During the Physician-Computer Connection Symposium 2013, sponsored by the Association of Medical Directors of Information Systems (AMDIS), and held at the Ojai Valley Inn and Spa in Ojai, Calif. June 25-28, HCI Editor-in-Chief Mark Hagland sat down for a conversation with Kshitij (“Tij”) Saxena, M.D., regional medical director, medical informatics, at the Altamonte Springs, Fla.-based Adventist Health System. At the 32-hospital Adventist system, Dr. Saxena, whose clinical background is in internal medicine, is one of four regional medical directors for medical informatics all of whom are deeply involved in post-CPOE (computerized physician order entry) work and physician documentation development (each is responsible for managing medical informatics at eight Adventist hospitals). Below are excerpts from that interview.
So what have you been working on recently?
Post-CPOE and physician documentation; everything in CPOE has been implemented. The last of our hospitals to go live on CPOE did so two years ago. So we’re focused on optimization now.
Kshitij Saxena, M.D.
Tell me about your current optimization work.
Optimization clearly comes after successful implementation and successful adoption. What you do in optimization is that you fine-tune what you’ve rolled out. For now, for example, we’re working on the ED modules and trying to improve patient care, as well as trying to develop solutions that are more patient safety-based, as well as in line with the ONC [Office of the National Coordinator for Health Information Technology] directives. For example, when it comes to readmissions, we are working with Cerner [the Kansas City-based Cerner Corporation, the organization’s core electronic health record (EHR) vendor], where we have developed a way so that whenever a patient comes within 30 days into our ER, a calendar icon appears on the ER electronic tracking board, and basically, we’ve educated the physician to understand that the patient is in the ER within 30 days of their last inpatient admission or ER visit. So that basically alerts the physician that you might want to get some data on that patient. And that triggers an HIE [health information exchange] function, because you can access data from the HIE.
So let’s say that Kshitij Saxena goes to the ED you, the ED physician, could look up my patient identifier, which might be my Social Security number, to see whether a provider in one of our clinics saw me. If I have CHF [congestive heart failure], you can fix my problem in the ED, and you can call my primary care physician, and can work to avert an inpatient admission. We’re working with the Cerner people, with their readmissions module, where the case management nurses do a follow-up with the patient.
You’re putting into place key things that have to happen proactively, right?
Yes, the cuts under the ACA [the Affordable Care Act’s avoidable readmissions reduction program] are already started.
What are the biggest challenges in all this?
Besides the process, technology, and policy challenges, vendor capability is a key issue. Everybody’s working on Stage 3 [of meaningful use preparation], all the vendors, but the government hasn’t provided standards; Stage 2 standards are there already.
Where are the biggest vendor gaps in the readmissions arena?
Their products are more based on the directives given by the government than what is good for the patient. Let’s say I have CHF; I go to the hospital, I get treated and I get discharged. The vendor needs to make sure that my discharge instructions and discharge medications were provided to me. That’s an area where the vendors might not be the best at; but they won’t leave the chance to pick you up when you come again. So the gap is incomplete education given at discharge, which causes the patient to come back. And then you get dinged again in terms of reimbursement. That’s where the vendors fail you.
One of the things that seems clear about Adventist is that you and your colleagues are changing the culture in terms of expectations of the care delivery process and of physicians.
Change of culture comes from the leadership. In everything we did before in medical informatics, we were trying to convince the CEOs. Now, the CEOs and CFOs are all over this when it comes to readmissions, because of the reimbursement, because of the money involved.
How are you and your colleagues working effectively with the finance people in your organization?
We’re giving them the analytics; we’re sharing with them the eight conditions that Medicare is zeroing in on, areas in which we’re not getting reimbursed in terms of readmissions. So we’re sharing the analytics with the CFO on this.
And you’re helping the finance people?
Yes, we literally bring the analytics to the finance people. And they get the information from the CMS [Centers for Medicare & Medicaid Services] regulations, but they don’t know how to interpret them, so they look to us.
How are you working with the physicians in your organization?
They are realizing the value of this now, two years after go-live. And now they hate to write orders on paper. In fact, now that the adoption is very high, now, the physicians are asking for better solutions to improve patient care. For example, for sepsis, we’ve put in a system that basically alerts the doctors if the patient appears to be going into sepsis. So if we put in alerts, or the system identifying certain conditions in patients in the EHR, virtually—so if my heart rate, temperature, respiratory rate, fever, serum lactate, go up, that can alert the doctor that I’m sliding into sepsis. These are different things that can help the doctor.
What are the couple biggest lessons being learned so far in your organization?
Optimization comes if there is successful adoption. And this is directed by the end-users themselves.
So the physicians really have to be engaged?
Physicians lead. The physicians will say, OK, I want you to create a dialysis order as a discrete set within the ordering process; or, allow me to order chemotherapy meds within the EHR, which is a very specialized thing.
What would your advice be to fellow medical informaticists?
I would request all medical informatics leaders to get more and more buy-in and adoption. If you make the lives of end-users/physicians miserable, they will never realize the value of what you’ve done, and you can forget optimization; it will never happen.