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Physicians Aggressively Pursuing I.T.
Health Data Management Magazine, September 2006
Many startup vendors vanished into the ether in the dot-com bust, however, and Triangle Orthopaedic's vendor was absorbed by another. But the I.T. bug had bitten Mallon, and he's still an active player in the Durham, N.C.-based practice's technology initiatives.
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His comment and efforts reflect a common commitment among physicians who have chosen to take on a leadership role in the use of I.T. Many of them, especially outside the hospital setting, do not have a technology title or formal I.T. duties. But they have taken on equivalent responsibilities just the same, on top of their clinical roles.
"Physicians are getting a sense of the importance of the I.T. task," says William F. Bria, M.D., chief medical information officer at Shriners Hospitals for Children, a 22-hospital delivery system based in Tampa, Fla.
"It's one of the most important 'aha' revelation points as they move from being casually involved in I.T. to physician champion to the longer term and more risky step of pursuing permanent information technology positions."
Whatever the setting, physicians who push for new information technology tools are developing skills-often on their own-and doing so in greater numbers.
"More physicians have gone from viewing I.T. as 'Oh, isn't that interesting,'-like a singing pig-to sitting in the executive board room," says Bria, who also is chairman of the Association of Medical Directors of Information Systems, Lake Almanor, Calif.
Many physicians who spearhead I.T. initiatives say necessity breeds their interest and curiosity brings out the scientist in their nature. Some of these innovators go looking for specific new technology, but others encounter them by chance.
At the 20-physician Triangle Orthopaedic Associates, EMR and practice management technology was in use, but there was room for improvement, Mallon says. There also were more products on the market from which to choose as vendors in the space continued to enhance their products.
Four years ago when visiting a friend practicing in Texas, Mallon came across an application from Watertown, Mass.-based athenahealth Inc.
"We liked it, but had just bought another practice management system," Mallon explains. "Then we got a new CFO and in 2005 he talked about looking at athenahealth again."
Athenahealth offers Web-based practice management software and business services for a percentage of a practice's revenue. Triangle Orthopaedics went live on the practice management application in May.
The practice also is exploring options for a new EMR, an area of strength for Mallon. He has written program code for EMR systems and has seen enough applications to know what works and what doesn't. He also has designed computerized operating notes software, which athenahealth licenses.
Mallon majored in math in college, which helped him quickly pick up programming skills.
"I would have majored in computer science, but it wasn't offered when I went to Duke," he says. His theory on tweaking applications is process-driven. "I never want to do anything on a computer three times. Twice is OK, but no more." His solution is to write codes or macros to shorten steps and streamline repetitive tasks.
Administrative and clinical factors driven by practice growth led physicians at St. Luke's Family Health LLC in Boise, Idaho, to deploy new technology.
Five of the practice's 14 physicians joined the group this past summer, says Bill Crump, M.D. The sunsetting of the group's practice management system was seen as an opportunity to replace it with technology that would enable the practice to keep up with the increased volume of data. The only way to expand the practice would be to go with an EMR, he says.
Crump had been interested in EMR technology for 10 years, since his residency days. He volunteered to do some legwork to examine available products that began with a trip to the 2003 American Academy of Family Physicians meeting.
What he saw was a mind-boggling range of functionality and pricing.
"Per-provider fees ranged from $5,000 to $50,000," he notes. "The average family physician with $325,000 in annual revenue is not going to be able to pay $50,000 for an EMR."
St. Luke's Family Health was using a rudimentary charting application, but it was too basic for the practice's needs. "We wanted something sophisticated, but affordable," Crump says.
Crump and members of a technology search committee investigated a half-dozen systems and then asked for demonstrations. He and the practice manager then attended the Towards the Electronic Patient Record Conference & Exhibition in the spring of 2004.
Meetings and displays
"We went to all the meetings and saw all the displays," Crump says. "By the end of TEPR we had an idea of where people were, and the practice was committed to doing something."
After extensive demos and reports from the search committee, the group selected practice management and EMR technology from eClinicalWorks LLC, Westborough, Mass. Both systems rolled out in October 2004.
Crump and practice leaders liked the applications' programming ease. Early connectivity issues to its four sites were resolved by using a shared data server maintained by St. Luke's Regional Medical Center, also in Boise.
The price also was attractive. Licensing was $10,000 for the first physician and $5,000 for each additional doctor. The practice's two nurse practitioners were included at no charge, Crump adds.
The whole implementation cost about $110,000, he says. That included servers for each location, seven Tablet PCs for doctors and nurses, and several hardwired PCs.
