(Part I, Part II)

GUERRA: And really what this is about, at certain level, is keeping the independent physicians happy. So, you might say that, if you have physicians referring patients to your hospital and you’re asking them to interface directly with the CPOE capabilities in Magic 5.63, but your competitor has a nice slick PatientKeeper front end, it’s not going to be tough for them to figure out which hospital they’re more comfortable interacting with.

CASH: Especially if we make it mandatory that they use it, which is what’s coming under HITECH. But we have taken a step beyond that, for what it’s worth, from a collaborative perspective in the community, to say we know they’re not going to learn to use a bunch of systems. Our competitor hospital uses CareCast – they were acquired by GE (Centricity), so they’re still CareCast but it’s under the GE name. The physicians, at least in our community, are going to be less inclined to figure out how to use CPOE and everything that goes with it in Meditech, and then walk across the street and do exactly the same stuff in the other hospital in a different system.

Instead, what we’ve done is PatientKeeper sits in both hospitals, we can do whatever we want with our own PatientKeeper platforms, but once you’re trained to use it in one location, it works the same in the other location, and the more we work together to create these common interfaces for our physicians – CPOE, whatever it might be – the better chance we’ll have for physician adoption in the community. If they ever split, and we’re two hospitals with two different physician user bases, it’s a completely different story, but I don’t see that coming.

GUERRA: Everyone has to do CPOE, but not all CPOE is created equal. There is a huge chance here to lose physician alignment.

CASH: The truth is we still don’t have to do CPOE. If we were willing to give up the stimulus reimbursements under ARRA, and accept the degraded Medicare payments, we don’t have to do CPOE. And if our choice was to have a much higher physician user base here at the hospital that’s still willing to provide services, but not at our competitor hospital because they’ve mandated CPOE, I think that’s an interesting concept to explore.

Don’t take this the wrong way. We’re going to do CPOE. But I guess what I’m sharing with you is that the stimulus payments are supposed to encourage us to do a whole bunch of things, including CPOE. And then there’s a 1 percent, 2 percent and 3 percent reduction coming in Medicare if we don’t, but I’m not aware that there is a legislative mandate out there that says we have to use CPOE. So if it meant we lost business with our physicians, you can do an ROI to decide how long it takes before you give up 30 percent of your surgeons because you required them to do CPOE, versus kept them on board and kept your surgery a robust part of your business. I think there’s some interesting conversations that’ll happen around that.

GUERRA: I think every CFO and CIO would want to have that conversation.

CASH: I think so too because we’re talking millions in terms of the overall revenue to the hospital, whether it’s surgery-related or the downstream side of surgery, the inpatient business or the outpatient business. We’re talking a lot of money in terms of the reimbursement from the stimulus act and a lot of money we could lose in Medicare if we don’t follow the path they’ve asked us to do. Steve Lieber (HIMSS CEO) and I had this same conversation. I said, “You go to that real senior group that’s not inclined to do CPOE, and what are you going to do with them? Are they going to retire because they don’t want to do it or are they going to go somewhere else, or are they going to move to practice and just work in their office and not work at a hospital anymore? What are they going to do?” It’s an interesting challenge coming our way with that group of doctors.

GUERRA: That reminds me that we won’t even know how this information has to be reported to CMS until next year.

CASH: But even reporting for the payments is just reporting to prove what you’re doing. So I agree with you. But that’s assuming you choose to do what you’re supposed to be reporting.

GUERRA: With so much at stake, I wonder if we won’t see people gaming the system, especially if it’s simply attestation.

CASH: For what it’s worth, I do support the concept of CPOE. We went live with CPOE in our emergency department four months ago. We do all that documentation online. It’s all in T-System and we brought up CPOE in T-System about three months ago. It’s all interfaced into Meditech, and we’ve got radiology, labs, progress notes; everything goes back and forth. The docs are all tapping their way through every patient encounter. I can tell you, if you can get that to work in the ED, you can probably get it to work with your inpatient doctors. So, we’re on the path of doing CPOE. But there is a population of physicians that are going to be more challenged by doing it. And then you have to decide how you’re going to do it.

