(Part I, Part II)

GUERRA: Do you think you’re in good shape to qualify for meaningful use funds?  

ROTHENHAUS: I do. I think on the hospital side, we’re covered. I don’t think there’s going to be much that comes up. I am a little bit surprised that everybody is focusing on CPOE because I’ve always felt that, from a risk and a safety standpoint, barcoding medications was probably a stronger intervention than CPOE itself. I would have thought that was actually an easier thing to implement, and it would have been a larger part of the meaningful use discourse, but it tends to be CPOE. We will have both of those things live and in all of our hospitals well before the deadlines.

On the EHR side, in our last two years of rollouts we have essentially 100 percent adoption. Everybody is using electronic prescribing, and they’re doing progress notes properly. So I think we’re probably okay on that.

When I look at meaningful use, there’s a lot of stuff in there which looks like typical pay-for-performance initiatives. We’re ok with it because we’re able get that type of data. I’m not sure what the ultimate attestation is going to look like, it’s confusing to me. I hope it’s confusing to other people as well (laughing). What is a bit of an issue is that you don’t need an EHR to do some of those reporting-type functions; you could just have a hand-written registry.

I’m waiting to learn how all this stuff will work mechanically, because if it’s just as cumbersome as some of the original P4P reporting, that’s a bigger deal than if there’s some attestation required or something bundled to G-codes that says, “I did this with an EHR system.” That’s what I’m really waiting for, because I think as soon as they finally set it, then there’s all the mechanics of how we’ll report it. There’ll be infrastructure and people and personnel that we’ll have to onboard just to get the dollars. It’s going to be interesting to see how it all works.

GUERRA: Do you have any concern for smaller community hospitals that may not be prepared to put in some of these systems? Is there a population of hospitals that will not be able to meet these requirements?

ROTHENHAUS: Well, I think there’s a couple of pieces to that. I am, and I see the stimulus bill as being very destabilizing to the traditional physician-hospital relationship. I think everybody is starting to realize that physicians and hospitals need to work very closely together in order to provide the best care. I think Atul Gawande’s article in the “New Yorker” a couple of months ago really spoke to that. It’s so clear that in places where physicians and hospitals collaborate and there’s communication and transparency, that the care delivered is better. And that’s what’s we’re looking to do here.

But fundamentally I see a couple of things. First of all, hospitals that have already spent the money and done it will benefit the most because there’s almost no work upfront. And the hospitals that haven’t started are going to have to ramp up tremendously in a market where access to capital is almost impossible. So I see all this money filtering down through the states, and there’s no way it can be used directly to support all the hospital system deployments for small- and medium-sized hospitals and small practices.

I think the money should be used to subsidize loans as opposed to a direct payment. It would probably go a lot further and hospitals could at least make a business case to say, “Well, I’m going to borrow money at such a low cost, I’ll be able to implement and recover money on the backside.” I’m not sure it’s enough to defray the cost for the smallest hospitals and the ones that are the most vulnerable, so I think it is destabilizing.

The second thing is that in Massachusetts, we’ve had our EHR program available to physicians in 2007, 2008 and 2009. Since the stimulus bill hit, there have been far more applications than there were in past. So I do suspect that there’s little bit of musical chairs going on with independent or IPA affiliated physicians who are going to look and shop around to get the best deal on an EHR (from a hospital). It’s important to us to have that deal because we want to be an attractive colleague and associate in care delivery.

But I can see that if you’re a hospital that can’t spend anything on EHR adoption for affiliated physicians, you could certainly find that groups are leaving you. These EHR dollars are small compared to the dollars that you’ll see by aligning with different IPAs. I mean the stronger IPAs generate major money, that’s just a fact of life, so this is only a part of the budget for an independent physician practice. But I do think that groups will align with the systems who have more means, just as they have been doing in the past based upon rates they can get from insurance companies.

I think it’s an accelerator to what’s already happening, which is this alignment, almost an exclusive alignment relationship with different health systems as opposed to the freelance doc who admits patients to four or five different hospitals and doesn’t really have a tight alignment with any one of them.

GUERRA: Tell me about lessons you’ve learned from working on CPOE. Does being an M.D. give you special insight into how to make it work?

ROTHENHAUS: That’s a good question. I think there’s a couple of things. When I started at Caritas Christi my first position was chief medical information officer. It’s a new role, and I thought it would be a great way of getting into the administration. It was a great pathway. I think that the CMIO role is there to translate requirements between the IT department and the clinical community, and it certainly doesn’t have to be a chief medical role, it can be a nursing information officer or a clinical information officer, but there is this stronger and stronger role to have clinical people embedded in IT.

It’s surprising that you can go to places that are implementing the same system – whether it’s a hospital system up on the floors or an ED system or an anesthesia system – but two customers can be implementing the same system with wildly different results. The physicians can have their shields up on one side and they can embrace it on the other. So obviously the implementation and the clinical transformation is critical, because the software is the same and physicians are fundamentally the same, although it may be the cultures at institutions are different. But the wildly divergent success of projects based upon the same vendor offerings is a real tip off that there are ways of messing this up and ways of doing it well. And I think having clinical people embedded in IT is the key.

The one advantage I might have is that I was part of that culture so I know how to work with reluctant adopters. It’s also important to be a realist and say, “Well, this is the way it’s going to be; it’s going to be hard for the first six months in your practice and there’s no way around it, but eventually you’ll like it. I promise you.”

I don’t really see myself as having any real ace in the hole. The CIO skill set is so diverse that I don’t feel like there’s really much of a leg up that I get from being clinical anymore. I do like being clinical, and it helps to be clinical when I go to certain meetings, but it’s in no way a true differentiator. You can be a great CIO without being a clinical person.

GUERRA: So having been a physician doesn’t mean you have a silver bullet that other people don’t.

ROTHENHAUS: Well, it has to do with the culture of that physician relationship. Within our own health system, we don’t want to alienate our physicians by creating awful workflows and inconveniencing them and making it a hard place to practice medicine. You just don’t want to do that.

Note that the first wave of wonderful articles about IT adoption in healthcare all came out of teaching hospitals. If you think about it, the most talented labor pool in the world is house staff. I mean, they’re brilliant people, they’re all young, and they can do anything. And so you could give them a terrible system and they would make it work, and they’ll work harder just to churn through because they want to get home at the end of the day just like anybody else. But you take a guy who is worth something to your hospital and is busy and could go to a hospital right across town instead of your place; you really don’t want to damage that physician alignment by creating bad stuff.

So a lot of hospitals will look at this and say, “The physicians don’t want to do it,” and they just stop. Other places – whether they have house staff that are going to bear the brunt of most of the work, or they have strong leadership – will just push it through regardless. Maybe it’s a hospital that has no competitor locally, so they’re not going to damage their physician alignment by doing CPOE. But those middle-ground hospitals where that’s a big issue, I think it helps to have physician leadership in the IT department to do the job as well as you can possibly do it. It’s important to get into a collaborative cycle where you’re building the system, taking a look at it, showing it to the docs, showing it to the nursing staff and saying, “Does this work for you?” and then going back and doing it again. It’s almost like regression testing. You just want to keep going through it until you take away as many clicks and take away as many menus and pop ups as you possibly can. You need to clear all that away and make it physician or clinician friendly.

You probably need a CMIO in a health system if you’re doing CPOE or some medical director of information systems, you absolutely need that person. That role has emerged, and if that person gets along really well with the CIO, then you’re fine. I think if you’re going into it without anybody clinical, that’s going to be problematic.