Have you had problems with doctors and nurses resisting these systems?
Kalkut: One of the things that distinguishes Montefiore is that out of our medical staff of close to 1,900 doctors, probably 1,200 are employed physicians, including 250 in our primary-care settings. And we also have 1,000 residents. We're not like many hospitals where the doctors are mostly voluntary. That may not make our doctors any less difficult on a day-to-day basis, and if you say, "This is what we're going to do," there's always going to be pushback. But you can leverage the employer-employee relationship in a way that you can't if your doctors are voluntary.

Wolf: I have another perspective on that. I spent 12 years in retail, and I'll take a surgeon over an imported-carpet buyer as an end user any day. Doctors know what they want, they know what they need to get their jobs done, and they're focused. Gary oversees the ongoing development of the clinical system and what direction we go with the product. He runs the group that tells us where we should be and what we should be doing clinically. They're well educated and they know exactly what they want the system to do, and that's a better direction for a CIO than "Make it work, make this faster, make me more money." It's a much better environment, and it's easier to put the right solution on the table. And ultimately, the physicians embrace it. Once they understand and see the benefits of it, they embrace it.

Safyer: I think Jack is ultimately right. The fact that our doctors aren't voluntary is a great lever. But if you lead, and stay focused, and the things you won't bend on are reasonable, it will work. We had a vision, and there was a lot of leeway along the way, and we learned a lot of things. The mistake many hospitals make is to try to do it overnight. I thought we would finish the initial implementation of our system in two years. It took us four years. But once you do one, the next one is easier.

I flip it around. If we were to take our clinical systems away now, there'd be a barn burning.

And your clinical systems now allow you to aggregate and analyze all your patient data?
Wolf: All these fully integrated systems sit on top of a data warehouse that we can manipulate. It includes the records of 2 million patients. That lets Gary know how all the diabetics in our system are doing, for instance, or all the diabetics in a particular community clinic, or all the diabetics Gary himself is taking care of. And that allows us to make interventions and then see later on if we've had any improvement. So we're using the systems to do that.

Isn't that also a cultural threat to some doctors in your experience? Pay for performance, results-based medicine, all those bogeymen?
Wolf: When you look back to the mid-1980s, people were looking at electronic prescription order entry with the same fear you're describing now. Yet one of the things that has helped Montefiore stay at the forefront of technology in healthcare is that we're thinking past that. We're thinking about physician order entry evolving to evidence-based medicine, not to make the decision for the doctors, but to put more information at their fingertips, in some very clear, concise form, so that they can take a retrospective view of other interventions and a prospective view of what's available, and make an educated decision. There's so much information available today in the outcomes data, wouldn't you want access to it if there was a way to get it to you?

Steve's thinking about what my IT system is going to look like in ten years, and how we are we going to get it there. That's what we're discussing with products like the clinical decision-support system we're developing here.

Kalkut: These systems let you evaluate doctors and make them accountable, and that's infinitely preferable to having to look through thousands of charts to get the information needed to do the best job possible.

Safyer: Look, all change is a cultural threat. We don't mind being evaluated. We seek excellence. And we get exceedingly good buy-in on these decision systems, and the accountability that our database analysis lets us do.

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