For years, McKesson HBOC has consulted with software user groups that give every customer a voice in how the company designs and develops its products. Everyone, that is, except physicians.
It's not that McKesson HBOC or the user group, which operates independently, banned doctors. It's that whenever they were asked to participate, they didn't seem to have the time. Plus, nurses, chief information officers and other staff members were the ones using the software.
The development of the electronic medical record and other clinical software has changed things. More doctors are working on computers, and that makes their input more relevant to software companies like McKesson HBOC, whose customers include 200,000 physicians.
Obtaining that input and turning it into new products or improvements isn't as easy as setting up a roundtable and asking questions.
But Louis Hermans, a member of McKesson HBOC's user group board, says physicians' voices must be heard or software systems worth millions of dollars might not be used to their fullest extent.
"In my hospital and the user group, the ones who speak are interested," says Hermans, CIO at Solaris Health System in Edison, N.J. "I love those people, because you get things done. I don't think (doctors are) a pain. They're a fantastic addition."
Physician involvement in software design "delivers an enormous credibility into this process" of getting doctors to use computers, he says. If doctors know their colleagues had a voice in the system's setup, Hermans says, they're more likely to use it.
"(McKesson HBOC is) very good people," says Raymond Zastrow, M.D., a member of the company's newly christened Physician Advisory Council, an offshoot of the user group. "They know systems and software inside and out. And I think they fall into a trap that anybody in this market can fall into early on, which is underestimating the complexity of what physicians do at work.
"That's not a serious criticism at all because, to their credit, they continue to engage and continue to ask us to explain ourselves to refine their product," says Zastrow, medical director of informatics for the Milwaukee division of Wheaton (Ill.) Franciscan Services, a system of nine hospitals in Illinois, Iowa and Wisconsin. "It's an important dialogue we're in."
What's a focus group?
San Francisco-based McKesson HBOC, the nation's largest healthcare software company, is not alone in championing the involvement of physician advisers. Most software companies have focus groups organized by doctors who have wanted --or been forced --to use computers in clinical care.
The software companies usually contribute a liaison to help arrange meetings with company executives and software designers.
Physicians who participate in the focus groups are volunteers. To maintain independence, they don't let vendors reimburse their travel expenses. The reward, the companies and the physicians agree, is creating a better product.
That's different from focus groups outside healthcare, in which people may be paid by a company and quizzed to see if they would buy its product or service, or vote for its political candidate. Healthcare software focus groups also are unusual because they consist of doctors who already use the product.
Selling their software to new customers is not problem most companies have; it's getting existing customers to use it correctly.
"It's kind of like asking a 15-year-old to criticize the driving wheel position in a car," says Daniel Russler, M.D., vice president of clinical strategy for McKesson HBOC.
Hospitals and health networks force systems on physicians at their own peril, since most doctors aren't hospital employees and therefore are not under direct control. The hope is software focus groups can lead to better-designed products, an exchange of ideas on how to use them, and a troupe of people with the credibility to convince physicians to become comfortable with the technology.
Zahid Butt, M.D., joined the 15-member physician advisory board of Westwood, Mass.-based Meditech late last year. Butt, director for clinical information at St. Agnes Healthcare in Baltimore, says he's not there to tell Meditech what software to design, but to let the company know what clinicians are thinking.
"Hopefully, (we can) give (Meditech) a clinical perspective from different institutions so that further development and enhancement by the Meditech developers (incorporates) those recommendations," Butt says. "Hopefully, (we can) make the product more user-friendly, more acceptable to clinicians."
Putting it into practice
Companies want physician advisers to know something about their products, have realistic expectations about what the software can accomplish and be willing to work to reach consensus. Otherwise, they say, little can be accomplished.
The companies hope to get physicians whom Russler jokingly calls "moderately geeky" --meaning they're at least somewhat aware of how to use the software but are not technological whizzes to whom the doctors' colleagues would have trouble relating.
"It's a real myth that (as a physician) you have to be a computer jock or a computer nerd to make a difference in rolling out a product," says Francine Gaillour, M.D., director of market solutions for Burlington, Vt.-based IDX Systems Corp. "We need physician leaders who can manage groups, manage teams. The informatics part --understanding the system --comes very, very quickly."
A typical group meeting, Gaillour says, may consist equally of sharing experiences about a product and talking about design.
However, many companies, such as Kansas City, Mo.-based Cerner Corp., set up boundaries of discussion to make sure meetings don't get out of control with unrelated side issues.
The other thing focus groups do is learn about the limitations of technology and the pace at which it can be developed, euphemistically called "managing expectations."
"I can shoot 3-D battleships with no problem, so why can't I shoot tumors like that?" says Rob McClure, M.D., a McKesson HBOC senior vice president, hypothetically posing a physician focus group question.
Also, groups are encouraged to have healthy debates, but the understanding is that the members must achieve consensus before any changes are made to a product.
Dick Gibson, M.D., medical director of information services for Providence Health System in Portland, Ore., remembers doctors learning that lesson at the early meetings of what is now McKesson HBOC's Physician Advisory Council.
"Doctors had to compromise," Gibson says. "Not everyone wanted that detail that was so crucial (to somebody else)."
Then there's the tension that erupts between physicians and other users, such as nurses and information officers. Companies say that comes in part from physicians joining the discussion relatively late and not holding back their feelings.
