Clinical Culture

By Edward H. Baker  |  Posted 08-07-2006

Expert Voices: Working Together to Improve the Healthcare IT Prognosis at Montefiore

The history of healthcare IT has not, in general, been a happy one. The industry has consistently underinvested in IT, and thanks to the ongoing misalignment of interests among the patients, providers and payors, it doesn't look as if increased pooling of efforts and more IT investment will happen any time soon.

Still, there are pockets of health in the healthcare landscape. Individual hospitals, as well as some insurers, continue to press for change in the use of IT so they can do their jobs better. One example is Montefiore Medical Center in the New York City borough of the Bronx. In keeping with its 15-year effort to expand from its stand-alone hospital base to integrate more hospitals and community-based ambulatory care units, Montefiore has embarked on a major effort to create clinical systems that combine single patient records, prescription order entry, and other elements that are tightly woven into the clinicians' workflow.

The team leading the hospital's IT effort includes Dr. Steven Safyer, senior vice president and chief medical officer; Jack Wolf, chief information officer; and Dr. Gary Kalkut, vice president and medical director. Editor Edward Baker spoke to the trio at their offices in the Bronx about the technological, political and cultural challenges of healthcare IT. An edited version of the conversation follows:

Next page: Integrating Everything

Integrating Everything


CIO Insight: Can you give me some history on Montefiore's use of information technology?
Safyer:
In the early 1990s, healthcare in general, and especially in New York City, was going through a radical change: to its payment systems, its delivery systems, its patient care systems. And Montefiore wasn't any different. We had to rethink who we were and what we wanted to be. How would we remain successful, and grow, and do the kinds of things we wanted to do the best way we could?

So we moved on a number of fronts. At the time, we had two hospitals (we now have three), and they weren't really integrated. We decided there were opportunities for efficiency, a higher-quality product, and greater synergies. So we began a vertical-integration effort. First we added a primary-care system, and then we integrated what we already had. We also added a managed-care product. By the mid-1990s we had all the elements of an integrated delivery system.

We came to an easy conclusion—not exactly rocket science—that clinical information systems could help us make all this work. They could help us manage care, they could help us on the quality front, they could help us on the safety front, and we knew for sure they could lower expenses. There's no question we couldn't have done what we've done without IT.

Still, we knew it would be expensive. We began with an investment of $20 million to get started building the clinical systems. At the time, that seemed like a lot of money to spend on IT systems. Now the joke around here is that we're $150 million into that $20 million investment. About half of that $150 million is clinically focused, not financially focused, and that's unusually high.

Instead of just dipping our toes into the healthcare IT waters, or simply letting someone else do it, we spent a full year in this room with 15 senior people in the organization. We worked with a facilitator, and we defined, in a very lean way, our objectives and goals. We were very focused on the kind of system we wanted as the outcome. We didn't know if it existed in the marketplace. But we had suspicions that it did.

By mid-1994 we had collected a group of 40 or so people, half of whom were high-level doctors and nurses, and we traveled around the country. We visited four vendors of clinical information systems, and for each vendor we also visited their best customer.

Long story short, three of the vendors just crumbled. They couldn't handle us. We knew what we wanted, we were tough and demanding, and they had nothing. It was vaporware. We gravitated towards the fourth vendor, but the company wasn't sound, businesswise. Lucky for them, lucky for us, somebody came in and turned it into a real business. Now it's part of General Electric Co.

Wolf: What you're hearing is that the strategy and the vision of the medical center—to provide integrated medical care to the entire community—is completely linked with the strategy and the vision for the IT systems. The people running a $2 billion healthcare delivery network in the Bronx are completely versed in IT issues, and that's the core of the success of IT at Montefiore. Everybody's part of the process, not just from the periphery, but engaged and embedded in the process of how we build these systems.

Safyer: That's really where Gary comes in. Gary was in transition from being a clinician to doing other stuff, and I think he and a number of other people really understood that you can't make change with IT if it doesn't fit in your workflow, if it actually takes longer to do your job. It needs to take less time and be the right thing and not bother you. IT should become almost like a third hand.

Was it hard to model the hospital's workflow processes?
Wolf: Yes. We spent an enormous amount of time doing just that. What we learned was that as we went from nursing unit to nursing unit, from department to department, each was very different, and we had to think about what the work-process flow would be in each of those departments and on each of those nursing units. An oncology unit is very different from a neonatal intensive care unit, which is very different from an adult ICU unit.

Kalkut: That brings up a problem: Because each individual department and location works differently, their requirements may not be met as well by a single enterprise system as they are by niche systems. But then niche systems don't talk to each other easily. So there's a "federal government versus locality" argument that comes up all the time.

We decided not to use systems that don't talk to our other systems, just because someone needs something right away. We're going to develop systems that are part of our overall enterprise system. It may take more time to build. It may not have all the bells and whistles you want. But from an institutional perspective it makes sense to have that integrated system.

There's still plenty of little IT systems that get uncovered all the time. But going forward, they're not going to be here, or they're not going to get support.

And the electronic patient record was one of the absolutes?
Safyer:
Yes, that's the center of the whole clinical system: one record that follows a patient from little old lady at home, to when that little old lady needs a heart transplant. We used to have 11 different registration systems. We have one now. It knows all your laboratory studies, your imaging results, the drugs you've been prescribed in the system, all your vital signs.

That record is really many records. But the doctor doesn't necessarily know that. As she looks at that record, she's actually going from the clinical information system to a lab system to a radiology system to a cardiology system, whatever, to retrieve information or make an order.

Everything that is digitizable (if that's a word) is in digital format now, though there are elements of patient records that are not yet there. Digital doctor's notes about a patient, for instance, are not yet ready for prime time. But we're currently working on that as well.

Next page: Clinical Culture

Clinical Culture


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.

Next page: Sharing Information

Sharing Information


And now you've begun sharing your patient data with other organizations, right?
Safyer:
Yes, the next step is to have regional sharing of information, and that's the purpose of regional health information organizations, or RHIOs. And we're on the verge of doing that. The Bronx RHIO just got funded with $4.1 million from a state bond act, and we've put together 12 institutions. The plan is to install a system that will allow us to share information. The problem is we have only enough money and gas in the tank to go so far. At some point, we're going to need more gas in the tank, and that's going to be a problem.

And from there we go to national sharing of information, which has a lot of political issues. The left is paranoid about the creation of a national identifier and everybody spying on everybody, and the right is paranoid about such efforts impinging on business activity and all that. So we're not there yet as a country. Definitely not there as a country.

What will it take to get there?
Safyer:
Here's the problem. We know we have saved money and gotten higher quality by using IT and sharing information. However, for the most part the rewards on a regional basis don't rebound to the providers, but to the insurers. So the motivation for a provider to fund more than the startup costs is low, because these regional entities will be expensive. And once they are set up, the winners will be the insurers.

So there's a disconnect. The consumer is frustrated because when he goes to different providers, they don't have his records. The providers are frustrated because it's hard to access information from elsewhere. You don't know what drugs people are on, what's happened to them. And then the whole healthcare system is feeling the pressure of the marketplace.

I think all this will eventually converge, because information sharing can save money for the big payors, the big insurers, and Medicaid and Medicare. But they're going to need to bite the bullet and pony up. So far the states haven't been willing to do that to any real degree, and the insurers are not willing to be the leaders because they're doing just fine the way things are.

I believe that in five years we will be sharing patient information nationally, but we can't do it until we do two things: the shared database, and a single identifier like Social Security numbers. One's a technological problem, the other's political. But it will happen.