Like Crump, other physician innovators often prowl the aisles of product exhibitions at industry conferences and trade shows to see what's available and to compare different products.
At The University of Texas M.D. Anderson Cancer Center in Houston, an internal study aiming to improve patient throughput and save time and materials led John Frenzel, M.D., and some colleagues to conduct a gap analysis. That laid the groundwork for a trip to the 2005 Healthcare Information and Management Systems Society conference.
Frenzel, an anesthesiologist and medical director of the ambulatory surgical center at the cancer center, also chairs the surgical informatics department. He wanted to examine "stress points" in the care process to see if technology could help, he says.
"The gap analysis examined the way patients move through the care system and we looked for things that bogged us down," Frenzel explains. "The patient consent process was one that commonly slowed us down."
The HIMSS product exhibition included several vendors with standalone products. A review of those offerings, combined with previous research, pointed Frenzel toward Dialog Medical, Duluth, Ga.
M.D. Anderson, however, wanted Dialog's standalone consent software integrated into its homegrown EMR, Frenzel says. Dialog also was interested in linking with the provider's EMR, so both parties were ready to talk.
Some of the other vendors were not willing to embrace integration, he notes. "They wanted to sell a monolithic piece to go into our infrastructure someplace. We wanted someone to build it as a service to plug into our system. Dialog understood where EMRs are going and not all of them can use standalone apps."
Discussions with the vendor got serious after March 2005, and I.T. staff from both sides began examining how to break the consent piece out of Dialog's system, Frenzel notes. Integrating the Dialog product began in June 2005 and go-live is expected this fall.
Once online, the system will enable surgeons and other clinical and support staff to confirm that patients have given their consent. That will head off embarrassing last-minute scrambles to locate consent forms and get them signed, as well as the delays caused by such scrambles.
"Having to do this at the last minute makes you feel like an amateur and shakes the patient's confidence," Frenzel adds.
Automating the paper-based consent process also helps the cancer center comply with Joint Commission on Accreditation of Healthcare Organizations' audit time out requirements. The system enables caregivers to document electronically that the "Five Rights"-confirming the patient's identity and scheduled procedures-have been reviewed for accuracy.
In the past, the review process for procedures involving anesthesia was documented, Frenzel explains. However, "most hospitals, including ours, couldn't tell you about other procedures."
Like Frenzel, some physicians take on or share the role of I.T. investigator after top management has agreed in principle that technological improvements are needed and should be funded. Others act on their own and initiate I.T. research before bringing ideas to executive leaders.
Selling the idea
Depending on management's stance, physician innovators might need to convince leaders of the necessity of a particular technology. Or they might need to persuade clinicians and other staff to use the tools once they are in place.
At M.D. Anderson Cancer Center, management was on board from the outset. Clinical and staff users "wanted it yesterday," Frenzel says. "They were drowning in paper. It's frustrating if the consent process has to be redone at the bedside."
For physicians like Darrick Nelson, M.D., access to data has become a passion.
Nelson is assistant professor of family practice at Texas A&M Health Science Center, Corpus Christi, and teaches at the Corpus Christi Family Practice Residency Program affiliated with CHRISTUS Spohn Health System. Spohn is part of CHRISTUS Health System, also based in Corpus Christi, a 40-hospital not-for-profit Catholic delivery system.
Nelson took his personal use of handheld technology to new heights when CHRISTUS Health System decided to implement patient data access software from PatientKeeper Inc., Newton, Mass., enterprisewide.
His and other physicians' use of PatientKeeper at CHRISTUS Spohn served as a model for how the technology could help physicians access patient data, such as test results, enter progress notes and access reference material.
"We were doing it here and were seen by the whole organization," Nelson says. "And with a little understanding, they saw the value of mobility."
His main role since the delivery system embraced the mobile technology has been advocating it to physician users. "I'm doing my best to promote the technology," he says. "I train residents and get them all handhelds and $400 of reference materials."
Physicians who have gone through a 10-minute, one-on-one training session and taken the time to try the system have discovered they can access valuable information, Nelson says. For example, they can download the day's patient load information to their smart phones while driving to work.
PDA gift
Nelson's first exposure to the handheld technology was through the gift of a Palm PDA, from Sunnyvale, Calif.-based Palm Inc., from his wife. She thought it would save him time when he began his residency.
"It didn't take me long to realize handheld technology could be a fantastic aid in patient care, education and safety," Nelson notes. "Even 8-megabyte devices were equivalent to 50 pounds of textbooks."
