Podcast interview with Suzy (Wier) Thorby, Chief Nursing Officer of T-System (transcript)

This is a transcript of my recent podcast interview with T-System's Suzy Thorby.David Williams:  This is David Williams, co-founder of MedPharma Partners and author of The Health Business Blog. I'm speaking today with Suzy Thorby, Chief Nursing Officer and Senior Vice President for Sales and Relationship Management with T-System, a leading provider of clinical documentation solutions for emergency departments.Suzy, thanks for being with me today.Suzy Thorby:  Thank you, David. I appreciate the opportunity.David:  Suzy, what is the T-System?Suzy:  The T-System is a chief complaint-specific documentation tool for clinicians in the emergency department. For example, if somebody presents with chest pain in the emergency department (most of our cases present as new, undiagnosed problems), we take the chief complaint, and, basically, if they have pneumonia or osteochondritis or an acute MI, you're able to rule out the highest risk things.It helps pull together the things that are most critical on any presentation. It brings your quality indicators to the bedside with you. We do that both with paper documents and our electronic documentation, which is a natural extension of paper products.David:  Tell me about how the emergency room is different. It sounds like people are presenting with undiagnosed problems, potentially of an urgent nature and without a lot of background knowledge of them. How is it different from what things would be like elsewhere in the hospital?Suzy:  Well that is a very good point. There is a different standard of care for the emergency department because if someone presents to the ED, they have a different expectation than going to the day surgery area or to their physician's office. They're actually frightened enough or sick enough to come to the emergency department. We're held to a different standard of care.You don't really have a diagnosis when they come. Even if you have someone with asthma and it's an acute exacerbation, perhaps they're presenting today with pneumonia. You have an episode-based document versus a document that supports the continuum. It becomes part of the continuum but you have an acute episode of a chronic illness or a new illness that is presenting.In that way the chief complaint-specific documentation works very well.

 You wouldn't say someone presents with asthma, you would say someone presents with shortness of breath. That way you're able to make sure if it's just an exacerbation of their asthma or they have pneumonia, you've captured the data that helps support the appropriate disposition and plan of care for that patient.David:  It sounds like you have both a paper system and an electronic extension as well. Can you talk about the relationship between those two and also how paper versus electronic documentation has different sorts of issues, in the emergency department versus other places?Suzy:  Yes. We developed the paper system in 1995 and 1996 because of the burden of remembering all the documentation guidelines, when CMS first came out with all the documentation guidelines. 

