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Driving Away Docs

September 17, 2009
by aguerra
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Before you get militant about CPOE, make sure you’re not the only one.

Let’s start with a few basic premises. Most hospitals in this country are “staffed” with physicians that don’t technically work for them. These independent doctors run their own practices; with their patients constituting an often formidable “book of business” that can be directed to the acute-care institution of choice. In all but the most rural areas, physicians have that choice, exercising it by where they obtain admitting privileges. This reality makes for an often lopsided power relationship in hospital/physician affairs.

Doctors, let’s be honest, usually run the show. Physicians who generate significant revenues are treated like royalty, especially at non-elite medical institutions (where reputation can tip the power relationship back in favor of the health system). But, alas, that is not where the majority of medicine in this country is practiced. For most acute-care organizations, it’s about how much they can do (ital) for (end ital) the doctors, not to them.

At least in its current iteration, CPOE is something doctors largely feel is being done to them. Perhaps this is because of immature user interfaces, perhaps because the methodologies used for obtaining clinician buy-in are still amateurish. (Though well intentioned, I’m not sure if buying a physician dinner constitutes advanced implementation methodology.)

For the latter, there are consultancies that claim to have perfected the rollout.

To address the former, CIOs try switching vendor systems (the grass is always greener), upgrading with the same vendor (the devil you know) or implementing add-ons (Web-native applications that sit between physicians and core clinical systems). In all cases, the goal is identical — giving physicians a Web-like CPOE experience, with IT tying everything together behind the scenes.

While KLAS confirms that the much-anticipated HITECH buying frenzy has yet to materialize, many are investigating the upgrade path. One can imagine the discussions CIOs are having with their vendors:

“My doctors absolutely hate your CPOE functionality.”

“How about upgrading to version X.2?”
“Is it any better?”


“But we just spent a few million getting on X.1 and have written all the interfaces between it and our ancillaries.”

“Oh, yes. That’s true.”

“And going to X.2 requires me to reconfigure my whole server environment.”
“Yes. I didn’t think of that.”

“And I’d have to retrain all my clinicians, which they certainly won’t like.”

“They sure can be ornery.”

“So what am I supposed to do?”
“Why don’t you buy the doctors dinner and convince them to use X.1?”

If, at that dinner, the local cardio-thoracic superstar surgeon (CTSS) repeats that he “didn’t go through 10-plus years of education to do data entry,” what will you do? What will your organization do? Will you banish his millions to the hospital across town which might be far more sympathetic to his position?

Perhaps that facility is playing the HITECH game more adroitly. You see, the initial definition of meaningful use only requires that hospitals have 10 percent of their orders going in through CPOE by 2011. Will slick hospitals get to that 10 percent on the backs of their junior (lower revenue generating) docs, while leaving Mr. CTSS alone as long as they can? Will crafty hospital administrators lure Mr. CTSS to the “more understanding” environment of their facility?

“Of course we don’t expect you to do data entry. You’ll find a home here.”

The games will get even more interesting next year, when CMS informs the industry exactly how hospitals are to prove their compliance with HITECH’s meaningful use and certification requirements. Will it be a simple attestation signed by the CIO, CEO and CFO (or any combination)? Will there be some inspection process for everyone (though I can’t imagine CMS has such manpower) or will reporting be like filing taxes, done on the honor system with the threat of audits as a looming stick?

Whatever is ultimately decided, there will be wiggle room in both achieving compliance with the objectives (getting to 10 percent) and in the reporting (we’re at 9 percent, they’ll never audit us). As usual, the uber-scrupulous may suffer for their veracity, while those with a more flexible interpretation of reality could find that approach yielding fatter margins.

It’s incumbent upon HHS, CMS and ONCHIT to scenario-play their meaningful use certification and reporting requirements all the way down the line to find the wiggle room many exploit. With some special interest prodding (see HIMSS), the government has started this ball rolling, so it has an obligation to ensure the honest aren’t left in fiscal disarray as a reward for their veracity. When there’s so much money on the line, someone will figure out how to make Mr. CTSS happy. When it’s time to talk to him about CPOE, tread lightly, or someone else will.

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