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What's a community hospital CIO to do?

July 15, 2009
by Neal Ganguly
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The Stimulus Bill and the billions of dollars it directs have hospitals and physicians scrambling to qualify as ‘meaningful users’ in order to collect significant incentive payments. Many community hospitals are working feverishly to develop EMR strategies that would link physician offices to hospitals in order to promote the exchange of patient information. The ability to exchange data was a requirement of the first draft definition of meaningful use, and there is no reason to think that it will not remain a requirement. So, what’s a community hospital CIO to do?

Let’s take the case of a mid-sized community hospital with an entirely voluntary medical staff of over 450 physicians, roughly half of whom practice primarily at the hospital. Mix in the fact that the environment consists primarily of small practices of 1 – 3 physicians with a very low penetration of EMRs to date. The stimulus bill woke up a number of physicians, who began to knock on the doors of administration looking for help. Of course, the physicians did not agree on any particular EMR, each citing particular features that they would require, or other concerns that emphasized their independence. So what kind of help did they want? What were their goals?

Wants were easy. They wanted subsidies to help purchase EMRs. They wanted advice on which EMR to purchase, but did not want to be restricted to a few choices. They wanted information on how to get their stimulus incentive money. The more thoughtful among them also wanted to know who would help them install, and maintain the technology, and who they would call when they had a problem. Ultimately, they were wanted assurance that they would be able to collect the stimulus dollars and end up in a better position than they were today (or at least not be in a worse position).

Goals were, unfortunately, very aligned with the wants. Few, if any, talked about the goal of using technology to improve their practice workflow – whether that is measured in terms of patient volume, or charge capture. Few, if any, talked about the value of being able to have a more complete picture of the patient available for review at the point of care. No one talked about the efficiencies that would accrue from less duplicative testing. The goal was money – saving money – making money.

Okay, so the physicians were struggling to understand why they should do this beyond incentive money. What about the hospital? The administration believes that an EMR strategy will be valuable to improving the quality of care and increasing the efficiency of that care. But what is that worth in terms of measurable value to the hospital? How can administrators determine how much to invest in an EMR strategy, and how can they measure success? These questions are landing on the desks of most CIOs and represent real strategic questions. Operational questions are also facing the CIO. Should the hospital contract with and build interfaces to a limited number of vendors, or support a mini-HIE environment that would allow a wider range of EMRs to connect? Should the hospital support a hosted model for small practices? Who will the physicians call when they have a problem? The EMR vendor or the hospital helpdesk? Or will the EMR vendor punt to the hospital anyway? What will it cost to support this operation?

There sure are a lot of questions – I'll let you know if I find any answers...



Neal, I was talking to some CIOs this week about these exact issues. Maintaining this stuff is not something the practices seem to be thinking about, You're right, it's all about, "I can get this, I want it." But if they're not talking about improving patient care by giving a more complete picture at point of care, someone needs to put that back up front where it belongs. I guess that someone is youand every other CIO out there.

All of these are very important questions that should be addressed within each organization as part of their comprehensive strategy. The Stimulus has the potential to change once and for all hospital's role in managing outcomes. Historically, health systems built facilities, installed technology and provided clinical support staff. No longer can an IT Strategy just be an application roadmap. To effectively deal with the Stimulus as well as looming healthcare reform, each organization must examine their own vision, and take on each question you addressed. We are finding for many CIOs this is the secret to C-Suite engagement that many have not been able to attain historically. In many community health sytems, the CEO and CFO are enaged as never before. The work will be difficult, the questions hard, but for those that invest the time, it will be valuable.

Neal, If you're saying that there isn't a concise, compelling, realistic vision that is shared regarding the goal of the stimulus event, then I agree. And that lack of shared vision really does put CIOs in an awkward place. If the problem is that the visions and machinery painted by the current meaningful use and standards process is too broad and grandiose as many would claim, perhaps turning back to David Brailler's thinking of five years ago would help. His analogy regarded standardization in the cellular phone industry. If our focus was a GSM for US healthcare, realizing that grander goals of semantic interoperability, full-touch point CRM and operationalizing episodes of care could be built on improved communication, we might be closer to having a clearer short term focus, ... and less immediate critical good questions.

Pam, you nailed the issue (again). See my recent Leap of Faith post for one connection between IT strategy and CEO/CFO issue of non-reimbursed care, addressing community mandate, and using HCIT to improve the health of an important segment of the population.

While I agree with your comments, the struggle on our side has been physician engagement more than C-suite engagement. The physicians are being motivated by stimulus money, and the hospital is trying to prepare them for the necessary change. However, resources are limited, and the direct return is not sufficiently clear to serve as justification for resource increases. Reform of our health system is needed, but has the short term effect of muddying the waters with respect to planning and resource allocation. True, that is the ultimate role of management, and the C-suite will have to make some tough business decisions, based in no small part on the counsel of the CIOs.

Neal. Please keep bringing this real-world perspective to our readers. I listen to every meeting of the HIT Policy and Standards Committees, and am often concerned that the grand vision of improving our health system in this country obscures some of the realities you describe in this post.

One of the most established principles of success is accepting the reality of one's situation and dealing with that reality. The opposite of which would be to create and implement plans based on wishes, detached from concrete obstacles.

The attitude (based on real-world financial challenges) from physicians you relate is a reality that needs to be dealt with honestly and directly, not wished away (be wary when you hear someone say, 'they SHOULD care about quality improvements').

I think you are right Daphne, CIOs and other execs have to help remind docs about the potential benefits to patient care. However, in their defense, they're often under tight financial constraints and there is a real risk to them in lost productivity. That's something that we're trying to address via education, and maybe other avenues.

I agree with your point Joe, that there is a lack of shared vision. I also agree with the comparison to the cellular phone industry as a cautionary example of how open competition resulted in multiple standards, and ultimately hurt an industry in the long run. A single, strong standard is critical. Information exchange is critical. But, as we look at the value chain, the incentives are still not well aligned to support investments in technology. What good is $44K in stimulus if the physician takes a 10% hit in productivity resulting in lower income? Perhaps the regional extension centers can help to establish best practice in implementing EMR technology to maximize workflow, but are the resources really there to do that - particularly in the timelines laid out by the stimulus package?