By the time you read this, the annual Physician-Computer Connection Symposium put on by the Association of Medical Directors of Information Systems will be under way in beautiful Ojai, Calif.
If youve never had the good fortune to have seen it yourself, Ojai is a small town of about 8,000 people near Santa Barbara about 10 miles inland from the coast.
Fortunately, the hundreds of fires chewing up California this summer have so far spared the mountains around Ojai. The town wasnt always so lucky. Much of it burned in a forest fire in the early part of the 20th century, but was rebuilt with a quaint line of arcade-style downtown shops along Main Street, a new post office and a bell tower that chimes on the hour.
Ojai is tucked in a valley at an elevation of 746 feet that stretches beneath a chain of mountains that rise as high as 6,000 feet and turn pink at sunset, just as they did a few minutes ago as I sat down to write about todays events and whats to come.
AMDIS Chairman William Bria, chief medical information officer at Shriners Hospitals for Children in Tampa, Fla., is giving the opening presentation of the status of healthcare information technology, followed by an address by Robert Kolodner, the physician head of the Office of the National Coordinator for Health Information Technology. The presentation of the AMDIS award winners for excellence in applied medical informatics is scheduled for later today, as well as the results of a membership survey by the Gartner Group and a report from the 50 Most Powerful Physician Executives, conducted by Modern Physician.
Tuesday morning, I met with Richard Afable, the president and chief executive officer of Hoag Memorial Hospital Presbyterian in Newport Beach, Calif., and Jack Cox, senior vice president and chief quality officer. Afable is the former executive vice president and chief medical officer of 31-hospital Catholic Health East, Newtown Square, Pa. Cox is the former group vice president and chief medical officer of Premier.
Hoag is a 417-bed hospital with a main campus surrounded by flowers and palm trees sitting on a bluff overlooking Newport Harbor, which is jammed with yachts. Even its parking lot is California fancy, with a vertical bas-relief featuring 16 leaping dolphins.
Afable said that Hoag is the only acute-care hospital in Newport Beach, and also serves five other Orange County communities with a total population of nearly 700,000, including Laguna Beach, Huntington Beach, Irvine, Costa Mesa and Fountain Valley, some of the wealthiest towns in the country. Hoags main competitors are medical-destination hospitals in Cleveland, Houston, Los Angeles and Rochester, Minn., Afable said.
Afable said hes a convert away from the conventional wisdom that a systemwide implementation of IT is an unalloyed good.
The key to successful implementation is local and individual ownership of the processes and the systems one uses to accomplish goals, Afable said. The problem with a systemwide implementation is that it assumes the processes of care are the same at all locations and thats simply not true. Afable said he used to think standardization, evidence-based medicine and protocols were an end unto themselves, but now, Ive gone 180 degrees on this.
I think it's a great place to start where structure is concerned, but in a knowledge-based industry, a learning industry, there is significant variation in how care is delivered as there are people on this earth. We want structure to a point, and it is after that point of structure that we want the knowledge-based worker to use that knowledge to innovate and create and provide whatever it is that that person needs. Were trying to limit variation, where my attitude is we want to motivate the knowledge-based worker to create and innovate. Thats where I have problems with systems-based approach and the leader has to know where that point is. And thats where it comes back to the physicians. I want variation at care at the bedside while the tools and the processes are as constant and automated and rules-based as possible.
Clinical IT systems today are limiting, Afable said. Computerized physician order entry "is a classic. There is a reason we only have 15% adoption, because the value has never been manifested to the bedside worker. The problem that it adds time to their work would be overcome if they saw clinical value to it, the clinical support tools are just not so profound that they allow for variability at the bedside. And these are really smart people.
We are creating those data-analysis capabilities as we speak, Afable said.
One barrier to IT investment is a disconnect between those who pay for the systems and those who benefit from them. About a third of Hoag's admissions covered by fully capitated managed care through its affiliated independent physician association. The hospitals demographics could figure into a positive return on investment, too, Afable said. Hoag is planning to spend $50 million to extend EHRs to its physicians to create a health information organization and improve its in-house IT capabilities.
Were doing it to improve care, and we ultimately believe it will reduce the cost of care, Afable said. If the economic environment does not change, (if) reimbursements do not change, it is absolutely a correct statement that the $30 million investment in the information exchange and the $20 million investment in IT at the hospital will only go for the improvement of healthcare. On pure financial terms, there will be no excess return above that. The worst-case scenario is we spend the money and we get better care. And they (the board) were happy with that.
Hoag will be offering its physicians three different EHRs, from Allscripts, eClinicalWorks and NextGen, Afable said, and integrating them into the hospitals multiple IT systems. Greater Newport Physicians, the 600-physician IPA affiliated with Hoag, has been a great help in planning for the EHR project, but Afable said it is yet to be determined whether offering three different EHR systems is the best way to go. At least it is consistent with Hoags approach to healthcare IT systems thus far.
This is best-of-breed land, Afable said. It is the result of a failed organizational approach to strategic planning and decisionmaking around information management. This is a hospital that had generous resources and thus it was reactive around information systems. ED docs wanted this and they got this, pharmacists wanted that and they got that.
In the hospitals own defense, Afable said that many of the IT system purchases were made when integration was less important than it is today. But still, integrating the disparate systems has been very expensive, very inefficient.
Were spending 10% to 15% more just because we have to do integration management. Its not pretty.
In a frame on the wall in the lobby is a copy of a newly signed resolution by the hospital board publicly committing the hospital to a two-year plan setting to performance goals to reduce Californias 28 "never events," launch a medication-management system and measurably improve performance in its centers of excellence, which include orthopedics and womens health. Board Chairman Steve Jones has made quality improvement job No. 1, Cox said.
Cox said that Hoag has brought in an outside consultant, CSC, formerly First Consulting Group, to help plan implementation of a closed-loop medication management system estimated to cost somewhere north of $20 million, Cox said.
For medication errors, we were depending on incident reports, Cox said, which were coming into risk management at the rate of about 250 a month, of which, only 700 a year were medication errors. But even the best hospitals have adverse drug event rates of 10%, so Cox said they know theyre going to need better data.
Having a best-of-breed system is a blessing and a curse, Cox said. Were not starting at the bottom of a pit. But there is an exponentially large amount of energy you have to expend to get from best-of-breed to Olympic levels of excellence.
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