PatientKeeper’s CEO and CMO speak about Meaningful Use in the hospital setting (transcript)

This is the transcript of my recent podcast interview with PatientKeeper executives Paul Brient and Dr. Don Burt.David Williams: This is David Williams, co-founder of MedPharma Partners and author of the Health Business Blog.  I'm speaking today with Paul Brient, President and CEO of PatientKeeper and Dr. Don Burt, Chief Medical Officer.  Thanks for joining me today.Paul Brient: Thank you David.Williams: What are some of the issues that hospitals are facing regarding Meaningful Use?Brient: Hospitals need to comply with 23 different criteria in order to achieve Meaningful Use.  Some of those criteria are relatively straightforward and things that most hospitals are doing or could easily do, for example filing claims electronically and checking eligibility.However within Meaningful Use there are several “third-rail” complications, things that people have tried for a long time and have been really unsuccessful with, especially in the community setting.  These include Computerized Physician Order Entry (CPOE) and the requirement to share information, although at least in Stage One the requirements for information sharing are pretty straightforward. But as we all know that is something that the industry has tried under different acronyms, starting with CHINS back in the late 80's and early 90's and the RHIOs in the early 2000's, neither of which got significant traction.  So there are real challenges within the context of Meaningful Use.Williams: A lot of the discussion about Meaningful Use has been about physicians and electronic health records.  Are electronic health records something hospitals have deal with as well?Dr. Don Burt: David, this is Don Burt and I'll take that question.  Adoption of EHRs for Meaningful Use is very clear for the physicians.  It means that they have to implement the electronic health record in their office.  They are responsible for making sure that happens in terms of effort and time and capital. The financial reward will also flow to the physicians through their office.On the inpatient hospital side of Meaningful Use the equation is quite a bit more complex.  The financial outlay is by the hospital and is layered on top of a lot of investments that the hospitals have already made in their IT infrastructure over many years.  The effort to get to Meaningful Use involves both physicians and hospitals, but the reward flows exclusively to the hospitals. The result, if it's not done appropriately could be a decrease in physician productivity.So for physicians there is a direct impact if their productivity goes down on their income and their ability to support their office.  Interestingly, if not done appropriately it could also decrease the hospital revenue if the physicians become less productive.Finally, even if hospitals install software 100 percent successfully, it won’t count as Meaningful Use unless the physicians actually use it.  Residents and employed physicians are a little bit easier for the hospitals to mandate,  but as far as affiliated or non-employee physicians it becomes very difficult.Williams: I'm just going to go back to CPOE for a minute. Paul you described that as one of the third-rail items. I guess unlike the CHINs and RHIOs it’s not one that's changed acronyms over time. But how does CPOE fit in here and why has it been a third-rail issue?Brient: CPOE fits in because one of the criteria for Meaningful Use is that 10 percent of your orders must be entered by physicians directly. As you point out, the acronym has been around almost since the dawn of computing.  The issue is that it slows physicians down or historically has slowed physicians down and requires them to change their workflow. That has been a real challenge to get implemented.Roughly five percent of hospitals in the country, mostly academic medical centers, have CPOE in some level of deployment and adoption. But if you look out into the community with a typical hospital, there is very little adoption of CPOE, largely because if it slows the doctors down they're not going to use it. And if they don't use it, why did you deploy in the first place?Burt: I'm a geriatrician and on average I could write my orders in maybe three or four minutes.  It would be longer for admission orders, shorter for follow up orders. There's documentation that some CPOE systems that have been deployed would actually take the physician 30 to 33 minutes to enter their orders. Because of the information needed --lab results, my test results, my notes-- I have to go to multiple places to find that information. When it takes that long, instead of decreasing medical error it can actually increase medical error. So these things have to be done very carefully.Williams: Clearly hospitals are in a challenging situation.  They've had all the problems with CPOE of trying to influence physician behavior. But now it's really going to start to count against them in terms of lost opportunities on Meaningful Use for incentives, and then eventually penalties.So what can PatientKeeper do about it?Brient: Our company was founded on the premise that in order to get physicians to use technology you have to save them time and improve the workflow.  If technology doesn't really help us or make our lives better, we're probably not going to use it.  We have always emphasized what we call “physician affinity.” When we go to a hospital we focus on how to make doctors happy and make them want to come practice medicine at that facility.  We are extending that notion into this dangerous third-rail territory called CPOE and the Meaningful Use criteria.Eighteen of the 23 Meaningful Use criteria are physician-facing or involved with the physician; we help our clients meet those 18 criteria.  The other criteria that are more administrative we don't play a big role in. But since Meaningful Use is about how to get the doctors to adopt it and use it and not slow them down, we think we've got a pretty big role to play.Williams: How can you do that when other CPOE solutions have had such a challenge?Brient: Our approach to building software is to start with the physician and work backwards. For some things that's pretty straightforward.  In CPOE when you do that you end up with a product that is radically different than the CPOE systems that are on the market today. In fact in some cases some of our design tenets fly in the face of what the traditional view of CPOE is.For example there is a view that you should have standard order sets for all of your conditions. That's certainly a noble end goal but most CPOE systems make that a prerequisite. As a result you have to change your physicians’ practice patterns when they're trying to use the computer system. And oh by the way, 70 percent of those orders in those orders sets aren't really evidence based anyway. So you've got to get physician consensus before you can start.Our philosophy is why do that?  