Of the many skills required to be an effective CIO, perhaps the most important is the ability to learn from past experiences and apply that knowledge going forward. At Trinitas Regional, Judy Comitto is leveraging the lessons learned from the organization’s CPOE go-live to facilitate an easier path for rolling out physician documentation. In this interview, Comitto talks about how Trinitas hopes to benefit from voice recognition and document imaging, and how IT leaders are working to balance the need for discrete data with the burden on clinicians. She also shares her thoughts on Allscripts going private and discusses her work with JerseyHealthConnect.
Chapter 1
- An Allscripts Sunrise Clinical Manager Shop
- Tying MU activities to ICD-10 preparation
- Front-end physician documentation/progress notes
- Voice recognition, CAC and Hyland for document imaging
- Kudos to the ICD-10 delay
- Balancing need for discrete data with burden on clinicians
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Bold Statements
We have a document imaging system that would create a paperless environment at Trinitas. And also, in the event that HIM should fall behind or we would have issues with ICD-10 coding, we could actually outsource some coding through the use of a completely electronic system.
How do you control those environments? You’re trying to do the upgrades for IDC-10. You’re trying to do upgrades for Stage 1. It’s really a very dangerous situation. It has to be coordinated and scheduled and it needs time. You can’t just pop these things in.
The amount of play going back to the physicians for information is going to be enormous. And you know, they don’t always answer us. That will be a challenge itself. So we want to try to mitigate some of the potential pitfalls that we’re going to have as much as we possibly can.
It’s no different in the paper world as it is today in the electronic world. It will be a different type of error, but we need to tighten our systems so that we have medical logic that will track some of this.
We have our select group of physicians where we find a specific nursing station. We start with that and we try to get the bugs out of there. We try to fix it with those folks that will be reasonable and will work with us, and then we start populating it through the rest of the enterprise.
Guerra: Good morning, Judy, I look forward to talking with you about your latest activities at Trinitas Regional Medical Center.
Comitto: Good morning, it’s good to speak with you again. So we’ve been really busy here at Trinitas.
Guerra: That’s good, staying busy keeps us all out of trouble. Tell me a little bit about what you’re doing. If you want to jump in with the top things on your mind, that’s fine.
Comitto: Absolutely. So let me tell you what our major focus has been in the past two years, which leads up to the conversation we’re going to have today. We were very focused on Meaningful Use. We run Sunrise Clinical Manager and we felt we were in a good position to report and attest as soon as possible, which we did earlier this year. We have been fortunate enough to collect our monies from CMS — our reward, so to speak — as well as from Medicaid New Jersey. We’ve already received two payments, and right now we’re in our year reporting period to finalize that stage.
During that process, however, we were tying these Meaningful Use requirements together with an ICD-10 initiative, and in some cases, they do work hand in hand. So what Trinitas has been planning all along is to automate our process for ICD-10 as much as possible, and what we called an ICD-10 project included many aspects of the clinical arena as well. Our number one finance requirement was that we have a document imaging system that would create a paperless environment at Trinitas. And also, in the event that HIM should fall behind or we would have issues with ICD-10 coding, we could actually outsource some coding through the use of a completely electronic system. So that was part of the plan.
Just to step back a little bit, we also included in this plan a lot of frontend physician documentation application, so the last piece of our automation in Sunrise is physician progress notes. We’d like to get that in, obviously in electronic format, with as much discreet data as possible using MLMs and other data available in the system to help guide the physician along the way. We are looking at voice recognition to start that process and some kind of template application frontend for the physicians as they do their progress notes that will actually do the coding. That will then get passed along to a computer-assisted coding program as well as the document imaging system. So that’s the high-level plan and we’ve been really busy working with vendors and trying to get a little of this integration. And let me just add that Hyland and Sunrise will be integrated, so our physicians will be working within Sunrise under our e-signature tab, and it should be pretty much transparent to them that they’re not in another system.
Guerra: Were you pretty happy about the ICD-10 delay?