It is very onerous, making decisions on patient care and providing care when you are trying to remember these guidelines, so the paper system developed as a way to say, if this is what CMS says is an appropriate level of service, let's make sure we get those things into a document.It becomes very difficult to remember how many reviews you have done or how many elements of a physical exam. What we did with the paper is basically presented them in a way that was specific to the patient's complaint. We incorporated in 1996 and it was astonishing because at that time less than one percent of the EDs had any templated documentation.Basically, everybody thought that dictation was the gold standard. Because dictation tends to be a narrative, you would get the story but miss the elements that supported your level of service. What we did is we made a data centric model that not only captures the clinical data but supports the level of service.Again, we found that we were able to take things like QA elements right to the bedside. It was a data push rather than a data pull. We were able to push the standards out in a way that physicians could use it at the point of care versus going back retrospectively and finding that the data was missing.David:  It sounded like when you were starting off that a very small percentage of people were actually using a templated system. So you're basically replacing a free form system. Is that still the case today when you go into a new customer? What would be the typical state of play? Would it be completely free form or would they have some sort of homegrown system or some competitor in place already?Suzy:  Interestingly, we have about 30 percent of the EDs in the U.S. where the physicians use the T-sheets. I think that is significant because the more users that we have, the better the documents become. It's a living body of knowledge. It's not static. We didn't develop the templates and they've stayed the same. We've actually received input from thousands of physicians, compliance officers, reimbursement specialists --and the documents continue to evolve. It's a dynamic process.But the biggest challenge was that it was a free form, so you'd have to make a right brain/left brain switch, where you're used to gathering the data in a storytelling format and now you're gathering data at the point of care that ultimately support your clinical impression.I would say it's the difference between a tape and a CD. If my favorite song on a tape is number five, I have to fast forward or rewind to it. If it's a CD, I go right to the information I need and I can document it in a nonlinear way. The other key thing is that we were able to do it at the bedside in parallel with the patient visit. You would be able to capture data in a nonlinear way at the bedside and therefore be able to spend more time with the patient at the bedside. Not too many patients are saying, 'That ED physician spent way too much time with me while I was in the department.'It solves so many problems that it was astonishing. You didn't have to wait for a registration clerk to put somebody in the system before you could start doing your documentation. You didn't have to wait until you had all your lab and x-rays back. You could get the history, your physical exam and you could do it again in parallel with the whole visit, which helped with a lot of bottlenecks.David:  Now that you've gotten up to 30 percent penetration, what are the key drivers these days? Is it simply that when someone comes into an ED that's not using the T-System they'll say, gee, we should really have this because this is what I'm used to and it makes so much more sense? How much of a driver is pay for performance?Suzy:  Look, for example, at Keystone Physicians. You have to consider if you have multiple emergency departments as a physician group that you're staffing, you have such wide variability of documentation. They said, we will make the commitment to standardize our documentation and even the playing field across our sites.If you think about all the new things that come out as far as documentation guidelines, present on admission criteria, pay for performance, not only by CMS but now various third party payers, it's overwhelming to try to remember all of those things when you're taking care of a patient and also to remember the critical things on a presentation.If somebody came in with back pain, you don't want to sit down and do your dictation and ask, 'Did I check thermal pulses? I can't remember.' Maybe you have to call them up and have them come back to the ED, which I actually had a physician tell me he did. It's better to have the data there with the patient.Whether it is clinical data, quality data, utilization data, CMS data, or quality indicators, having it there during the point of care makes a huge difference in how consistently you capture it. Then you can compare across your enterprise if everyone is doing it the same way. You can make changes according to your practice. So, for example, Keystone Physicians is really helping in meeting their clinical and business objectives based on a prototype that we provide.David:  Keystone is an outsourced emergency department group so they're working across different areas. Would they have some of their same employees or contractors working across multiple sites?Suzy:  Frequently, if you live in one town and they staff two hospitals, they'll go from hospital to hospital. Again you're really decreasing variability and allowing the physician to focus on the thing that is most important, which is medical decision making and patient care.David:  When a hospital is deciding to implement the TSystem or is evaluating it against other sorts of systems or keeping things the same, what is the typical process that you go through and how do they look at it? Who are the constituencies that are involved and do they evaluate financial measures, clinical measures, safety measures, or risk management/defensibility measures? How do they look at it?Suzy:  All of those. It varies by site. Dictation is very expensive and we see margins of health care decreasing and you get no consistent ability to capture data. They tend to vary widely based on a provider rather than a tool. They will look at things like, 'What does this do for our bottom line as far as dictation?', also the medical/legal exposure because you're able to take your QA indicators to the bedside. You're able to capture things that support standard of care for the practice of emergency medicine.Additonally, you're able to have physicians spending more time with patients. A lot of hospital CEOs are very concerned about their Press Ganey scores or whatever tool they're using to measure patient satisfaction. You also have utilization review who's saying, 'We need to make sure that we have this documentation if we're going to have an admission.