Computers do a great job of customization and personalization, so let's start with personalized order sets and work our way in a change management approach towards standardizing the things that matter. Frankly the things that don't matter -- let them be different.  So it puts a lot less change on the physician and makes it so that you don't end up with these nine page consensus order sets that are really more Frankensteinian than anything else. This is a very radical approach but one that has been almost universally embraced by the community hospitals with whom we work.Williams: A lot of folks are talking about Meaningful Use these days because that's where the money is.  If Meaningful Use weren’t in the picture would your approach be different?Brient: Our approach would be the same.  In fact we've been designing our CPOE products for the past seven years. However our timing would be very different.Left to our own devices, if Meaningful Use had not occurred, we would probably be starting our CPOE product in a year or two. We would expect it to be almost like a long-burn R&D project where we would have to convince the market that CPOE would actually work, because most of our clients before Meaningful Use were hoping to retire long before they had to deploy CPOE.So because of Meaningful Use we have definitely stimulated our little part of the Boston economy. We have almost doubled the size of our R&D organization to build this product that we always wanted to build because it's an important part of the physician workflow. We believed well before Meaningful Use that we could do it differently, but the marketplace frankly was not in any way, shape or form embracing the concept at all.Williams: I've seen some speculation that the Meaningful Use requirements might be scaled back because they're considered to be difficult to meet, especially by some of the constituencies that you're serving, in other words the community hospitals.  Do you think that's likely to happen and do you think that's a good idea?  Have we been too ambitious in setting out Meaningful Use requirements?Brient: If you look at the delta between what was published last summer and the regulations published in December, to some extent they've already been scaled back once. I know there's certainly a lot of speculation and requests from different provider organizations to scale them back more.My personal view is that hospitals may say, “Hey there are 23 criteria. As it's written now, if I do 22 of them and miss one of them, I don't get any money at all.  That seems a little harsh, frankly, especially when you look at some of the criteria.”If were king for a day, I might create some core criteria - ten or twelve things that you must do-- then require some percentage of the remaining.  It might be a nice way to peel it back and not compromise the core.  But fundamentally, the notion behind Meaningful Use and the notion that we want to automate the workflow is a good tenet in getting people to focus on CPOE, whereas before no one was focused on CPOE.The question is can we do it in a way that doesn't have a negative impact on the health care system? The reason we want to do it is to make the health care system better. If we go about it in a way that decreases productivity we'll have to make health care more expensive and maybe cause physician shortages.Error is another issue. Handwritten records often have errors.  Well computers make errors too, just different kinds of errors.  So there have been certain situations that have been put in place that actually decrease productivity because new insidious errors show up.  If I type 54 instead of 45 you don't even know there was a problem there.  It looks perfectly fine.  So there are other kinds of errors that can be made in the electronic world.  As long as it's done right, I think we're very much on the right track.I know the folks that are working through this have a very difficult challenge with balancing the political constraints, the realities of the health care world and a desire to create change. Change requires work and costs money.  They're doing a very noble job and I do not envy them.Williams: Don, what are you hearing from your physician colleagues who are hospital-based?  Is there an awareness of Meaningful Use and that things are changing or has it not risen to the top?Burt: It has very much risen to the top.  There is a big difference between self-employed and employed colleagues.  The largest concern I'm hearing is from community physicians. They have to implement an EMR. Basically if they do it all 100 percent right maybe they get $44,000 out of it. But if it decreases their productivity their income suffers as well.Then on top of that they're very much aware of the fact that the hospitals are all trying to get them to use their hospital information systems, specifically CPOE. They're very concerned that their productivity and income will suffer while the hospital is getting all of the gain.Williams: Most of the money for ONC as part of the stimulus package is for these physician incentives and hospital incentives for Meaningful Use. But there's another couple of billion dollars for things like Regional Extension Centers, statewide HIEs, Beacon Communities and the SHARP grants.What impact will those programs have?Brient: These programs are a really interesting idea and if executed well, in some ways could have a bigger impact on the health care cost and quality equation than just about anything we're doing.If you think about this as a broad package, wiring up the practices and getting all the hospitals on electronic systems, that is in some ways a first step toward dealing with the health care delivery challenge that we have in this country. And these programs, especially the Beacon Community grants, are really focused on trying to identify where there are opportunities to reduce cost and improve quality and hopefully, frankly just to reduce cost. This will be done locally with physician engagement, which I think is very important.I'm a little bit concerned given the reaction of the U.S. population to the mammogram study that came out recently changing the recommendations for when women should received mammograms, based on what appeared to be some scientific analysis.  If we're not willing to make changes to our health care system based on understanding the efficacy of different treatments and procedures as a society, we're going to have a very difficult time and these programs will have a low impact.I'm hopeful that as a society we can start learning from the potential that exists in these databases and the practice of medicine throughout the country and really start to make some changes to how we deal with health care.Williams: I've been speaking today with Paul Brient, President and CEO of PatientKeeper and Dr. Don Burt who is Chief Medical Officer.  Thank you very much.