Published in the December 2010 issue of Today’s Hospitalist
When Virtua decided to transform itself in just two years from a paper-based health care system to one that is nearly paperless, administrators knew they needed physician champions.
This past summer, Virtua “which is based in Marlton, N.J. “cut the number of shifts that hospitalist Tarun Kapoor, MD, works in half. Instead of holding down a traditional seven-on/seven off schedule on the wards, Dr. Kapoor now works clinically just one week a month. That allows him to work 80 hours spread out over the other three weeks on Virtua’s health information technology system.
Dr. Kapoor is far from alone as a hospitalist who splits his time between clinical duties and medical informatics. A number of hospitals have figured out that diverting physicians from clinical duties may be their best hope for tailoring technology to doctors’ needs and moving into the new (and incentivized) electronic era.
At Virtua, Dr. Kapoor explains, administrators realized that they couldn’t meet their “very aggressive timeline” by asking physician volunteers to meet over dinner twice a week. “And hospitalists are the natural people to be involved,” he adds. “If you are designing an inpatient electronic medical record, who uses it more than hospitalists?”
While Dr. Kapoor says that having a foot in both arenas makes him a more efficient clinician, he sees his new role as a natural outgrowth of the specialty’s track record in quality improvement and patient safety. For hospitalists, it’s also one more emerging professional option, with some hospitalists now eyeing chief informatics officer slots as a way they want to eventually go.
Ignore doctors at your peril
With $5 million to $10 million of government stimulus money per hospital on the line, health systems are scrambling to demonstrate over the next few years that they have an electronic medical record (EMR) up and running and are putting it to “meaningful use.” But hospitals that have failed in their drive to go electronic have learned one hard lesson: Ignore clinicians at your own peril when planning, customizing and implementing an EMR.
“There is an 80-20 rule in informatics: Technology is only 20% of the issue,” Dr. Kapoor explains. “If you don’t understand the workflow and you don’t tailor it to your workflow ” the way that the people who need to use it will use it “it won’t work.”
For hospitals with a short memory, he says, one IT project at Cedars-Sinai in Los Angeles serves as an important reminder. In 2002, that hospital had to shelve its $34 million computer system after just three months when the clinical staff rebelled against using it. “Everyone in information technology remembers the lessons learned at Cedars-Sinai,” Dr. Kapoor notes. “It’s like ‘Remember the Alamo!’ ”
Identifying “super users”
While the idea of paying physicians to do something other than treat patients may seem extreme, the cost of physician time pales compared to what hospitals are investing in information technology.
“Hospitals realize it would be a shame to invest so much money and time and miss the meaningful use deadlines,” says Jill Goldenberg, MD, who splits her time between hospital medicine and clinical informatics at Mount Sinai Medical Center in New York. Putting in an EMR is “a huge expense, so buying out one physician’s time to make sure that deadlines are met is a pretty small price to pay.”
Hospitals are so keen on getting physician input that some are turning to physicians with little or no formal informatics training.
Abby Agulnek, DO, a hospitalist at Northwestern Memorial Hospital in Chicago, is a good example. She was asked to spend time as associate medical director for clinical information systems, even though she has no IT training nor is a natural techie. What she has been, however, is a “super user” of the hospital’s EMR.
“There are definitely tricks you can learn to help in notewriting, for example, or ordering labs,” Dr. Agulnek says. She spent first her residency and then her years as an attending showing colleagues how to customize note templates to save themselves time.
When Northwestern decided to upgrade to a commercially sold system, she says, it became clear that the health system’s programmers and analysts could use “clinicians’ eyes and input when bringing in upgrades, managing orders, and creating new rules and alerts.”
Doctor vs. programmer
For example, Dr. Agulnek says that computer experts who aren’t physicians “when left on their own “tend to build tools that either give too much or too little information.
Consider the sign-out form. “You don’t want one patient per page because you don’t want 90 pages of notes to hand off” to the night hospitalist, “and you don’t want hospitalists spending more than a few minutes preparing the sign-out before leaving for the day.” At the same time, the form needs to “communicate the key elements of the patient’s stay and what to look out for going forward.”
Getting that balance right, Dr. Agulnek points out, requires physician input from the get-go “and, often, user testing. “Hospitalists have been broken out as a distinct EMR-user group,” she explains. She takes her colleagues’ experience back to the programmers for more fine-tuning before anything is rolled out to the entire medical staff.
Matthew Fred, MD, who works full-time as an informatics expert at New York Presbyterian Hospital in New York and one week a month as a hospitalist at Virtua, says that his clinical expertise is particularly helpful in the area of electronic documentation. One key concern, he points out, is finding the right balance between structured notes and free narrative.
While there’s a natural tendency in information technology to opt for more structure in notes, Dr. Fred says that as a physician, he knows how structure can sabotage nuance. “It’s easy to lose the subtleties of the clinical situation,” he points out, “when you’re forced to fit everything into checkboxes.”
Then there are prescribing issues where physicians need to step in and overrule programmers’ instincts. According to Henry Feldman, MD, a part-time hospitalist who works 70% of his time as chief information architect for clinical informatics at Beth Israel Deaconess Medical Center in Boston, a programmer will say that physicians shouldn’t be allowed to order the same prescription for the same patient at the same time twice.
That seems like a good protection for patient safety. The problem, Dr. Feldman notes, is that doctors sometimes need to write a duplicate prescription.
