To say that there is a strong focus on innovation at Vanderbilt University Medical Center would be quite an understatement. In fact, it’s more like a way of life at the academic medical center, which includes an acute care hospital, children’s hospital, clinic, and cancer center. If there is a tool that clinicians need, the IT team will determine whether it can be developed in-house before turning to a vendor. For Deputy CIO George McCulloch, this type of environment may be challenging, but it’s also deeply rewarding. In this interview, McCulloch talks about balancing the needs of different constituents, how practicing medicine is both an art and a science, the importance of working to meet the needs of specialists, and his organization’s road to Meaningful Use.
- Thoughts on Meaningful Use
- “The biggest issue we have with Meaningful use is the collision with ICD-10”
- “CPOE is a huge cultural shift and will likely be the toughest one for community hospitals”
- Physician freedom versus evidence-based medicine
- “There’s still an art to this as well as a science”
- Incorporating genetic information into the EMR
- The future of small hospitals and physician practices
I think if Meaningful Use and ICD-10 weren’t laid on top of each other, we wouldn’t be as concerned, because we could focus the clinical business on Meaningful Use, and get some of the revenue and some of the clinical business in ICD-10.
Our experience has been that you really have to go after the quality component and understand and be able to sell and communicate clearly why CPOE and some of these other things make a difference in patient care. Because that’s what it’s all about.
The community hospital model, as opposed to an academic model, is maybe a little different. But clearly we’re going to need to understand the choices that we’re all making in the clinical processes that we have in place, and build those evidence-based processes to the decide what’s a good thing and a bad thing—what works and what doesn’t work.
I think there’s going to be a learning curve as we go through this in terms of what we know and what we don’t know. And there’s going to be some level of—I don’t want to say experimentation—but judgment in building that common wisdom.
How do we provide things for safety net hospitals and the solo practitioner that, economically, a community cannot afford to do? Clearly the technology can help. We can take a look at outreach things like telemedicine where we can get some information there.
Guerra: You work at a very sophisticated organization that is very advanced from an IT point of view—even more so than many of the vendors out there. How has Meaningful Use impacted your organization? Obviously I can imagine it’s been a huge stretch—I mean, you’re so far along, although it seems to be a bit of a stretch for everyone. In terms of the way it’s directed your work, do you think it’s been a good thing or has it taken you down a path that you wouldn’t have gone and don’t necessarily think you need to have gone?
McCulloch: No, I think it’s generally been a good thing. Not that we weren’t focused before but it’s certainly given us a particular focus. It’s not about the money; it’s really about the quality of care and the things that we needed to do, so I think we’ve really used it to focus the organization on what the mission was to begin with. With certification and some of the other things we described, it has taken a little bit of a resource hit and made us say, ‘Okay, we’ve got to go get certified,’ even if we didn’t have to. But in general, I think it’s been good.
The other thing is that it really is going to help us with areas of adoption that maybe we haven’t gotten to and forced us to say, ‘Okay, for Meaningful Use, in terms of the adoption piece, we have to go into areas that maybe we didn’t figure out exactly how to go do it for them, or if they weren’t quite interested at that time, now we get to go back to them. So we’re really looking at it as an opportunity for us to expand our reach, go into some new areas, and really get adoption where maybe we didn’t have as much as we wanted to.
Guerra: Has there been anything in Stage1 or Stage 2 that’s made you scratch your head?
McCulloch: In some particular areas, we really looked at the intent of that and said, ‘Do we generally agree on where they’re going and where the industry is kind of being pulled or pushed to go?’ And I don’t think philosophically we disagree. Some of the mechanical things aren’t quite clear, and maybe we’ll know more about them in later components. We’re really looking at the clinical impact; we look at the value there and see the congruence rather than distance in terms of what we’re being asked to do versus what we want to do for the quality of care standpoint to begin with.
Guerra: And the timeline looks okay to you?
