As a physician, former CIO and now CMIO, Lynn Witherspoon has operated in the healthcare system from a number of angles. And having lived through Hurricane Katrina, he has a better handle on disaster recovery issues than most. But one impact of the storm that the organization is still working to recover from is the interruption it caused to adoption of inpatient CPOE. To learn about these issues, and tap the wisdom of one wiser than most, healthsystemCIO.com editor Anthony Guerra recently chatted with Witherspoon.
… my challenge really is creating that quality management system, if you will, and not building a reporting extract tool that is technically able to upload data so I can get some ARRA dollars.
… the downside is to chase after those criterion as opposed to keeping the patient squarely in your gun sights here.
… this is not about the money and, really, if we forget about the money and continue to do the right thing and do what we know we want to do and need to do, the chances are that will all work out anyhow.”
GUERRA: Tell me about how things are going in your neck of the woods. How’s your day been today?
WITHERSPOON: Here in New Orleans, we’re still in a bit of a recovery mode. This organization, Ochsner, has grown dramatically since Katrina, and in fact we’ve acquired an eighth hospital across Lake Pontchartrain just here in the last few months. So we continue to grow and diversify from a large clinic doctor practice to a large multi-hospital system. So that keeps all of us well-focused.
If you look at my calendar from this morning just for a minute, I started off with a quality meeting, moved straight away to a discussion around measuring quality metrics, being able to organize them in a fashion so that they can be presented back to clinicians at the point of care with one eye focused on the ARRA quality reporting requirements, and the other on why we’re doing this in the first place — to help our doctors take better care of patients.
That segued right quick to another hat that I wear which has to do with radiation safety and radiation protection. You may have noticed that as CT scanners have acquired the capability of generating many, many more slices — and if you think about each slice being a dose of radiation — radiation exposure to our patients has increased pretty exponentially. So we’re concerned about that dosing on our patient side, as opposed to our employees where we often are.
We just had a lecture about how to give an effective lecture. We have a series of conferences that many of our staff attend pretty regularly because this is a learning environment. And now, I’m talking to you.
The rest of the afternoon has to do with studying HIMSS’ proposed response regarding Meaningful Use. We have a process-improvement project in place that revolves around interestingly, meaningful use. So we’ve spent a number of years deploying electronic health record technology, and now we’re in the process of understanding how to leverage that, figuring out what our doctors really need to be able to do a better job.
And then after that discussion I’m going to go to a concert tonight. So it’s been a pretty full day. And I guess the point of all this is life is really busy, and I’m sure I’m not unique in that regard. I know from looking at some of the blogs that you’ve done that this is a phenomenon where all of us see our lives accelerating away from us as time goes by here.
GUERRA: Let’s go back to the quality measures discussion. You mentioned that it’s very important to create the type of quality measures that can be useful to the physician. You also said you’re doing this with an eye towards Meaningful Use because CMS is going to require certain quality measures presented in a certain way. Those two may not be the same thing.
WITHERSPOON: You know, I’ve thought a fair bit about that, and it seems to me that the notion that CMS will require us to report that we’ve done certain things or that certain results are trending in a particular direction really implies that there is a management system that underlies that — a system which has been carefully crafted to propel patients in a trajectory towards better health. The name of the game here isn’t to be able to tell you that I measured my diabetics glycohemoglobin every three months like I was supposed to, but it really is to be able to say: “You know, my diabetic patient and, by extension, all of the diabetic patients that I take care of are doing better today because of efforts that I made to ensure that they got the things they needed to get when they were supposed to get them. I thought about what those results were as opposed to just accumulating them so that I could electronically upload them to CMS; but was able to meaningfully apply that information both for the patient who’s in my office today but, increasingly importantly, for the entire population of such patients that I take care of.”
Again, as I would think about it, my challenge really is creating that quality management system, if you will, and not building a reporting extract tool that is technically able to upload data so I can get some ARRA dollars.
GUERRA: The current rush for those dollars seems so at odds with the way non-profits-hospitals are supposed to view such things.