Comitto: We were pretty happy. It would be very difficult to implement Stage 1 and Stage 2 Meaningful Use, as well as all of these new applications that we’re implementing in the very near future as well. There are technical issues with doing all of that at the same time. We can’t corrupt our databases. We don’t have enough test databases, so we need to schedule all of these so that we’re developing, testing, and then activating these systems without making too many changes that will lead to problems going forward.
Guerra: So you think that’s the word that got to the folks in DC and finally resonated — that it was just too much too fast?
Comitto: I believe that to be true, because if you’re doing a Stage 1 or 2 or whatever you’re up to, it doesn’t really matter. You’re making changes to your databases — how do you control those environments? You’re trying to do the upgrades for IDC-10. You’re trying to do upgrades for Stage 1, for example, as most vendors had their clients do. It’s really a very dangerous situation. It has to be coordinated and scheduled and it needs time. You can’t just pop these things in.
Guerra: Right and if you’re popping so many things in at once, nothing’s being sufficiently tested or checked after the fact. And if you have a problem, you don’t know what caused it if too many things are going on. Does that make sense?
Comitto: That’s exactly right, and you don’t really hear that being postulated out there at all, yet it’s the operational issues as well that are really important. And that’s where errors occur.
Guerra: Yeah, and I guess sometimes you have folks making policy that don’t quite understand the ground level stuff of how this gets enacted.
Comitto: Correct.
Guerra: I don’t want to get into politics here, but I saw there was a letter sent that said to cancel the whole Meaningful Use program because not enough is being achieved for the money. In my opinion, you can say let’s cancel the program for a number of reasons, but I do not think the idea that not enough is being required of a hospital is one of them. That didn’t make much sense to me. It seems like a lot is being required for the money, do you agree?
Comitto: I definitely agree with that. People really have no idea the amount of effort and resources it takes. And remember, our primary focus is patient care. At Trinitas, we do use our users to do final testing. We have doctors, we have nurses and all various types of staff who will get on and test their function. How do we pull them away? I think that we’ve made enormous progress in the past couple of years on these projects, and I for one am pretty impressed, not disappointed.
Guerra: Yeah, definitely. Do you feel like the new ICD-10 date is doable?
Comitto: I think it will be tight for many people, but I think it is doable. We’re in a pretty good position. Other than, as I mentioned earlier, taking advantage of the situation to bring more automation in, we don’t do all that much coding for our various other systems. So once we upgrade our finance side, which is where most of it takes place, we’ll be in a fairly decent shape, but even that’s a stretch.
Those hospitals who don’t have centralized EMRs are just working on it. I would understand that they may have to deal with their lab systems coding, their radiology systems coding — they have many different systems that they will have to deal with to get that done. As I said, we’re fortunate in that although those systems have a capability, we do not use it for our billing. So it is not our primary concern at the moment.
Guerra: You said that finance wanted these documents to be electronic just in case the switch over to ICD-10 caused a delay. Where you wanted to outsource some of that work, it would be a lot simpler emailing or by whatever means transferring that information electronically, rather than boxing up folders and papers. Is that what you meant?
Comitto: Exactly right. How would that work? That wouldn’t buy us any time at all. We want to keep our coding at the rate we’re currently at, if not better, of course. There’s always room for improvement. But really, the Canadian experience has been such that productivity in HIM has been reduced in coding record. Also, the amount of play going back to the physicians for information is going to be enormous. And you know, they don’t always answer us. That will be a challenge itself. So we want to try to mitigate some of the potential pitfalls that we’re going to have as much as we possibly can.
Guerra: It make sense, but it makes me chuckle. When I interview CIOs, it’s obvious that nothing will create action or activity in a hospital more than the possibility of AR days going up. That will get everyone on board, get things done, and get money allocated. Everyone is definitely afraid of that, right?
Comitto: Absolutely, it worked here — we had a whole motion that involved about five or six different applications that the board approved. We haven’t implemented all of it yet, but a picture was painted for them as to what the automation would do for us, and they did agree that they felt this was the prudent way to go. So that’s what we’re doing.