He began taking notes on his handheld that enabled him to look up details when he got home at night. In 2001, he began using PatientKeeper as a patient tracker. He thought it was a tremendous improvement over the usual 3x5 cards.
In the end, Nelson's wife turned out to be right. "I'm able to do more work and faster because I can do electronic progress notes," he says. "The mobile technology makes doctors' lives easier and improves quality of care and patient safety."
Getting other physicians and staff to use new technology is where some doctors step up to the I.T. plate by sharing their own enthusiasm for a particular tool.
Chris Mescia, M.D., is one of four pediatricians at Nassim & Associates in New Albany, Ind. His practice is planning to buy an EMR system, and to get to this point has required some I.T. support from Mescia.
Nassim & Associates has had document imaging technology from Allscripts LLC, Chicago, in place since the summer of 2005 and is phasing in MicroMD, practice management software from Microsys Computing Inc., Boardman, Ohio.
Assist in training
The practice relied on Medical Software Associates, an I.T. services vendor also in New Albany, to help evaluate practice management applications. Once the decision was made and implementation began, Mescia stepped up to assist with training. "That was my baby," he says.
The practice was moving to a new location and upping square-footage from 4,000 to 12,000. The timing was right for the new practice management system purchase, and the fairly straightforward, Windows-style pull-down screens made it easy for users to find what they sought.
"We had a software demo that showed the advantages over our previous system," Mescia says. "With the simplicity of use and pulling in doctors' schedules, staff took right to it."
Clinicians have adapted to the TouchChart application from Allscripts and are learning to use MicroMD's electronic billing capabilities. 'We can search ICD-9 and CPT codes and that enables us to be more precise," Mescia notes. "We had to learn to do it on the computer, and it's not as fast as checking boxes on a sheet of paper, but it's more efficient."
Physicians contemplating taking on I.T. initiatives often aim for new efficiency or quality targets. And as the industry moves into the pay-for-performance era, information technology will be essential for keeping track of details, experts say.
Doctors must consider several points when pondering I.T. projects, says Kip Webb, M.D., associate chief medical officer at BearingPoint Inc., a McLean, Va.-based consulting firm.
"First, think of where you want to go," he advises. "So many I.T. implementations are trying to electronically duplicate what they are already doing, and that's a mistake."
Workflow, which for many physicians is what they are trying to improve with technology in the first place, should be viewed in terms of how changes will help with quality of care, Webb says. "Look for ways to offload work from physicians to someone upstream, such as front desk staff or nurses."
To many physicians, technology is at the heart of health care's most important issues. M.D. Anderson's Frenzel recommends that doctors looking to spearhead I.T. projects address process changes by building consensus for technology and a shared vision of the desired results. "But the really important thing is patient safety," he says.
Pay-for-performance initiatives and the drive to reduce patient mortality rates are focusing on the quality and safety of care. Frenzel and other physicians see a clear link between clinical and financial goals, including patient safety improvements via I.T.
"Patient safety has to do with economy of action and resources and making the right choice the first time," Frenzel says. "All those things save money. It all drops to the bottom line."
Many factors to consider
The economic impact of I.T. is one of several factors that can define an initiative's success, says Nelson at CHRISTUS Spohn Health System. His advice to other physicians: "You have to show an I.T. project will demonstrate one of three results: improvement in business literacy, patient safety or quality of care."
By business literacy, he means return on investment, broadly, or "taking technology initiatives that will not negatively impact the bottom line."
Part of ensuring an I.T. project's success is in evaluating products, advises Mallon, at Triangle Orthopaedics Associates. He recommends being wary of vendor product claims unless physicians can see them in action.
"Go to other practices and see what the process was like when they converted to new information systems," he says. "We probably didn't do as many site visits as we should have."
Triangle Orthopaedics is willing to share all the gory details of its I.T. projects, he adds, and now serves as a showcase site for athenahealth.
Sidebar
I.T. Innovators Are Problem-Solvers At Heart
For many physicians who take on I.T. projects, it's a matter of fixing what they know or suspect is broken in health care delivery processes. For example, Chris Mescia, M.D., a pediatrician at Nassim & Associates in New Albany, Ind., has been involved in implementing a practice management application from Microsys Computing. He also has been spearheading rollout of e-prescribing software from Allscripts LLC, Chicago.
Mescia's participation goes deeper, however. He developed an electronic prescription refill request form to work with the TouchChart application from Allscripts.
"When nurses take a patient's call they can pull up blank refill request forms," Mescia explains. The form asks the medication name, what it's for, and whether and when the patient is due for a follow-up visit.