WITHERSPOON: Yes. You know, I think that’s one of the real dangers or hazards here, and I think especially so for organizations like ours where we’ve spent a considerable effort over a number of years to understand how to do better and to leverage automation to help us in that quest. The prescription here is becoming increasingly specific, and I was interested that the latest from the Policy Committee, from the high level folks, was, “Well, gee, they sort of relax their push towards an all-or-none set of criterion,” but at the same time, if you look at that, they’ve layered on yet a number of additional requirements around process support and/or measurements. And I just worry a little bit that the patient gets lost in this quest towards fulfilling that prescription as opposed to remembering why we’re here in the very first place, and that’s really about better care.
The good news is perhaps it will enable us to focus on some of the things that we need to do to take better of care patients and maybe, if we’re really lucky, we’ll be able to get a little bit of outside support to do that. But the downside is to chase after those criterion as opposed to keeping the patient squarely in your gun sights here.
GUERRA: How would you describe your organization’s attitude towards qualifying for the stimulus fund? Is it basically, “Lynn and Chris (Belmont, CIO), make sure we qualify for this money”?
WITHERSPOON: You know, at first blush it was, “Gee, this is great. You guys go make sure we get the money.” As the year has gone by here, and we’ve thought about that, we’ve also thought, “Well, what does going after the money require us to do differently than we’re doing today?” And as much as anything else, it really means still doing what we’re doing now but better and maybe accelerating towards an end point a little bit faster than we had previously been going.
Interestingly, in the last conversation that Chris and I had, we looked at each other and we said, “You know, this is not about the money and, really, if we forget about the money and continue to do the right thing and do what we know we want to do and need to do, the chances are that will all work out anyhow.”
As it’s become a little clearer who’s going to get paid what for doing what and providing certain services — specified services to federal payers — the bandwidth of whose really in line to get money here gets a little bit narrower and narrower. Yes, I think we’d be happy if there’s a little bit more support for this, but that has ceased to be really the driver here at our organization. It really honestly is about how we help our doctors leverage automation to take better care of patients.
GUERRA: Where are you on CPOE?
WITHERSPOON: It’s really pretty interesting because we started out as a large physician practice. Yes, we had an acute care hospital, but the point of the thing really was more focused on that medical home group practice model. A major part of our focus around what has come to be called Meaningful Use in our world has been around physicians in an ambulatory setting. It turns out we had automated orders processing in the clinic a decade ago. And as time passed and we built tools around process support for physicians in their office environments, we never ever said anything to anybody about, “Why don’t you go to the computer and personally put the order into the system.” But it turns out that today, of our 800 physicians, about a third of them are electronically entering some significant number of orders in the ambulatory environment, unbidden and without any prompting on our part. They’re doing that because they figured out it’s actually easier and more efficient and more effective than writing something on a piece of paper and giving it to their medical assistant for someone to transcribe.
The ramp up to increase that automation of physician direct entry of orders in our clinics would appear to be relatively straightforward. In our hospital, for a variety of not very good reasons, not the least insignificant of which was an event called Katrina back here awhile ago, we really never completed an implementation of CPOE. We were hard at it prior to the storm. We did accomplish a great deal of order set development, and I think very importantly the standardization of order sets across disparate departments and physicians, so if you come into our hospital with community-acquired pneumonia; there’s really only one best practice order set that anybody, regardless of which service you come in, will use.
So we’ve achieved some significant value in CPOE, if we use that term to describe the automation of the process all the way from where the order was written until the test is completed or the medicine is administered. We’ve got lots of safety measures as it would relate to medication management and the management of dispensing our pharmacy platform as well. We’ve done a lot of that work, but we still have some work to do in the hospital. The thing that I think is interesting is that many of those very same doctors who are directly entering orders in their clinic come to me and say “What’s wrong with you, why haven’t you done this in the hospital, when can we have this?” So I’m not sure that in a year I can transform not one hospital now but eight, but I think we’ve certainly taken significant steps along that journey.
I wish I could tell you that like some of our other colleagues we were further along, particularly in our hospital environments, but I bet you there’s not another clinic environment any place that has a better success story around direct physician order entry than what’s happened here.