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Smoothing the Path to Inpatient/Outpatient Integration

November 1, 2010
by Mark Hagland
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An Interview with Janie Tremlett, Senior Vice President of Strategic and Clinical Consulting, Concordant
Janie Tremlett
Janie Tremlett

Janie Tremlett, an expert who consults on a broad range of issues, including electronic health record (EHR)/electronic medical record (EMR) integration and health information exchange (HIE) development, spoke recently with HCI Editor-in-Chief Mark Hagland regarding the challenges of inpatient/outpatient clinical information systems integration.

Healthcare Informatics: Tell us about your recent work in the inpatient/outpatient integration arena.

Janie Tremlett: Concordant, as a company, focuses on the EHR and on ambulatory and clinical information systems; and I head up strategic consulting. So I work with hospital CIOs and with physician groups to make this stuff happen. And I recently held a CIO forum on this topic. That gathering came about because five CIOs were calling me with the same kinds of questions, so we ended up holding the meeting on July 15 in Boston. I had about five CIOs. And I asked them for their top three to five issues, and also presented some industry information on where people were at.

HCI: What were the concerns that were brought forward in the meeting?

Tremlett: Among their top issues was the patient master index; and people are really struggling with this now, because the interfaces had been point-to-point, but doing it holistically across the health system is really magnifying the problems. Others were integration of multiple EMR platforms; patient consent; medication integration; the cost of HIE sustainability; and affiliated physician networks. And what we talked about there was governance. And regional versus enterprise, versus statewide HIEs, and who should do what, where. A couple of light topics for breakfast! [laughs]

HCI: What does that list of concerns say to you about the challenges that CIOs are facing broadly in knitting all these systems together?

Tremlett: I think this list of concerns was inevitable. As you know, healthcare has been so siloed in so many ways, in terms of the culture, the technology, the workflow, everything. And everybody's been fine with that isolation. But now when technology is being leveraged to try to bring this together, initially, the hardest thing is actually getting rid of the cultural and process silos. And changing things across a whole integrated health system is a tremendous challenge. In fact, this list is a subset of the headliner issue, which is the human nature piece of this, of having all these little silos; I said to the CIOs, those are the underlying issues you bang your heads against every day.

HCI: Doesn't that speak to the need for CIOs to gather all the right people together at the table to begin with-the clinician leaders, clinical informaticists, and the other leaders needed to really make things happen?

Tremlett: Exactly. We talk in depth with CIOs about governance and staffing; and in virtually 100 percent of the organizations we go into, they find they need to change structures around people. We've had staffing engagements with people for three years now, where, once they've implemented the EHRs, they then find themselves looking for the people who can help create continuity across the continuum of care. So you might have great clinicians who can go out and figure out a practice workflow; but now they need to go out and talk to the lab directors and the long-term care directors, and I think that, there, you need a different skill set.

HCI: Isn't it a chicken-or-egg problem, in terms of needing clinical informaticists to help to begin to solve these problems to begin with? Yet the reality is that most organizations don't obtain those informaticists until they're up against the problems.

Tremlett: I so agree with you. You know, the vendors expect their customers to have clinical informaticists in place. Even in organizations that have CMIOs, the vast majority of CMIOs still partly in practice; yet the CMIO job really is a full-time job. And we've encouraged people actually to look at a complement of people. You might have a physician lead, but with an R.N. who leads the day-to-day on the street. And at Concordant, we've formed a team of nurses to fill that gap. When we started this practice, we had five contracts immediately, because there was such a gap in the industry around that need.

HCI: So when your team goes in, they're probably facing huge gaps in the customer organizations?

Tremlett: Yes, and there's also a huge issue around clinician credibility. I've been in meetings where the IT person says something in IT-speak, and a clinician says the very same thing in clinician-speak, and the other clinicians say, ‘I'm going with you’-the clinician-just because they can't understand what the IT person is saying.

HCI: The core problem is that the non-clinicians don't understand what the clinicians actually do, correct?

Tremlett: Yes, that's a gaping hole that we continue to make our living off of! [laughs]

HCI: What are the more advanced organizations doing around improving the situation around the inpatient/outpatient systems gulf?

Tremlett: The leading-edge ones are really bridging the gaps across the care continuum through a rhythmic, production line-type process. They understand the care management process, they understand what they need to do IT-wise, and the building blocks are there in place. The ones who can't even get the physicians over the adoption and acceptance issues, they're finding themselves stuck. And really, this is a give-and-take situation. And especially to your point with the affiliated practices, I haven't seen too many organizations make massive progress. Let's face it, we're sort of where other industries were 10 or 15 years ago in terms of the IT piece. We're all talking about all this cool, innovative stuff, but overall, as an industry, we're still at ground level. What's more, there are a lot of people who don't recognize that this is a huge transformation process, and they're not addressing the transformative aspects. They need to understand what the physicians are facing, for example in primary care, where reimbursements are being reduced, and the physicians are working longer hours and seeing more patients just to keep up; and especially at core implementation times, the physicians are having to reduce their schedules to adopt the technology, which is leading to physician pushback every time; and we haven't solved that problem. We're pretending that we're in Star Wars, and we're building railroad tracks. I sometimes put my face in my hands and then say, ‘Guys, we're just doing the basic things here!’

HCI: Do you think physicians are finally realizing as a group that IT is no longer optional?

Tremlett: I think it's still very stratified. I've heard 90 percent of physicians who are within five years of retirement say, if you force me to do this, I'm retiring. On the other end, people are having recruiting problems if they don't have an EMR in place, and residents and younger doctors won't join them. The heavy complaints come from the doctors in the middle of their practice. So I'm still seeing tremendous stratification out there. And I'm about to give a presentation to a group of doctors that's already 80 percent implemented, and I'll be talking to them about standardization versus personalization, and yet they don't get that you need standard processes for data capture for quality outcomes reporting yet. It's like when ATMs first came out, and people said, ‘I'm not going to use a bank card.’ And this is the thing with a lot of these docs-they're vehemently against it, but once they get on, they'll never let you take it away from them.


HCI: Do you think organizations just starting out are learning by example from the more advanced organizations now?

Tremlett: I'd love to say to you that we're closer now, but I really don't think we're even close yet. Just getting things into normal production mode in terms of implementation is still a struggle. I was just talking to a large health system, and there are so many challenges within that system, and you know they're going to fail and end up calling you back. I've heard people say, ‘Oh, EMRs, aren't they just turnkey now?’ That came as part of a discussion with a COO, who expressed the idea that he had heard that notion from ‘everyone.’ I had to say to him, ‘We're not talking about Microsoft Word here!’

So, to your point, so many hospital-based organizations are trying to implement core clinical information systems without clinical informaticist leadership, and without the right methodology in place; as a result, they're only implementing the vendor's piece of it. Now, the vendors do an awesome job, but there's still a gap, if you follow that path. And that's hard for us, because it sounds self-serving. But so many organizations are just not in production mode yet; in fact, they reject the ideas that are critical for success.

HCI: What's your advice to CIOs?

Tremlett: That they should use their instincts and successes from other areas, and understand that in this area, all the issues they've faced in other areas, are magnified 100 times. So all the tricks and tools they've employed around governance in other areas, will have to be used exhaustively here. And there's got to be some merit to it, because other people have been very successful using these concepts and methodologies.

Healthcare Informatics 2010 November;27(11):52-53

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