to 100 percent as a practical number. We essentially have universal adoption of CPOE. What prevents us from having a perfect score, if you will, is that there are situations where a physician needs to admit a patient, or write admission orders for a patient, who is not yet in the system. In that context, we certainly allow the physician to go ahead and write those admission orders, and by the time that patient arrives at the hospital, they are in the system. So those orders are transcribed into the system.
Another artifact, if you will, that accounts for 15 percent is there are times when the pharmacist needs to adjust a physician’s order. The physician electronically enters a medication order, perhaps it’s a non-formulary med and some adjustment needs to be made by the pharmacist. The reentry of that medication order counts against our CPOE numerator because it is a pharmacist-entered order.
So, in essence, we actually are now at a point where we have universal adoption of CPOE wherever it’s available. There are always going to be verbal orders and that sort of thing, but it’s not a case where we still have some stragglers, if you will, that are sneaking around the system and writing things down.
GUERRA: Talk to me about standardized order sets, and the overall importance of order sets. We’ve heard how important it is to work on those before you roll out CPOE, to make sure you’ve got them right. You made the point that 50 percent of your CPOE orders are standardized order sets. So that means 50 percent are not. What is the difference between the standardized order and the non-standardized order, and why is it important to get people towards these standardized orders?
VELASCO: Order sets are critical to CPOE’s success, and that’s why I think we are achieving the adoption we have. You just cannot pull this off without order sets. Prior to coming over to THR to become the CMIO here, we actually implemented a very early version of Eclipsys at New York Presbyterian, and I know you’ve had interactions with Aurelia. We didn’t have order sets back then. I can’t imagine trying to do CPOE without order sets. They’re so essential; they make CPOE acceptable.
Now, beyond just that aspect of it, they obviously are a vehicle for facilitating adherence to evidence-based practice, and we are very conscious about incorporating that into this design, into the content of order sets.
Prior to the implementation of Epic and CPOE at THR, we collected all the preprinted order forms that existed in the system and analyzed them. First of all, there were no system‑wide order sets or preprinted order forms before the advent of Epic. So each hospital had its own pneumonia admission order set, its own heart failure admission order set, etc., and within each hospital, there was great variation in terms of accommodation and individual physician-specific orders for postop knee, pacemaker insertion, you name it.
So one of the things that we established from the get go was to really move away from physician-specific practice and standardize care as embedded in these order sets. What the 50 percent refers to is that we’re moving towards system‑wide standardized order set. All order sets are standardized so don’t have each individual physician’s order set built just for them. What we’re working towards, for example, is having a consistent pneumonia order set for all hospitals across the system. So we want a consistent standard of practice at all THR facilities, and we’re 50 percent there.
Actually, in our monthly report to our system executives this morning, that number is now up to 60 percent, just to show you the rate of progress we’ve made since Ed published his blog post on this a couple of months ago.
In those standard order sets, we have links to clinical evidence. We hardwire performance related to core measures, so that the ACE inhibitors and vaccination for pneumonia is already plugged in. We have alerts built in, so that if you opt not to prescribe the aspirin on arrival, you have to document the reason for not prescribing it, etc.
GUERRA: Ed wrote that physicians can only do CPOE upon completion of training. I thought that was a very interesting way to reverse the dynamic. Most hospitals are begging docs to do CPOE, but you’re saying that they can’t until they train. Was that intentional?
VELASCO: It was. It’s really no different than the usual model in healthcare, in the practice of medicine. You don’t get to start operating on people until you have a degree, you have been board certified and have a clinical license. To get those certifications, you need to have training necessary to qualify. So it’s really an application of that model. Using the system is not unlike having a scalpel. Being able to prescribe a medication can have significant consequences if you don’t know what you’re doing. From a principle standpoint, it wasn’t difficult for us to establish that as part of a requirement for being able to get into the system.
You’re right, it does set up a barrier to entry, but when the hospital or the medical staff leadership is saying, “In order to practice at our hospitals, you have to be using the system, and in order to be using the system, you have to get trained,” it establishes the expectation that they have to get the training, or someone else will wind up caring for their patients.
GUERRA: That’s a change in the dynamics that few hospitals are brave enough to try.
VELASCO: We didn’t do it necessarily from the beginning, it has been a journey to get to where we are today. We were certainly very much in an accommodating mode initially, where you can use it if you want to, you don’t have to use it if you don’t want to. But the medical staff recognizes that we can’t continue to live in this dual world, because it compromises patient safety when some physicians are using it and some aren’t. It sets up challenges in terms of patient safety.
So to their credit, it was the medical staff that said, “Enough of this duality, enough of this dual workflow, let’s set some mandates here.” Being able to accomplish that has allowed us, at our subsequent installs, not only to be more stringent earlier and earlier during the go live, but to actually make that part of the initial go live implementation itself. That’s the advantage of being a health system – you can build on the success of earlier hospitals; whereas if you are standalone independent entity, you have to struggle with this until you get over the hump.