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Dancing With the Docs

October 16, 2009
by aguerra
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It’s 8 p.m. and you just arrived at the high school dance. You think you’ve got all night to ask someone to do the fox trot, so you stand around for a while, have some punch and work up the courage to make a move. But by the time you’ve detached yourself from the wall, everyone has partnered-up. Maybe when this song stops, you think, a few of the couples will separate and you’ll get an opening, but something is strange about this dance, as the couples remain on the floor all night.

What went wrong?

You didn’t realize that there was one golden opportunity between 8 and 8:15 p.m. when you had to find a partner; you didn’t realize that, once together, the couples wouldn’t separate.

Check your watch. It’s 8:10 p.m.

As CIO, you must stress to senior management that today’s window of opportunity for electronic integration with the area’s mega-IPAs (MIPAs) is quickly closing. This is not just good for business, or great for healthcare in the community, but a matter of life and death for your organization. If you aren’t courting the MIPAs in your area, your competitor health system is, and by the time you ask them to dance, they will be attached to another.

But what about HIEs, you ask? “We’ll all soon be able to plug into an HIE-utility hub, so point-to-point integration is a waste of money,” you say.

I don’t think so.

Ninety-nine percent of HIEs (formerly RHIOs), have no business model and run out of gas as soon as they run out of taxpayer money. These organizations consume grants like Takeru Kobayashi devours hot dogs at Nathan’s, leaving little discernable value in their wake. Don’t count on them to solve your ambulatory integration problem.

Many organizations embarked on a sound MIPA strategy when the Stark prohibitions were relaxed. In fact, subsidizing EHR purchases is an excellent way to achieve some stickiness with these practices, while controlling the point of integration. “We’ll pay for your EMR (one that we’ve pre-screened), and you’ll give better care! (And oh, by the way, you’ll probably refer a heck of a lot more patients to us since you’ll be able to see their hospital discharge summaries right in your office system and good stuff like that).”

But then HITECH came along, with its direct incentive payments to the practices, taking the hospitals out of the loop. Some CIOs I spoke with said, “To heck with our Stark plans. Why should we pay for an EMR when they’ll get the payment for its use?” This made sense to me for a while, as I worked through the issue in my mind.

But then a strange thing started to happen, some CIOs continued with their Stark plans, despite the HITECH monkey wrench. My initial reaction to this was to blame it on inertia — once the Stark programs were in motion, bureaucracy made them more difficult to stop than it was worth. But I kept hearing it, and decided it couldn’t all be attributed to red tape.

Slowly I started to get the picture; despite the cost of subsidizing hundreds or thousands of ambulatory EHR licenses, it’s still beneficial for health systems to “lock up the docs,” as I’ll call it.

When I covered Wall Street, the buy side, or investment management organizations, held the power (think MIPAs); while the sell side (think hospitals) courted the buy side with every legal enticement imaginable (some only semi-legal). In healthcare, it’s the MIPAs that everyone wants to dance with; it’s the MIPAs imprimatur that can make or break you.

It’s 8:11 now and everyone is partnering up. Make your move.



Actually the bad economy is helping give hospitals a little more time to figure this out since the IPAs are finding physicians reluctant to 'pony-up' for what is still a significant investment. And the ongoing maintenance and support scares the 'bejeezes' out of them too. Two other relevant factors are georgraphy and evolution. A physician/practice in downtown Chicago (like Lyle) is much different that one in rural Nebraska (or even central IL). So hospitals need to understand their specific physician environment to know how to proceed.

Nice conversation opener, Anthony!

We're seeing hightened interest in the connection to (aka interoperability with) ambulatory systems, with-or-without Stark and HITECH incentives as strong drivers. It's for exactly the reasons you outlined. It is 8:11pm.

There's another dimension you captured, the Wall Street view. I'm told that their model can be very black or white. You're either predator or prey, from a Wall Street thinking standpoint. No moral judgements or perspectives are part of that picture and no apologies. Those who have coupled up are the predators. Those who havent are the prey. Many doctors and hospitals see the dance as survival. All that said, it's a very regional thing.