Thomas Tinstman, M.D., chief medical officer at Cerner, says it's made clear to physicians that their suggestions won't be automatically implemented. The company must decide which suggestions make the most sense.
"That's why they're called advisory groups --they give advice, and we reserve the final decision," Tinstman says.
Lost in the translation
Asking physicians what they think of software isn't a new concept. Jacob Kuriyan, the founder of Dallas-based Physmark, remembers a physician's suggestion in 1983 that completely changed the direction of his software company.
Kuriyan's company started out providing practice management software, but that changed when an obstetrician customer said he needed a product that could handle issues related to managed care. Kuriyan designed software to meet his needs, and it became the basis for the financially oriented managed-care software he still sells.
Kuriyan acknowledges it was lucky the opinion of one physician could be applied to other offices. The only guarantee the obstetrician made was, "If you design it and bring it to me, I'll buy it."
It used to be more common for companies to call on physicians who were avid computer users, says William Bria II, M.D., director of information services for University of Michigan Hospitals. But they failed to realize doctors won't follow the lead of hard-core techies, colleagues or not, Bria says.
"The graveyards are full of companies that went down that primrose path," Bria says.
Another problem: Companies failed to recognize that what one doctor thought was good would not likely meet the needs of another. Some companies just stopped asking doctors what they thought because they were "burned going down a road too far, getting a product that nobody wanted," Bria says.
But the development of the electronic medical record required physician input, if only so companies knew what to put in it.
Companies hired doctors to help with development, but physician customers also voiced their opinions through user groups, which became more popular in the early 1990s.
Bria in 1990 and 1991 was president of the Medical Information System Physician Association, a 500-physician user group associated with Technicon, which was later acquired by Eclipsys.
"It's accelerated over the last five years," Bria says. "They're so plentiful. It's hard to find any major players in healthcare that don't have a physician user group.
"What's nice now is the quality of the exchange is different. A lot of companies brought physicians in more as demonstration physicians, more as a sales strategy. It was very superficial."
In the past five years, physician input has evolved to where companies such as McKesson HBOC, IDX Systems and Malvern, Pa.-based Shared Medical Systems now have physician advisory groups that meet up to four times a year to talk with executives about what they'd like to see in their products.
Whether they're called advisory groups, focus groups or something else, the point is to find physicians who can make sure a company is heading in the right direction.
Physmark's Kuriyan, who sells financial software, says despite his success from one physician's suggestion, he's skeptical that what one group of doctors says can apply to customers at large. However, he says talking to doctors can at least prevent a company from doing something stupid.
"What I've thought was a great product (sometimes) didn't go anywhere," Kuriyan says.
The big player gets into the game
McKesson HBOC was relatively late in getting formal physician feedback. Dick Gibson in 1996 called what was then Atlanta-based HBOC & Co. to ask what its physician user group had to say about software he was having trouble with. Gibson was shocked at HBOC's response: What physician user group?
So in January 1997 Gibson and about nine other doctors started the first HBOC physician focus group, which would meet separately from the national user group. Also, physician sessions were set up at user group meetings. McKesson HBOC was formed Jan. 13 through the $14 billion merger of software company HBOC and McKesson Corp., a San Francisco-based pharmaceutical distributor.
As is the case at most companies, the impetus for physician involvement came from the doctors themselves. But McKesson HBOC's Russler says the company also recognized the need for physician involvement three years ago when it hired him as vice president for clinical strategy.
"I think (the company) viewed mostly the hospital (as) the customer," Russler says. "Now (it) views the physician as the primary customer."
Having physicians involved has "made a clear improvement," Gibson says. He gives the example of one product, Care Manager, in which nurses entered information in three-letter codes incomprehensible to doctors.
"It's hieroglyphics," Gibson says. "We (changed) them to English words. It was a simple move, but it was very practical. It was causing physicians a lot of resentment to use a 'nurses' product.' "
Gibson's group in January was rechristened the Physician Advisory Council. It will now look at big-picture issues while other physicians start focus groups that consider specific products. Last fall, McKesson HBOC started meeting with focus groups about physician-office and emergency-room products. There's even a physician advisory group starting up to look at products developed by the company's managed-care-oriented Payor Solutions Group.
Other voices, other rooms
Physicians aren't the only voices McKesson HBOC must listen to regarding its products. Its user group, Insight, a merger of two groups consummated Jan. 1, has 3,000 members, about 40 of whom are physicians. CIOs, nurses and others have their own focus groups.
McKesson HBOC's McClure says the biggest problem was determining who would be responsible for looking at long-term trends and who would handle product-specific problems. The user group, he says, is becoming the forum for long-term trends, while the focus groups handle specific products.
But the advice can be solid. Cerner, for example, tests products at eight practices before bringing them to its physician advisory groups.
"If you have five physicians who stand up and go thumbs down, and then you look back at the data at the eight practices (saying the same thing), then that's probably true," Cerner's Tinstman says.
Physician focus groups and their relations with vendors continue to evolve. The only thing known for sure is vendors will lean on doctors to make sure they're doing the right thing.
"(McKesson) HBOC is not exploiting us as much as they could as physician champions," Zastrow says of his physician advisory group. "We could be doing more for them. I think it's just kind of too new of a process for them. They haven't figured out how to use us best."