Straight talk: Clinical information systems

Where are we today, where do we need to be, and how do we get there?

This is the first installment in a series of group discussions by top executives on key issues in healthcare today. Straight talk is presented by Modern Healthcare and PricewaterhouseCoopers. The first Straight talk session tackles the subject of clinical information systems. The discussion was held on January 9, 2002 at Modern Healthcare's Chicago headquarters, moderated by Charles S. Lauer.

CHARLES S. LAUER: We'll start with the basics, gentlemen. Can you provide the definition and scope of clinical information systems?

SAMAHA: A clinical information system is much more a strategy than a product or an architecture. I define it as a combination of clusters; one cluster will have physician order entry, result retrieval, documentation, decision support, the flowcharts and the notes. The second is ancillary services-radiology, lab, and pharmacy; and then two new components, such as PACS (Picture Archiving and Communications Systems) and biomedical equipment.

FURRY: I agree. It's the group of systems dedicated to collecting, storing, manipulating, and providing access to a clinician in a secure fashion. And it's across the continuum of patient care. It's not just in one location: a hospital, a doctor's office, a pharmacy, or a lab. We're not there yet, but when we get to the point where we have systems that support the continuum of care, we will be.

HICKMAN: I'm at least in the same ballpark with my two colleagues. I talk about the definition as either basic or advanced. I agree it is a suite of applications, but it's a suite of functionality. Basic would be those kinds of things like order management, online order results, charge capture, vitals, nursing acuity, medication administration recording, clinical notes, basic formulary and static decision support, and ancillaries that have basic functionality. The advanced class is where our interest is for a large part of this discussion. Because it's where we now start seeing a discrimination in the market. Most of us have tackled the basic list. An advanced system would have physician order entry with distinct functionality differences, not just the clerical process, but with rules firing to be sure that the clinician practices best interventions. It would create flags to address compliance and coding concerns, care alerts, rules firing against protocols and pathways. It would integrate with mobile devices as part of the whole process. And the physician functionality would be remotely accessible from anywhere for the sake of how they want to practice their art and science.

SAMAHA: Today we have systems where I can order something and it can check for cross-complications. But they're not smart, so physicians won't use them. For example, the system only warns you when you're doing something wrong, not when you're not doing the right thing. It's not going to come after you and say this patient has congestive heart failure; you did not consider this treatment. E-mobile devices are valuable if you have good push technology, when my handheld or my Web phone beeps and says I've got an alert on lab results. But to have a physician take a three-by-three device and try to put an order in has no value. And most of what they're doing is just putting Web access to this.

LAUER: If I were to go to a CEO, would his or her definition be close to what you're saying? If not, what would it be?

FURRY: I think they'd be more on the basic side of our definition. I think they would say, "We've got a clinical information system." Up until now, IT has been responsible for collecting data to help an organization run. IT has been a support mechanism for really every part of the hospital other than patient care. Today, the healthcare organizations that do it right are not just investing in a clinical information system. They're saying, "We need that data to be able to deliver patient care." A clinical information system becomes the key asset.

LAUER: What's the vendor's role in clinical information systems? How effective are the vendors today?

FURRY: Chuck, they're market-driven like any other industry. If clinical information systems aren't selling, they're not going to devote millions of dollars in R&D to develop them. So, now, all of a sudden the market's ready, and people are looking at the vendors to say, "Why didn't you anticipate this?" "Why don't you have all these capabilities?"

HICKMAN: Y2K knocked the vendor market off balance clearly in terms of activity on the clinical side. The Institute of Medicine (IOM) report (on medical errors) was released soon after. I think the vendors and others have latched onto that and said, "This is an opportunity to sell." We all have to be discriminating buyers and make sure we're astute in how we move into this activity. What are we expecting from an advanced clinical information system? Is it going to be just enough to get us there and back on a daily basis, or is it going to be built into our identity as an organization?

LAUER: You've brought up something that I think is terribly important for us: What is the strategic value of a clinical information system?

SAMAHA: I believe the potential strategic values of a clinical information system should result in a reduction of preventable errors. And if this is not a strategy of a healthcare organization, I think it's falling behind. Another one is efficiencies. A system that properly integrates workflow may give you a lot of efficiencies and may help with shortages. Proper documentation, billing, compliance and so on should help you.

FURRY: Traditionally, we have measured the value of IT in healthcare by saying, "OK, where's the service-cost benefit?" Today, the most important benefit of a clinical information system is its effect on quality and safety. Cost has to be in the equation, but I would look at quality, safety, service, then cost. Unfortunately, we don't know how to measure quality well yet, and it's going to be tricky in terms of measuring.

HICKMAN: I believe the metrics are there for the quantitative part of this measure, the kind of things you can affect: Reduce medical errors, reduce clinical utilization, better charge capture, etc.-those are things you can measure. On the other hand, the qualitative stuff, the ones you can't measure without sounding too grandiose, these kinds of applications do have the potential to save lives. Once we do truly get our hands around what our medical error rate is, now that we're more acutely aware since the IOM report-now we've got a basis to say, "Are we changing that rate as a result of what we've put in place?" We do need to be looking back to see.

SAMAHA: Physicians play a key role in quality. I'm not advocating that every executive in healthcare ought to be a physician, but the role of the physician executive in healthcare is not properly defined.