The other challenge that I’m still waiting to learn about is that we use more than Meditech, such as PatientKeeper and T-System, for example, to create a usable solution that our physicians have adopted, are willing to champion. As much as I hate to say it, it’s best of breed. There are areas in the hospital where you almost have to stay a little bit best of breed and interface back together, if you want to really get the usability out of the system for those doctors.

Well, if HITECH requires we get the system certified, and all we can certify is Meditech, we have a big challenge coming in our direction because we’ll never limit those physicians to only using Meditech to provide all services.

If that certification process doesn’t allow us to use PatientKeeper for our physicians to electronically sign their reports and to do their structured documentation, and if it doesn’t let us use T-System in the emergency department to do all the things that we’re doing, then we’re not going to meet the requirements of the act anyway. But we’re doing it all, and we’re doing it in a very cost-effective fashion. They’re going have to find a way to allow us to use the solutions of choice in our communities to do all the functions they’ve asked us to do, to certify that appropriately, and allow us to report on it in a way that we can prove meaningful use. Otherwise we’re not going to get meaningful use. We’ll get some use, but it won’t be meaningful.

And the other part I would share with you is if we change the wording, in my opinion, of CPOE to COE, I think you’d go a lot further in terms of being able to adopt it in different areas. The computerized provider order entry is the intent of this. But as long as at least someone is entering this order into the computer system and running all the alerts, I think there’s a halfway point here that we’re not really considering today.

As important as it is that the physician click the button to submit the order on the computer, even if they’re not used to it, I think it’s equally important to make sure that whatever they’ve told us they want that order to be, somebody enters it into the computer system, so that it’s validated, checked and all that kind of stuff. And I think there’s an interesting conversation that could be had around that.

GUERRA: You mean not requiring it to be the physician?

CASH: Yes. If I had a very senior surgeon, for example, who’s not inclined, necessarily, to learn the interface well enough to be able to put all of his orders into the system, is that really the only way to accomplish the same goal, which is getting that order electronically into the system for all the decision support and validation? Does it have to be the surgeon who clicks the button?

GUERRA: The meaningful use matrix is a little unclear around who has to put the orders in and what percentage of each type of provider must do so.

CASH: I would agree with you. And I’ve not been able to determine that either. There’s some interesting times coming. We’ve gone beyond a lot of hospitals in the clinical use of our systems, electronically, and we’ve had very broad physician adoption. Most likely we’ll be doing CPOE through PatientKeeper into whatever systems that they need to access. We’ll probably be doing it before the requirements; but I would just say it’s going to be an interesting time to walk through all of that. As long as the integration is allowed and the certification is allowed through an integrated system, as opposed to a single-vendor solution, I think we stand a pretty fair chance of meeting the requirements for meaningful use.

We’ve already got CPOE figured out to a large extent, because of what we’re doing with T-System which is covering a broad array of orders for the organization already. And then what we’re doing with our clinics, all of our outpatient orders are starting to come that route anyway. We use an ASP service called Clinician. It’s provided by WebMD. And that’s what Sage required that we use, but it has some really nice, interesting things that go along with it.

So in an outpatient setting, a physician in his office either does the lab draw and sends over the order, or creates the order for them to show up at the hospital, or for one of our clinics to have it done. Electronically, it goes to Clinician which delivers that to Meditech. So when they show up, we provide the results back to Clinician, to Sage which is the EMR. So that’s really the same thing as CPOE, but it’s being done by the provider office.

The nice thing about Clinician is that it’s already connected to other reference lab providers; so we at the hospital have to become a reference lab provider to Clinician, which means now we can accept orders from anybody that connects into Clinician, not just our own clinics. So other Sage users in our community can have an established relationship with Clinician, and then they can submit their orders to me or any other lab-connected system that would talk to Clinician through a single connection.

GUERRA: We’ve talked for almost an hour and I feel like we could talk all day, but I’m going to let you get some real work done.

CASH: (Laughing) Thanks a lot. This was fun.