'We have present on admission criteria now, which say that if you don't have it documented that a patient had a urinary tract infection at the time they were admitted, CMS is not going to reimburse you for treatment of that. We generally have a positive impact on reimbursement just because you're able to get a lot of consistency. Again, it's right there. You see what you need to document.I always say with a caveat, if you're a high performing organization, we want to make you better performing. Maybe you don't increase reimbursement but you see an extra patient every two hours because you're able to do it in parallel with the visit as opposed to many documentation methodologies that have to be done in sequence. You can not begin a dictation until you have everything back on a patient and have made a disposition.It's the ability to get consistent documentation, to do it in parallel with the visit, to break up the bottlenecks in the ED and provide the quality indicators and the clinical indicators that really help make care better.David:  What do you find in terms of how hospitals look at T-System within the context of their overall information strategy? For example, do you find a hospital that's doing a general digitization push but then also would consider putting in the paper-based T-System at that time? Do they tend to go with the electronic T-System or do they say, "Gee, as part of our comprehensive package we're going to bring in some other solution because it's integrated in with our main system that we're putting in'?Suzy:  A lot of people have a long term IT strategy that says they're going to have a single enterprise vendor. However, the clinical verticals aren't that well built out on enterprise vendors. They take the overarching clinical premise and try to make that work in the ED. Because the ED is such a unique environment, you don't necessarily have the ability to take, for example, a consult in the office where you're doing follow up on hypertension and make that work in the ED. It's building out those verticals on the large horizontal platform that is a challenge.So, people may say, long term, that they're going to go to an enterprise vendor, but there's not really one that leverages the technology to make the work flow better, the clinical care better, that has a content that is really collaborative content, not specific to what that hospital needs. And, I think that's an overarching strategy.I use Salesforce.com every day. Salesforce works very well for me because they understand my work flow. The technology leverages what I do. And in one of your blogs, somebody said, 'Getting adoption is difficult with clinicians'. And, it is one of those things that if you don't leverage their current work flow, it is very difficult to be successful. And you may be successful from an IT perspective with some applications, but we say your core competency in a hospital is patient care.We leverage the current work flow and the processes to make the patient care better, not detract from it. And I think we do that uniquely. And also, our content, because it's dynamic. Because we get feedback from users. Because we're constantly updating our content. That makes a huge difference in how people are able to use it and realize the benefits.David:  Suzy, I see on your website, a picture of what looks to me like a motion C5 Mobile Clinical Assistant computer and I have to ask you about that since my friend, Scott Eckert, is the founder of that company. Do you work with Motion Computing and what's your impression of them.Suzy:  Yes, we do. We have a great relationship with Motion. We have them at a lot of our sites. It's amazing to me when we first started to implement our electronic record, that the mobile devices weren't what they are now. You'd have to stand right over it. They weren't as rugged. And the connectivity was not as good.Now we're finding that, with the Motion devices, we get great connectivity. We have great screen resolution, great screen size, and the images are so much better. Handwriting recognition is so much better. What was really a difficult thing to get people to transition to at one point is now easier and easier so they can basically take that device to the bedside and capture the history, the past family social history, review a physical exam. It's basically the paper sheet metaphor with a mobile device.David:  You've been at this for 12 years, or so. I'm sure you're not counting, but it's been a while. If you look ahead five years or so, what would you think might be the biggest difference between where we are today and what you'll see at that point in time?Suzy:  Well, I think the biggest differences that I see are these quality measure initiatives or value-based purchasing both within CMS and third-party payers. Now, there are those who would say 'This is payment reform in sheep's clothing', and that may not be too far from the truth. It is basically saying, the fee for service, making more money by delivering more services is not what we want to pay for. We want to pay for appropriate care, appropriate utilization. We don't want to pay for something that you created in the hospital, for example, pneumonia or a decubitus ulcer, or a urinary tract infection.

That train has left the station and gained speed every day. I'm actually on a work group with the AMA and HIMSS to say 'How are we going to get electronic records to report on this so that we have consistent, reproducible, quality data on patients when they present? How are we defining the data? How are we recording the data? How is it extracted?' Those are all things that are going to happen, are already happening. It increases every day.And so my thinking is that in five years we're going to be seeing a lot of value-based purchasing and quality measures that must be reported to get reimbursement. So, pay for performance for physicians now is sort of a voluntary thing that you get a little bonus. My thinking is that if you don't do it, your percentage of Medicare fee schedule is going to drop, or as Aetna's doing in California, they're going to say 'If you are not one of our certified quality providers, you won't be in network'. And you put the quality stamp on anything and it's hard for beneficiaries or hospitals or employers to say it's not good.But, I think it needs to be watched carefully because there are some agendas that could be followed if it's not implemented and recorded appropriately and well defined. My issue is that they have quality measures that are poorly defined at times. You're going, 'how do we make sure that if this is a quality measure, it's being measured consistently and predictably across, not just a site, but a state, a system. How are we doing that consistently?'David:  There's a lot of talk about consumerism in health care and I would say the Emergency Department might be the last place that you'd expect to see it, but tell me if I'm wrong there or how that might change. Is consumerism something that is actually coming to the floor in the Emergency Department as well, or are patients still pretty much passive when they come in?Suzy:  No, I think a lot of times what you'll see is that people will have looked something up before they come in. They'll have sort of run through the WebMD, 'What do I think I have', and will come in with sort of an idea of what they think their plan of care should be. That is something we see in Emergency Departments all the time now.There are still a lot of patients who will acquiesce to whatever the clinicians tell them when they get to the department, but we're seeing that more and more. And that empowerment is good. It would be nice at some point for us to have good data on cost/benefit ratios to say, 'We can do this and it will cost you x, we can do this, it's 2x and your outcome is going to be the same'.David:  I've been speaking today with Suzy Thorby, Chief Nursing Officer and Senior Vice President for Sales in Relationship Management at T-System.Suzy, thank you for your time today.Suzy:  Thank you very much, David. I enjoyed it.