McCulloch: We’ll make it. We’ll do what we need to do. I think that the biggest thing that we see with Meaningful Use is a collision with ICD-10. That’s the biggest resource issue. I think if Meaningful Use and ICD-10 weren’t laid on top of each other, we wouldn’t be as concerned, because we could focus the clinical business on Meaningful Use, and get some of the revenue and some of the clinical business in ICD-10. We see that as the biggest issue that’s going to hit us, and I think that’s going to make Meaningful Use harder—how operationally coding is going to change in the clinics and in the practices from what we would want them to go from a Meaningful Use standpoint. That’s the biggest problem that we see.
Guerra: Do you think there’s any chance they’d postpone ICD-10?
McCulloch: We’re not planning on it. If it happens, we’ll be ready. It’s one of those tsunamis that you hope is not going to happen, but boy, if it does, you better be ready. So we have an ICD-10 plan we’re executing on now. And again, we’ve identified the collision with regard to what’s going to happen in the clinics and how we’re going to help our practices go from X number of codes to Y number of codes, multiplied the certain areas back quite a bit. So we’re running full speed ahead on ICD-10.
Guerra: As we said, you work at a very sophisticated organization. Is it possible for you to put yourself in the shoes of the CIO working at, for example, the average American community hospital?
Guerra: Can you maybe touch on a little bit of your past career if it’s relevant, and tell me how you think those institutions will manage with Meaningful Use—if they’ve got a good shot at it.
McCulloch: Sure. I spent most of my career in community hospitals of 500 beds and 200 beds. I think you’re really going to have to rely on your vendor; you’re going to have to have picked your vendor and your relationship carefully, and make sure that it works. I think that the challenge there is going to be the physician relationship with independent practices—being a faculty model, which here is good thing and bad thing at the same time—and trying to get them engaged and involved. The upside in the community hospital is going to be that everybody is doing it. So it’s not as if you’re punishing your folks by telling them they have to do this. And they’re not going to have that many choices with regard to going to the community hospital down the street, because they’re going to do ask them to do the same thing.
McCulloch: There’s not going to be a particular place where a physician is going to get a potentially better deal or get out of it, because everybody is going to have to go do it. So I just think it’s going to be tough having been through CPOE, which we’ve been doing here for several years. That’s a huge cultural change, and I think that’s probably going to be the toughest one for a community hospital to go through given the penetration of CPOE in the organization. That’s the toughest one, and our experience has been that you really have to go after the quality component and understand and be able to sell and communicate clearly why CPOE and some of these other things make a difference in patient care. Because that’s what it’s all about; that’s what makes the difference, and there’s value there.
Guerra: I’ve heard that making the quality argument is a good way to go, but I wonder—when you make that argument, do you get physicians that are somewhat offended that you are insinuating that they don’t practice the best care they can?
McCulloch: No, the way in which we approach it, especially in the academic environment, is that we know that data has changed since the time that you went to school. You’re always trying to understand what the new parameters are, and we’re really here to help you—we’re not going to tell you how to practice medicine. And there’s so much data out there that our job, in our informatics model, is to bring data to you and guide you through the things that you need to be aware of. We don’t make decisions for you. We will tell you things that you probably don’t know and things that you probably should know, but we’re pretty good at balancing what we think you ought to know versus having us doing it for you.
So we err on the side of, ‘You’re the clinician. We didn’t go to medical school.’ (I didn’t, but some of our leadership has.) ‘And we’re going to tell you these things. You make the call; you decide what you’re going to go do and try to bring evidence based medicine and other kinds of things to the choices that you ought to make.’ So culturally here, we’ve not gotten push back on what we’ve suggested to folks and what we’ve brought to them.
Guerra: You mentioned about clinician freedom, but it seems like overall, we’re going to go away from that, or with CMS we need to go away from that to some degree. And it seems to me that we’re going to go to a world where if a clinician wants to deviate from the evidence-based medicine best practice, they’re going to have to explain why, and we’re going to have problems like with the insurance companies. Don’t you think that’s where this whole thing is going?
McCulloch: I think clearly that’s going to be part of it, and even in the things that we do, we go back and take a look at whether have we changed practice. And again, the community hospital model, as opposed to an academic model, is maybe a little different. But clearly we’re going to need to understand the choices that we’re all making in the clinical processes that we have in place, and build those evidence-based processes to the decide what’s a good thing and a bad thing—what works and what doesn’t work.