FURRY: Since physicians are the key piece of the quality issue, we look at what will affect better-quality care. I don't think the medical education process is going to change drastically. I don't think human tendency is going to change. To me the best way to improve the quality of care is through good information systems.

LAUER: Is it the role of the hospital, the physician, or both to help the vendor in providing better or more-effective solutions to support the clinical information system environment?

FURRY: There are a couple of things we need to address on the vendor side. One is that the physician now becomes the buyer, if you will. Traditionally, vendors have sold to CIOs, CFOs and department managers. Today, they need to be selling to physicians. And some are. The other thing that's going to have to change is the time from idea to benefit has to shrink. In other words, I need clinical quality and I need it today. Traditionally, vendors have said, here are the products and here's the process you have to go through to implement those products. By the time you get done, there's no benefit.

HICKMAN: What I need from a vendor relative to this discussion is simply honesty. Can they truly do what we're asking them or not? We have a responsibility to find the right questions to ask so that if they'll give us the honest answer, then we're able to discriminate.

SAMAHA: To be quite honest, it's like being in a marriage-it's both sides. It becomes a bad marriage when the hospital in our setting isn't totally honest, doesn't do its homework, or doesn't put proper expectations on the table. You can put blame on the vendor for not knowing their limitations. What we're all saying is that there is a big gap between the buyer and the vendor. They have to work together.

HICKMAN: You're right, and we are still a cottage industry in healthcare. And, as hospitals, our goals and missions are different from a vendor's, and perhaps in conflict. How do you build a mutually beneficial relationship? It takes work.

SAMAHA: It also goes back to the role of IT in a healthcare organization. If your IT is focused on data processing, and your CIO does not have the resources to put a good RFP together, to articulate and understand the vendor, you won't be successful.

HICKMAN: I think there is a convergence occurring in the vendor market. You've got the big players, we know who they are. We've got the middle-sized players, and certainly ones to watch. You've got that other class of new entrants in healthcare all the time. If I talk about the big players, which is where most organizations are likely to go from a risk-bearing standpoint, there is some convergence occurring. I'm talking about convergence around a functionality set that is very similar. There are discriminating factors in that convergence, different identities and different timing in it.

SAMAHA: They're all using the same terms, but the functionality may be different from one vendor to another. All of them talk about clinical information systems and support, but some of them mean "real time" and the process of order entry.

FURRY: I see something completely different, though. What's happening now, you look at Siemens and GE and McKesson, you're now seeing them not just as IT product vendors. They now provide the complete clinical information system. That includes monitors, lighting room design, redesigning the clinical process and providing the products. They're partnering with you to recast the whole clinical process.

HICKMAN: There's convergence expressed in terms of market functionality. We all are talking about medication administration errors, so we want to provide closed-loop systems; we want dynamic clinical support with all kinds of rules firing against different concerns. Functionally, it sounds alike. As soon as you start to look, you see discriminatory differences, and that's something that we've got to look at hard.

LAUER: What are some of the effective ways that physicians have sponsored clinical information system initiatives?

SAMAHA: It's a challenging role and has to be thought through. Physicians have a very important role. The first thing you ought to do is educate your physicians on the definition of a clinical information system. Second, educate physicians on what it takes to assess a system, to implement a system, and then go after physician leaders, not technical physicians.

HICKMAN: Another element I would add-I find in the academic setting there are some who really get it and want to move forward. In the community hospital setting, because the physician economy works very differently, I believe that we need to lead and then come to them as a second round. For example, medication administration error, closed-loop application, go after everything except the physician role. Fix the rest of the problem first. Let's go after the places for error within the organization that we have responsibility for, fix that, show it to the physicians and then say, "We want you to play, too."

FURRY: We used a new process in Indianapolis for a new heart hospital being developed out of an existing community hospital, a brand new hospital. We went into the physician's element. We took along clinical info systems specialists, nonphysician clinicians and physicians. We went through their daily environment with them. They were heart surgeons, so we witnessed their prep, we witnessed their surgery, we witnessed their post-op, and then began making them, not us, design how to do that differently, and how we could prevent errors. We basically made them the CIOs without them knowing. They designed the system from scratch.

SAMAHA: Let's take it a step further, a recent study launched by the American Medical Association showed physicians who compared themselves to other physicians in the same field actually experienced a significant improvement in patient care.

HICKMAN: It has to be physicians peer-to-peer.

FURRY: I believe that to succeed in the eyes of a physician, there is a set of "must dos" that a clinical information system must accomplish. It must:

1. Enhance his or her recall capabilities (such as drug interactions).
2. Measurably improve his or her performance.
3. Broaden his or her access to pertinent data.
4. Alert him or her to risk when or before it happens.
5. Be his or her own system. It can't be IT's system. IT can't design a system that will meet the needs of all physicians. It must be tailored to the individual.

HICKMAN: There are great opportunities with our vendors. What we need to do as leaders is seek those opportunities.

Want to learn more about clinical information systems?
Contact Stephen L. Furry, Partner, Healthcare Consulting Practice, PricewaterhouseCoopers in Indianapolis at (317) 453 4100.

Participants:

Charles S. Lauer Publisher Modern Healthcare Chicago, IL

Simon J. Samaha, MD Vice President for IT and CIO The Cooper Health System Camden, NJ

Stephen L. Furry Partner, Healthcare Consulting Practice PricewaterhouseCoopers Indianapolis, IN

George Hickman Vice President, CIO West Virginia United Health System Fairmount