CMIO views it as a boon to patient care

MEMPHIS, TN – Methodist Le Bonheur Healthcare, a seven-hospital, multi-campus health system in Memphis, Tenn., recently completed a CPOE implementation after two years of taking a “hard-and-fast” tack. Today, hospital officials boast 86 percent adoption across the system on the inpatient side and more than 96 percent across its emergency departments.

Alistair MacGregor, MD, CMIO at Methodist, came to the health system after 11 years at Kansas City, Mo.-based healthcare information technology company Cerner, where he created a for-profit practice for Cerner as well as an implementation methodology.

As a Cerner employee, he worked at Methodist as consultant in 2006. But, he would soon be pulled off that EMR/CPOE project to create the practice for Cerner. In March 2009, MacGregor returned to Methodist, this time as CMIO. He credits the hospital leadership in 1999-2000 credits for a visionary outlook for recognizing then that an integrated EMR was better than the best-of-breed approach many healthcare organizations espoused at the time.

While the Cerner EMR was up and running by the time MacGregor returned to Methodist in 2009, the CPOE project begun in 2006 had not fared as well, never advancing beyond a small pilot.

“It was going very badly,” MacGregor said. The project was marred by low adoption rates and high medical staff frustration. There was a multitude of factors for that, MacGregor says. “Not enough training. The design and build could have been better. And, there wasn’t a structured post-go-live physician support model.”

Fast-forward two years, and the outcome is brighter. MacGregor talked with Healthcare IT News about what led to led to the high CPOE adoption it experiences today.

Why is CPOE so important?

Patient care. Many other organizations have looked at illegible, incomplete medication orders. We we’re counting before we got it down to about 6 percent for medication orders. That goes to zero immediately on CPOE. Other things that we have metrics around are turnaround time. For patients with acute myocardial infarction, we reduced the door-to-balloon time. We’ve got some metrics around start lab results, start radiology intervention, start medications – all being given with a shorter turnaround time, which is all positive for patient care.

Do you see an advantage of having a CMIO on board?

I’m actually the third CMIO the organization has. In the early 2000s, all credit to the previous CIO, who said, ‘This needs to have a physician leader.’ That was a very visionary idea a decade ago. So I came (in 2009), and I came with a wealth of experience and knowledge of best CPOE practice and having had many large Cerner clients, I was the lead consulting physician with them. I was outsourced to Shriners for six years and led their 20-hospital CPOE rollout in the early 2000s. Bringing that experience and teaching a much broader approach to design-build, build quality, communications, production. We put a huge focus on workflow re-engineering and especially training.

Were there other physician leaders and champions?

I was the principal full-time one. Each of our six hospitals has a CMO who is in an administrative role. They have all been incredibly supportive. The chief quality officer is very supportive. Individual physicians have been supportive, but coming from Cerner, I brought with me a methodology where we look at all the physicians who go to our hospitals, hospital by hospital and identify their revenue to the hospital, their level of influence across the hospital and across the specialty and their level of support or resistance to the EMR/CPOE. I work very closely with each hospital CMO and physician analyst who is dedicated to that hospital and profile these high-revenue generating physicians, high volume physicians and look at giving them support. We also measure utilization of their electronic medical record system. And, if they are high volume and are not using the system optimally, Cerner’s got lots of tools. We can look at whether they’re using it efficiently or not. The CMO and I – or the physician analyst – target individual physicians. They get used to a support model and, they’re being given supplemental training to optimize the EMR even before we get to CPOE.

What happens once the physicians adopt CPOE?

Once they go to CPOE, we actually measure by individual physician whether they’re doing CPOE, whether they’re doing telephone orders, whether they’re doing verbal orders, whether they’re doing written ones, and we can profile it. What we discovered was nurses would put in telephone orders and doctors would know nothing about it and that would dilute the target of CPOE that we had set as an organization. So, we now have very detailed reports looking at everyone who places orders, not just the medical staff, and they’ve appreciated that. They are trying to reach their 80 percent target and discovered that nurses are going ahead and putting orders in without consulting them and trying to help them, but in fact it’s not helping. So this is part of, I think, an exciting transformation. Once we go to CPOE, we can see behavioral patterns some of which need remedial effort to change.

What was the hardest for you during the implementation?

It was making the leadership decision whether to put a lot of resources into the hospital that was struggling with CPOE or think, “I’m here, it’s my watch, use my experience and methodological approaches and go hard and fast throughout all the other hospitals. I’m hoping and praying that my methodology would make a difference. So within a year we went live at our tertiary care pediatrics hospital – house-wide inpatients and ED. We certainly blew through the 80 percent target in inpatient, and we hit over 90 percent in the ED. So that was proof of concept. I’ve always believed that once you start a rollout, you should go hard and fast – as fast as your team can support, as fast as your hospital staff can train. With each go-live, you’re building on a foundation of lessons learned. Each go-live becomes better and better and better.

How much did the EMR/CPOE project cost?

The initial cost was $100 million to $110 million back in 2001. But I think the whole healthcare industry is now moving to total cost of ownership, where you’re looking at not just the software life and maintenance costs, but you’re looking at staffing costs, consulting costs and device cost. I wouldn’t be a bit surprised if our total cost of ownership was more than $200 million over the last decade. From my past Cerner client experience, for large, multi-campus health organizations that is kind of par for the course and probably is low-end nowadays.

What about return on investment?

I think it’s very hard to measure. It tends to be done on a piecemeal basis. The hidden benefits are the rationalization and digitization of healthcare, meaning that we start capturing data that’s much more consistent than free text. Once it becomes discreet within an electronic medical record system, you can then start analyzing it and looking at variation. The second huge benefit – I’ve seen this all my professional career in informatics – is the variation in processes that are frankly not justified, and we put a huge effort into process engineering current state then future state when we turn on a system. It’s interesting when doing future state process or workflow assessment how many processes are broken in the manual world, especially in a multi-campus organization. When you look at other industries for process and data variation, they’ve increased predictability, improved outcomes and improved revenue. I think healthcare is just at that inflection point of starting to do it.