Guerra: Right. You talked about voice recognition and templates — doing more on the front end to get discreet data in. Definitely that’s the way to go for the future; that’s the trend. What you’re doing is trying to mitigate the burden that’s on these clinicians while still getting the discrete data you need for the backend reporting. That’s a sensitive dynamic, correct? Tell me about how you balance that and what you do if you find yourself in a situation where you say, ‘This is too front heavy on the clinicians. What are we going to do here?’ Tell me about that dynamic.
Comitto: We had not the same experience, but a similar experience when we first went up with CPOE in that everybody was getting alert fatigue. It’s a similar issue — how do you mitigate that? So we went back and we reviewed all of our alerts. We tightened some, we took some away, and we modified some. So we did a lot of work on that a number of years ago, and frankly haven’t heard any more complaints on that. Do I know that they ignore some? Yes, I am sure they do, but it seems to me at this point in time it is not that much of a nuisance to them.
I think we’re going to have to go through the same process with progress notes and coding. I think we’re going to need to pick the data that’s absolutely essential to be structured, and give them an opportunity to still state the patient’s story, which is what they typically do today. But I know they wouldn’t type all of that, and that’s why the voice recognition will help. It’s very similar to the radiologist world; it’s almost the same.
Guerra: I’m chuckling because whenever I ask this question, the transcriptionist we use emails me and says, ‘Are you talking about me?’ And that will make sense when I ask you the question. No matter whether it’s voice recognition or a transcriptionist, the best transcriptionist can make a mistake unintentionally — one word sounds like another and God knows with medical terminology. So my question is around verification of data. We have all these tools that are trying to make it easier for the physician but this stuff has to be right. Every word has to be right — every number. So the physicians they have to check their stuff, no matter what kind of tools you give them.
Comitto: Well, yes. They’re going to electronically sign it. And it’s the same thing with an order or an order set. You ask them once; you ask them twice. ‘Are you sure? Click here.’ That is a big issue anywhere in healthcare. It’s no different in the paper world as it is today in the electronic world. It will be a different type of error, but we need to tighten our systems so that we have medical logic that will track some of this.
Guerra: Right. You make a great point. So it’s not totally different than it was. I guess my concern is that we don’t want them to think that these tools that they’re getting are going to be 100 percent perfect — they should be on guard for an error here and there. I guess the idea is that we want to make sure that whereas they were getting something back with two errors, they’re not now getting something back that was electronically transcribed with 15 errors, right?
Comitto: That’s correct. It’s going to take a while. It takes a while to refine these systems, as I said earlier, with alerts to get them where you have the most practical there or the most essential there. And we’re doing work with quality measures where we’re leading the physicians down certain pathways as well using that kind of tree logic that I think will help us. So we’re going to get the information we need that will explain why they are or are not prescribing certain medications — things of that nature. This all stemmed from Stage 1 Meaningful Use and how we were able to do some of the quality measures.
Guerra: When you roll things out — and I’m thinking of the CPOE example — is it important to tell the physicians, ‘Hey, bear with us. This isn’t going to be perfect but it’s going to get better’? You want them to know that kind of dynamic.
Comitto: We absolutely do. Communication is the biggest part and the biggest challenge as well, because we’ll send out 50 emails and you’ll still have a physician who says, ‘you never notified anybody.’
Guerra: Right, because he intentionally made a rule for all your emails to go on the spam folder.
Comitto: Exactly. And we posted in physician work areas and the physician lounge. We have a whole process. We’ve been doing this a lot of years, and there will always be those who will say they were not notified. But what we started doing as much as possible is we have our select group of physicians where we find a specific nursing station. We start with that and we try to get the bugs out of there. We try to fix it with those folks that will be reasonable and will work with us, and that has been really great, and then we start populating it through the rest of the enterprise.
Guerra: In your description of the products and what they do, did you cover natural language processing? Is that in your plans?
Comitto: Yes, it is. That will frontend these — and I hate to use the word — template-driven progress notes, but the reality is I believe that, just as with radiologists, the voice recognition part of it is going to be key.
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