"Then they can fire the e-form to a doctor and we can check a box to fill, or limit fills, or whatever is called for. Then when we're all done we send it back to the nurse."
Some physicians have parlayed their inherent interest in I.T. into formal advisory roles. Darrick Nelson, M.D., teaches at the Corpus Christi (Texas) Family Practice Residency Program.
He has used mobile technology as a medical resident and at CHRISTUS Spohn Health System, where family practice residents work. The successful use of I.T. at CHRISTUS Spohn helped convince parent organization CHRISTUS Health System, also based in Corpus Christi, to deploy mobile patient data access software from PatientKeeper Inc., Newton, Mass., across its 40-hospital delivery system.
That experience landed Nelson on a committee of physician-technology champions that meets several times a year to review new I.T. tools.
Facing the realities of today's health care environment is causing physicians to overcome a natural aversion to I.T., says Donald Bialek, M.D., senior consultant at Computer Sciences Corp., an El Segundo, Calif.-based I.T. services and software company.
"Many physicians think I.T. just gets in the way," Bialek says. "But they also are starting to realize that 40% of their time is spent acquiring information and 40% disseminating information. Only 20% of their time is actually spent practicing medicine."
They are seeing that clinical information systems can help them get and disseminate data much more quickly, he adds.
Sidebar
Want Hospital Data On Your Patients? Just Ask.
In late 2004 it didn't sound like too much to ask. Michael Mignoli, M.D., just wanted to get information on his patients from Littleton (Colo.) Hospital's information systems into his practice's EMR, from Seattle-based Practice Partner, formerly named Physician Micro Systems Inc.
"I wanted to play with the data in my own sandbox," says Mignoli, one of two physicians at South Park Internal Medicine in Highlands Ranch, Colo. "I didn't want to deal with outside paper."
Mignoli is a self-described dedicated EMR user, having used some form of the technology for 11 years. The key to an EMR system's usefulness is interfacing with other applications, especially lab systems, he says. "I had interfaced with two major outpatient labs. So I decided it was time to see what I could get from my hospital."
Littleton Hospital is one of 12 hospitals in Centura Health, an Englewood, Colo.-based delivery system.
Fortunately for South Park and other community practices in the Denver area, the hospital already was pursuing the same idea, says Michael Shrift, M.D., Centura's chief medical information officer.
"Just about every doctor in the community had been thinking about this," Shrift explains. "We were fortunate to think it through enough to know we needed a partner, an expert in document management on a large scale and with health care expertise."
It found that partner in Mobile MD, a Newtown, Pa.-based company with expertise in health information exchange software has already discussed data networking with Mignoli. Mobile MD is part of IntraPrise Solutions Inc., Warminster, Pa.
"We happened across Mobile MD and they met our concept for an information clearinghouse," Shrift says. "Then they brought us together with Dr. Mignoli and we ran with the pilot."
Centura's plan is to use the software to push data out to community physicians' EMRs. Mignoli's history with EMR systems and his relationship with Littleton Hospital made his practice a great place to test the application.
"Mike is passionate about patient care," Shrift says. "And Centura has a passion for physician engagement. We are looking for ways to serve community physicians."
Group practice-based physicians are pursuing EMR systems in greater numbers than ever, experts say, to improve quality control and patient care, but also in anticipation of pay-for-performance initiatives among public and private payers. These physicians often must look outside their practices for assistance with I.T. projects, says Kevin Carr, M.D., senior manager in the clinical transformation practice at BearingPoint Inc., a McLean, Va.-based consulting firm.
"One of the ways physicians are adopting I.T. is through an organizational approach with hospitals and regional health information organizations," Carr says. "These are the 'champions' that have a passion for quality improvement."
Hospitals face significant costs to interface with physician practice EMR systems, however. Most would prefer physicians to buy compatible practice EMR systems, Carr says. But community physicians can help by approaching their local hospitals as a group with a common goal to get data electronically.
Many physicians look to their local hospitals to help them bridge I.T. funding gaps. Centura picked up a one-time charge of $7,500 for Practice Partner to set up South Park's interfaces with Littleton Hospital, Mignoli says. His practice pays 18% of that fee for annual EMR support, and Mobile MD charges $75 per provider per month.
The benefits of linking with the hospital include accessing data in a format with which Mignoli is comfortable with, and it's fast.
"I can do a history and physical one night and get it into the EMR by 9 a.m. the next morning," he says. Eliminating the hassle of scanning paper reports also cuts labor costs, he adds.
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