Physician executives who see an obvious value in computerized physician order entry and electronic medical records systems often find themselves in the position of having to justify these technologies to management using terms that sound alien.
I'm convinced many hospital administrators were forced to write the words "return on investment" 100 times on a blackboard before they were hired. So you have to know your audience.
For the truly vapid, you must be buzzword compliant: Is your hospital re-engineering? Are they obsessed with "medical error reduction"? How about Total Quality Management? Six Sigma? Perhaps you have "service lines" or "centers of excellence"?
In fairness, not all hospital administrators are victims of management fashion trends. They usually can understand that, unlike the classic business systems of human resources and accounting, clinical information systems can be strategic in nature.
As such, the payoff comes in the long run, just as it does for basic research or a new building. (But if they can't understand strategy, ask them to write an ROI for the elevators or the parking lot.)
Convincing your management
The expense of installing many of these systems is a cost of doing business in the modern world. That should be the framework of the discussion. Tragically, the content (which is usually lost on bullet-point-only management) must be reduced to money, money, money. If donors are around, you can mention quality.
Risk is also an attention-getter because you can put scary monetary figures next to it.
But alerts will be your biggest seller. Tons of data show alerts can improve quality and save money. These data are almost all unscientifically collected, though they're better than the average MBA standard for ROI data. Anyone with scientific training generally pulls their hair out when they read a typical ROI analysis because the methodologies are often less rigorous than a high school science fair project. So start with the money, as quality doesn't sell. (If it did, how many HMOs would still be around?)
A good EMR with real-time alerts at the point of care can do fun things like force (I mean, suggest to) physicians to put the correct diagnosis down when they order something. Just one of these alerts for our EKG orders gained us more than $200,000 per year in what had been lost revenue. Add Local Medical Review Policy rules, and the dollars will add up quickly.
Drug dosing for renal medications alone can measurably reduce length of stay. A very similar argument can be made for reminders to discontinue hypoglycemics when patients are NPO. These and similar common mistakes can reduce morbidity while helping the bottom line. (This is tricky, because it does this by reducing errors that hurt people. Because some centers get paid more if they hurt people and generate more work, you have to be careful with how this is presented.)
Advice on which antibiotic to give is a tough sell unless you know your formulary and the details of which drugs cost more or less to your center. Your systems folks have to be prepared to keep up with susceptibility patterns.
The documentation tools built into these systems are a tough sell because all of the tools are horrible--some just suck less than others. The financial fantasy is that you can get the codes to fall out of the documentation. In highly stereotyped settings, template- and macro-driven documentation can speed up documentation and enable reporting and research that are very hard to do with paper. But if this ever works broadly, I'm sure the rules will be changed to make it hard again.
Convincing your physicians
Management is more apt to care about the compliance angle, but physicians will object if you use the system as a bludgeon to make them do things they should be doing already, but don't.
If you focus on a couple of areas where you are losing revenue or have serious compliance exposure because of inadequate documentation, then you should be able to get management buy-in.
But note that the sales pitch to highly compensated physicians must be different. They don't generally care about savings, compliance or coordinating care. And don't suggest IT will increase quality, as they will be offended by the implication they aren't perfect. They can afford serfs to act as computers that prevent them from ever having to touch one.
The systems can't work their magic as easily when the physicians don't actually use them. Still, these doctors generally understand the utility of standard data for research and reporting.
Of course, thanks to managed care and Medicare cuts, soon enough there won't be many highly compensated physicians to worry about.
Meanwhile, younger physicians tend to be "technology dependent." They can't imagine practicing without a computer. In time, they shall overcome.
Finally, depending on the nature of your practice, internal retention of referrals may be an issue. A shared EMR is a major incentive for doctors to keep patients inside the system. They get their results back. The consult notes are there even if they are never written, because you can read the visit note.
Finally, orders for labs and radiology, etc., will tend to stay inside rather than leaking. In the first six months of our outpatient EMR installation, with fewer than 40 doctors up and using the system, we estimate that roughly $400,000 of revenue that had been leaking was kept inside the system.
We are blessed with physicians at the helm of our hospital, our medical school and our practice. They all understand the importance of IT. Balancing a budget is fine, but you can't give up quality. They understand that quality EMR projects must be led by physicians and nurses.
This is the ultimate lesson: The quality of your leadership matters more than your sales pitch. The best EMRs require management that sells them to the IT staff, not the other way around.
Curtis Cole, M.D., is director of information services for the Weill Physician Organization, Weill Medical College of Cornell University, New York.