In a clinical environment that's just starting to warm to the idea of physicians entering orders, a prominent brainstormer on how doctors use computers says it's time to think past that idea.
No matter how "friendly" the computer acts toward its intended users, the on-screen routine "turns the physician into an order clerk," says William Stead, M.D. He has been working since 1991 to build a system at Nashville's Vanderbilt University Medical Center that he says will think for doctors instead of just prompting them for decisions.
Competitors may dispute how much more the system will offer than other clinical decision-support applications already on the market. But McKesson Information Solutions saw enough to snap up the Vanderbilt product a few months ago at a price that takes into consideration its technical sophistication and diagnostic intelligence.
It's an outside contribution to an intensive internal software initiative bent on creating a single integrated foundation for a full line of clinical-care management systems, says Graham King, president of the Alpharetta, Ga.-based healthcare information services business.
The research and development end of the business spent $100 million over the general budget for the unit during the past 12 to 15 months to engineer the cohesive computer architecture and leading-edge software it's now putting on the market, says Michael Myers, vice president and general manager of the new line, called Horizon Clinicals.
Already the investment has paid off in the opportunity presented by the Vanderbilt product, Myers says.
Without the engineering progress, which involves doing things the same way at the transaction and database levels of all applications, McKesson wouldn't have been able to bring in the similarly engineered order-management system and integrate it into the overall effort in short order, he says.
And speed to market is of the essence for the company, formerly called HBO & Co., which bulked up on software acquisitions in the 1990s to broaden its product line-and boost its stock price-but faced a gargantuan task of making the disparate systems work together.
Meanwhile, HBO & Co. fell behind the competition on clinical IT and then was sidetracked in a securities-fraud scandal after its January 1999 acquisition by McKesson Corp., further diffusing its focus. "The company kind of took a few years off" in product development, Myers says.
King took over the division in July 1999 in the midst of a shake-up, and says he immediately got to work creating a clinical repository based on the latest technology. The repository is a key component of the developing Horizon package of interlocking systems.
Along with that new development, McKesson hopes to gradually weave the new products in and around the older-model order-entry, documentation and departmental information systems sold by the hundreds to a customer base comprising 40% of U.S. hospitals.
"They're doing the right things," says Thomas Handler, M.D., a research director with the healthcare group of Gartner, Stamford, Conn. "They now have a vision and they're moving toward a truly integrated approach."
McKesson still has much to prove, he says, to a huge client base that's looking for proven products. But the company has no choice but to keep at it: "What they're doing is absolutely what they need to do to remain players."
Paying for a physician-centered market entry
The information systems division bought some accelerated development when it acquired a physician decision-support system that Vanderbilt had been working on for six years. "This is in global use at Vanderbilt," Stead says. "And it has been in use largely the way it is now since Christmas of '97."
All inpatient care is plugged into the system, which handles 7,000 to 10,000 orders per day and triggers 300 daily alerts about possible medication problems, he says. Though it needs some application interface work to be nested into the McKesson line, it's "a working, living thing" and not just a test-stage product, he says.
The agreement sets up Vanderbilt as a continuing test site for the product line that McKesson will sell on the open market. To pull that off, Vanderbilt gradually will re-install its own system as tweaked by McKesson to make sure it's further enhancing the marketed version.
"The only way we can gain value from this relationship is by enhancing the product that was made commercial," King says. That includes tuning it so it functions well as a component of the overall Horizon line and incrementally "back-installing" new components at Vanderbilt as they are developed, he says.
The university will be well-paid for its work in a deal that includes royalties as well as a multimillion-dollar purchase price. King doesn't cite a specific dollar value but says, "It's eight digits up front and it will be eight digits in the royalties."
The clinical system is designed to directly link established best practices with the routine of ordering drugs and treatments. Both components are online in many hospitals but not linked together, Stead says, and doctors should not have to pore through medical findings and lists of possible drug therapies to make decisions.
The Vanderbilt system anticipates scenarios for the actions required in an intended course of treatment and offers choices for approval or dismissal, Stead says. The computer presentation incorporates current medical knowledge that might not be brought to bear in the bustle of a physician practice, and it cuts down on searching, scrolling and clicking to round out an order set, he says.
Instead of deciding what to order, doctors tell the computer what they're trying to accomplish: Rule out pulmonary embolism, for example, or evaluate deep-vein thrombosis. The system comes back with pertinent information from a patient's record, reaches back for practice options as established by committees of staff physicians, and presents one or more avenues of action along with the orders associated with each option.
"It assembles the relevant pieces in front of the physician at the time he needs to decide which of them to carry out," Stead says. A check/uncheck feature on the order screen will "allow (the physician) to say, 'What's different about this patient that makes me want to jiggle this a little?' "
Catching up to the competition
At Providence Health System in Portland, Ore., one of two test sites for the commercialized Vanderbilt system, clinical leaders are trying to promote medical management and give doctors "a reasoned and viable way to guide their practice in the preferred direction," says Dick Gibson, M.D., chief medical officer of the seven-hospital network.
The provider organization, a McKesson customer, had held out for something that represented more than order entry, and the Vanderbilt deal gave it reason to stick with McKesson, says Rick Skinner, chief information officer of Providence.
"You're trying to move the practice of your physicians, and that has the potential for serious repercussions," Skinner says. "The software seems to work in a way that's synergistic with how physicians work and, more importantly, how they think."
The testing at Providence will begin in 2002 at one intensive-care unit in 369-bed Providence Portland Medical Center, Gibson says. Once it works there, the application can be implemented rapidly to other departments in the hospital, he says.
But at that rate, McKesson won't have something to sell until competitors have had time to make sales and establish themselves, Handler says. "Vanderbilt has a great system. Let's see it commercial. And how long will it take?" he says.
There's no reason to expect that competitors such as Cerner Corp., Kansas City, Mo., will allow McKesson to close the gap in development of clinical-care management systems, Handler says. For example, "Cerner is two years ahead of them on (clinical) documentation. Without significant effort, Cerner will still be two years ahead two years from now."
McKesson has installed an older-model version of clinical documentation software at 104 provider organizations representing 122 facilities, says spokesman Craig Heighton. It also has a pre-Horizon model of a clinical repository running at 28 organizations representing 30 facilities, he says.
McKesson's new repository is live at three organizations, including Providence Health. And the pilot of the Vanderbilt commercialization is scheduled for one other site besides Providence: 653-bed St. Luke's Episcopal Hospital in Houston.