LOL. It's a fascinating topic. I interviewed the CIO and CMIO of Texas Health Resources (14 hospitals) recently, and they said that there's a race to get EMRs into the ambulatory practices between the hospitals and the IPAs. If you're a primary care independent physician, everyone is coming after you. Let's make a deal!

Great post, Anthony. This issue is so big right now. One really interesting thing I found at MGMA is that some of the vendors are focusing heavily on physicians, with the angle of "we want you to have the right product for YOUR practice, not something a hospital forces on you." Not all vendors, of course, are doing this, but some are certainly going in that direction. Something to keep our eye on.

And what on earth is a "fox trot"?! Is that the dance they did in It's a Wonderful Life when the gym floor opened up?

Right- the irony is that the EMR giveaway via the Stark relaxations did EXACTLY what STARK was "afraid of" - it allows the hospitals to spend some money to "buy" the favor of local doctors. Now this might sound bad initially, but the reality is that having a unified EMR provides great benefits to both. On the other hand, one of the reasons it has not spread like wildfire is that the doctors don't trust the hospitals - either to implement well (many hospitals have a long track record of failure in working with outpatient docs on most any project), and more importantly- they don't trust the hospital to "hold their data" - they wonder if the hospital will use that data in some way to hurt them, or to help their competition... and some docs ever bemoan the idea that other docs at the hospital could look at "Their" notes...

So in the end, the financials might make sense, but the cultural issues continue to be a bigger barrier in many cases.

Great point Lyle. I just interviewed Texas Health Resources CIO and CMIO, and they said the physicians are just not ok with the hospital housing their data, no matter what assurances are offered of data segmenting or separation. Maybe that independent streak is a little stronger in Texas, but I'm sure it's generally representative of physicians around the country.

The model which has the vendor hosting the data in an ASP model is much more palatable. In that scenario, the hospital seems to have some ability to push and pull the data for information exchange, but doesn't house the data on hospital servers. A distinction without a difference? I'm not sure.

Thanks Frank. What is new is the chance to integrate with the practices electronically. Don't you think this is a level of "stickiness" that has never existed before?

Interesting but really not a new issue...

The disconnect between hospital & docs goes back to 1939-1941 when Blue Cross and Blue Shield were set up as separate entities. Then in 1966 Medicare put it in concrete with Part A & Part B.
Name one other industry where the lead marketer, and production control person is NOT an employee? It's a business model that won't work — ever.

If you look at all the places where the EMR for both inpatient and outpatient really works its doc owned hospitals (a la Geisenger, Mayo, Kaiser, etc) or military hospitals where the doc must salute and say 'yes sir' gimme that laptop, sir!

So the community hospital has to 'ask 'em' to dance then hope they get a positive response...or go home crying!

For more on this topic, this week, there's a meet-up opportunity in Austin Texas: (from http://www.torchnet.org/ )

2009 Hospital Information Technology Conference (HITCON)

The TORCH Foundation and TORCH are pleased to host our 5th annual Rural Hospital Information Technology Conference on October 20-21, 2009 at the Hyatt Regency Hotel in Austin (map). We have an excellent program planned and invite everyone to attend this unique education event and exhibition. Topics presented include:

* Keynote Address: Delivering on the Promise
* Rules of Engagement: Defining "Meaningful Use"
* Market Dynamics: Where Will You be in the "Buffet Line"
* Strategies to Effectively Secure, Manage and Protect Your Data
* Business Intelligence and Clinical Transformation (Bormel)
* Evaluation and Selection of EHRs
* Going LIVE: Achieving Successful Implementation
* The Art of the Deal: Mastering the Devil
* Technology and the Human Factor
* To Be or Not to Be: Hospital as Data Center and IT Shop
* Putting "IT" in Perspective

Plus, we have planned for an expanded tradeshow that will feature quality health IT/EHR products and solutions in the marketplace. Also, there will be dedicated product demos to allow you the opportunity to see highlights of various EHR systems.