While meeting Stage 1 requirements of the Meaningful Use NPRM is a daunting challenge to most, a few are just about there. One such institution is University of Wisconsin Hospitals and Clinics, a HIMSS Analytics Stage 7 facility. And though VP and CIO Mike Sauk has just a few odds and ends to deal with, as far as the two dozen measures are concerned, he certainly is sympathetic with the plight of others as they try to garner HITECH incentive monies. To learn more about his journey at Wisconsin Hospitals, and get some advice for others, healthsystemCIO.com editor Anthony Guerra recently caught up with Sauk.
I’ve been associated with systems in the past where there was so much clinical decision support built in that you had popup fatigue.
I know that some organizations have put in scribes that can quickly enter the order. It’s understandable that there are cases where verbal orders are appropriate …
I would never push to the point of sacrificing quality and patient safety in order to meet a federal regulation whose reward is money…
GUERRA: One question at a recent policy meeting was who needs to be exposed to the clinical decision support at academic medical centers — you might have students or residents deciding on the order and entering the order and, at some point, that’s supposed to be supervised by the physician who’s mentoring or managing that student or resident. So who needs to be exposed to the clinical decision support, and if it’s the person who’s ultimately authorizing the order, what is the workflow? Does that make sense to you?
SAUK: Yes, it does. Residents don’t need their orders to be reviewed. Medical students placing orders would need to have physician review before they could be executed. That’s my understanding.
First you have to get the system in. You have to build the foundation, and then you can build the house and put in the swimming pool in the backyard. For us, we’ve just begun to decide how much and where we should have clinical decision support inserted into the workflows and into the system. I’ve been associated with systems in the past where there was so much clinical decision support built in that you had popup fatigue. Those were eventually ignored because there were just too many of them, and it became annoying to the people who were supposed to be aided by the advice. It was just so much that they didn’t read any of it. So there’s a happy medium there somewhere, and we’re just beginning that process of putting in an appropriate amount of clinical decision support.
GUERRA: And I think those would be two separate issues —one is a workflow issue about which clinician is exposed to the support, and then the second issue is the degree of clinical decision support.
SAUK: Absolutely. I’m not the decision maker on this, and I’m not involved in this discussion, but I would doubt we would create a clinical decision support system just for the residents or medical students that wouldn’t be seen by the faculty. My guess is that the clinical decision support that we do develop will be useful for all levels of providers and not just focused on a single level.
GUERRA: There are still quite a few verbal orders flying around. How do we apply clinical decision support to those?
SAUK: For us, that is a small percentage of all orders because we have so fully implemented provider order entry. Certainly there’s still verbal orders, but only in environments where it’s been approved, such as trauma. We have a trauma center, and I know that some organizations have put in scribes who can quickly enter the order. It’s understandable that there are cases where verbal orders are appropriate, and we try to limit it to that, and we certainly have reduced our verbal orders. Regarding verbal orders that would have to be signed in the paper chart in order to validate that the order was placed, those have gone away. So we’re in a good place right now when it comes to verbal orders. We’re still working on it, but we’re in a good place.
GUERRA: What are your thoughts on scribes in the ED?
SAUK: We’re implementing Epic now. They have a multi-step ordering concept in which the order’s entered by the scribe or somebody else — and this is really more on the ambulatory side and in particular on the surgical side — but then it’s queued up for the physician to sign before it’s actually sent to the ancillary systems. So they physically don’t have to enter the order, but it doesn’t get executed without their electronic review. I see nothing wrong with that.
When you’ve got a provider, particularly in surgery, where they’re seeing 60, 70 patients per eight-hour day or more, you just can’t expect that they’re going to be able to place their own orders. I think it’s expected that they review and sign the orders, but I think having a scribe in that case makes sense. You would have to reduce their patient load in order for them to have enough time to do everything themselves. So where would those patients go? It just isn’t going to happen.
GUERRA: So you’re a full-boat Epic shop?
SAUK: Yes. We’ve installed every module Epic sells except Stork (OB module), and that’s because we don’t deliver babies. We’re also the Alpha site for their transplant module which we’re installing right now. We’re the Alpha for the mobile meds for medication administration.
GUERRA: So you shouldn’t have a big certification concern. It’s not like you’re running a shop with 12, 15 different applications all cobbled together?
SAUK: Correct. We still have a separate lab system, and we have a separate radiology system. However next year we’re installing Epic’s radiology system, so it’ll probably be a couple of years before we would ever replace our lab system. But we’re pretty much now a single integrated, single database shop.
GUERRA: Who do you use for lab?
GUERRA: From what I hear, Epic’s lab module is a couple of years away from primetime.
SAUK: I physically have never looked at it or sat in a room where it was demoed. I’ve only heard that it’s really not ready for an academic medical center environment. But we have had enough going on that we haven’t spent a lot of time thinking about that, and the McKesson lab system works well for us, so it’s not a priority. But in radiology, for sure we’re going to be installing the Epic radiology system. It’s better than what we’ve got.
GUERRA: Who do you have now for RIS?
SAUK: Siemens NOVIUS.
GUERRA: And PACS?
SAUK: PACS is McKesson.
GUERRA: And you’re just going to keep PACS?
GUERRA: You mentioned earlier there were three or four Meaningful Use items you’re working on. Are those the major things on your plate, or are there some other projects that haven’t been pushed to the side because of Meaningful Use?
SAUK: I don’t think Meaningful Use will push any of our current projects to the side. It’s just going to require some focus, in particular, on those three or four items, but none of them are something that we can’t overcome fairly quickly. Like for instance, one of the requirements is that, at the drop of a hat, you need to be able to give a patient an electronic copy of their record upon discharge. Well, Epic has that functionality — we haven’t implemented it yet, there’s a workgroup currently focused on it. I’m sure within a month or two we’ll be able to do that. So it’s things like that which just accelerate the development of some functionality.
GUERRA: And you see no stretching or stressing of Epic’s resources? They’ve singed a lot of big clients.
SAUK: One hundred and fifty. We don’t see any of that at all. First off, their current product has been certified. They believe they’ll be able to have a certification that now meets the new regulations available within the next couple of months and Epic, out of the box, probably meets 18 out of the 23 or 24 Meaningful Use 2011 requirements. In fact, it may even be higher than that. So I don’t see Epic really scurrying to do anything other than go through the recertification.
GUERRA: You’re in a great position, but some of your colleagues aren’t so fortunate. What’s your best advice for those that are not quite as far along?
SAUK: I think that you first have to focus on the priorities and the needs of your own hospital, your own patients, your own practice, try to parallel it to Meaningful Use, but don’t let it take you from addressing the needs of your specific organization. Don’t let it be the only driver for where you go. If you’re starting on a reinstall or having to pick a new solution, you have to get the foundation in first before you add all the extras that are going to meet a lot of the requirements in Meaningful Use. As we talked earlier, I would never push to the point of sacrificing quality and patient safety in order to meet a federal regulation whose reward is money, because the money that’s really available to hospitals for Meaningful Use wouldn’t even begin to dent the cost of a solid EMR install. So it’s really more about the penalties down the road that you probably want to avoid, but I don’t think you should make short-term decisions that haven’t been well thought-out just to get that first wave of incentive pay.