“Maybe the patient gets halfway through the prescription and you want to double the dose, but you don’t want to give him a whole new prescription for 20,” he says. “You want to give him an extra 10 but a programmer would want to restrict that. That’s where informatics is the real bridge between programmers and clinicians.”
The view from the trenches
According to Dr. Agulnek, working as both a hospitalist and an informatics intermediary helps her identify systems problems much sooner. She’s personally seen colleagues, for instance, develop workarounds for IT problems that she’s been able to report back to IT and have fixed.
“People tend to complain, but they don’t really call the help desk or report their concerns,” she explains. “By continuing to work clinically, I can gather more relevant feedback to help fine-tune the system.”
That view from the trenches is critical, say physicians, given the current emphasis on quality of care and patient safety. Hospitals realize that too much is at stake to roll out a system without at least input from the front lines.
“If you come up with a computerized workflow that doesn’t match the human workflow, you are going to hurt people,” Dr. Feldman explains. “It’s like an airline pilot getting into a 747 in which you have swapped the position of the gauges. He might look at the wrong gauge, and that one second might make a difference.”
“Of the 12 patients I will see today, I could hurt at most 12 people,” Dr. Feldman adds. “But if our order entry system decides to deliver the wrong meds to the wrong patients, we could kill everybody in the hospital.” Put in that context, he continues, you have to wonder why more hospitals aren’t paying clinicians to work on their informatics systems.
Customizing for culture
But even if the stakes weren’t so high, physicians bring a certain sense of clarity to a process that can sometimes take on a life of its own. At New York’s Mount Sinai, Dr. Goldenberg has stepped in as one committee works its way through a seemingly never-ending and growing list of potential “alerts.”
“This committee may be going forever,” she says. “If you have too many alerts and they are not appropriate, they are worthless.”
She also points to another big reason why doctors need to be involved: While hospitals used to think that the money they paid for commercially available systems was their biggest investment, they now realize that writing that first large check is just the beginning. Off-the-shelf systems need to be customized to the culture of individual hospitals.
“All the vendors give you content to work with,” Dr. Goldenberg says, “but it would be challenging for us to just take their out-of-the-box system and use it. We have a way of doing things here at Mount Sinai, and the change would be too disruptive if we didn’t spend a lot of time molding the system to our wants and needs.”
Another benefit that hospitals derive from embedding hospitalists in IT initiatives: They are relatively cheap, at least compared to surgeons and other specialists. Robert Lineberger, MD, says his hospital “Durham Regional in Durham, N.C. “offered to buy out half of his clinical hospitalist work after a specialist it approached first turned the job down, saying the hospital wouldn’t be able to pay him to give up half his practice.
But Dr. Lineberger also says that hospitalists come with built-in credibility. They work closely with other specialists, which is a big plus in IT development. And whenever physicians complain about an electronic glitch that happens when they are trying to admit a patient at 3 in the morning, Dr. Lineberger says, “it’s easy for me to say, ‘I know what you are talking about.’ That’s credibility that another type of physician may not have.”
In Dr. Lineberger’s mind, one of the most important roles that hospitalist-informaticians like himself play is to stop hospitals from moving too fast as they implement their EMRs, despite all the financial and regulatory pressures to speed up.
“One of our roles has to be to say, ‘This is ready and this is not,’ ” he says. Hospitalists need to speak up when a particular rule or order set that is about to change may cause problems for clinicians used to a particular workflow.
That’s particularly important now, Dr. Lineberger says, because few hospitals are truly going from zero to 100% electronic overnight. Most instead have some electronic information systems in place “for viewing computerized lab results or billing “that physicians are used to. New systems, he adds, sometimes can be harder to use than old systems.
That’s why Dr. Lineberger doesn’t see an end to a need for hospitalists like himself who can bridge the two worlds. Even though his hospital has had its CPOE system up and running for several years, Durham Regional is just starting to move toward meaningful use in medication reconciliation and problem lists.
“My challenge now is to try to get some protected time for other hospitalists in our group,” Dr. Lineberger says. “We have so much going on that I can’t do it all.”
Nor is there any real end in sight in terms of how long hospitalists will be splitting their time between medicine and IT. At Virtua, Dr. Kapoor says that having the dual roles is intellectually stimulating, while gaining a third weekend a month is “priceless.” However, his involvement with the IT project is scheduled to last only one year.
“But everyone thinks that once a system goes live, the work is done,” Dr. Kapoor notes. “If anything, going live is just the beginning. When Apple released its first computer, they didn’t stop development, did they?”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.
What’s involved in “meaningful use?”
Health care reform created incentives for hospitals to not only get electronic medical records up and running but to put those systems to “meaningful use” in improving patient safety, quality of care and public reporting. To qualify for incentives, hospitals have to demonstrate varying levels of the following core electronic objectives. (They also have to meet five out of 10 additional menu options, which include such items as drug formulary checks and medication reconciliation.)
- Record patient demographics, vital signs and chart changes
- Maintain up-to-date lists of active diagnoses, as well as medication lists and medication allergies
- Record smoking status for patients age 13 and older
- Provide patients an electronic copy of their health information and discharge summary and instructions, on request
- Maintain CPOE, and implement drug-drug and drug-allergy checks
- Electronically exchange information among providers
- Implement one clinical-decision support rule and protect data security
- Report quality measures to states or the CMS
Source: New England Journal of Medicine