Our VAP process was an interesting one because we really hadn’t sat down before that, to my knowledge, and gone through and said, ‘Okay, what task do we really need to perform? What really makes a difference in these?’ And so we’ve helped on the front and we’ve also done some work on the backend of looking across patients for all those indicators to say did we do that for every patient every time? Clearly that’s where we’re going, and as you pointed out, that’s clearly where we need to go in terms of taking a look at practice and what’s good practice and what isn’t.
I think that physicians are scientists, though, and they really do indeed want to understand what a good practice is and what a bad practice is in the context of the treatment of a particular patient. So I do think there’s still an art to this as well as a science in trying to say, ‘Okay we know that would be the right thing to do except for this, and I really need to try this and see if it indeed works, because there are indicators that it might.’ I think it’s that balance of prescribed process that manufacturing might have that’s so different than what we see on the health care piece, because we’re not sure and we don’t know in a lot of cases what the important things are.
What we’ve done recently spend a lot more time on the genetics piece, and looking at what are predictive things where we can make a difference—like Plavix, and understanding that people either metabolize that drug well or they don’t. We never necessarily knew, before some of the genetics was done, why somebody that we put a stent into kept on clotting, until we came back and said, ‘Now wait a second. That is not metabolized well by this person for this particular genetics component.’ And so now we’re able to do some testing, and we put that into our clinical decision support. And we’ll say, ‘Wait a second. We’ve tested this person—you don’t want to put him on Plavix, because it’s not going to work. Don’t do that—do this instead.’ So I think there’s going to be a learning curve as we go through this in terms of what we know and what we don’t know. And there’s going to be some level of—I don’t want to say experimentation, but judgment in building that common wisdom of what we should do or not do.
Guerra: What does an EMR need, or is your EMR equipped to handle genetic information? And do you think the majority of commercial EMRs are ready to handle that kind of information?
McCulloch: Ours is; because of the flexibility we have with the tool, we’re building that as we define it. And so we’re able to put that data into our EMR and make that available to our clinical decision support component. I really can’t speak to what some of the other EMR vendors are doing or not doing about that. Clearly as we’ve figured out that it’s an important component of what somebody needs to know about providing quality care, it’s something that we’re putting in there.
We’re trying to design it so that can be flexible, and so that as we learn more things, we can change the formatting and change the descriptions of what’s really there, because that’s clearly an evolving area for everybody. So we’re beginning to use it in a particular way. It will clearly expand, and we’ll change what the content looks like and how we present it over time.
Guerra: Medicine is just changing. I mean, it’s moving away from the small to the very, very large and complex in terms of institutions. The single-doctor practice sitting out there alone—are these things sustainable? Are small hospitals sustainable? And how does the nation going without them in terms of the reach in rural areas and things of that nature?
McCulloch: Well I think that to your point, how do we provide things for safety net hospitals and the solo practitioner that, economically, a community cannot afford to do? Clearly the technology can help. We can take a look at outreach things like telemedicine where we can get some information there. We really feel that the decision support piece is of huge value in that regard. For example, you see a particular style of patient in your community that you don’t see very often. What can we help you with that if you give us some parameters, we can come back with things that can make you smarter and help make you make decisions there.
So I think it’s going to be tough. I think, as you said, we have to pull toward the geography and say, how do I take care of a community when the community is very small and economically can’t support that, but we still want high quality care for the folks that chose to live in that particular area. I think it’s tough, but we have to look to technology first and see what we can do to try to make that provider the best that they can be.
Guerra: The disparities in health between the areas with access to organizations like yours and those without is going to get wider and wider as your care becomes more sophisticated and specialized, and the other level of care does not.
McCulloch: Right and again, it’s getting back to evidence-based practice—what is good practice and what’s not good practice, and what evidence do we have for that. In our model, it would be what clinical decision support can I help you with. I think as we share that kind of data—that kind of information—across providers, and help those kinds of things, hopefully with Meaningful Use and other kinds of things we can get at some of those components. I think it’s really that technology component that we really need to look to and say, ‘What can I do to help the clinician in the moment,’ because they don’t have enough time to do research. It’s what can we bring to them at the moment that they’re making a decision on what to do, and bring them information back that says, ‘We think you ought to try this.’