Louisville, Ky.-based Norton Healthcare is composed of five acute care hospitals: Kosair Children's Hospital (263 licensed beds); Audubon Hospital (480 licensed beds); Norton Hospital & Norton Healthcare Pavilion (719 licensed beds); Norton Suburban Hospital (380 licensed beds); and Norton Brownsboro Hospital (a brand-new 127-bed facility). Additionally, Norton Healthcare provides service through 10 immediate care centers in the Louisville area. Recently HCI Editor-in-Chief Anthony Guerra had a chance to talk with VP and CIO Joseph DeVenuto about how he’s handling HITECH, among other challenges, at his sizeable health system.
GUERRA: Can there ever be an ROI on these technologies, when we see agreements for $50-100 million, while HITECH can only net a hospital a fraction of that?
DEVENUTO: It’s hard to say. There was an organization in the Northeast that was planning to roll out a practice management system to all its doctors, and they were budgeting around $75,000 to $80,000 a doctor. Well, the maximum those practices can receive under ARRA is $44,000. So that’s what they were budgeting and that doesn’t count the reduced productivity a physician has when he comes online initially over what he’s doing on paper right now. Theoretically, the physician is getting better reimbursement because he’s documented more effectively. But at the end of the day, he’s not seeing as many patients, at least for the first month to three months, that he was seeing prior to the system turning on. How do you factor that into the total cost of the system?
GUERRA: Based on your experience, how are physicians, especially the independent, admitting physicians, reacting to CPOE when they come into the hospital?
DEVENUTO: Well, right now we’re going to turn on CPOE in the new hospital that is being built. And we’ve made it a requirement to practice in the hospital. I think one of the things you will see as a byproduct, especially of CPOE in the hospitals, is an increased use of hospitalists. So I think the days of the general practitioner or internist coming into the hospital to follow their patients and then going back to their offices and seeing another 30 patients are going to be a historical note at some point in the future.
GUERRA: That’s very interesting.
DEVENUTO: I think you’ll see an increase in the use of hospitalist. Plus, hospital medicine is becoming more and more complicated because the acuity level of hospital patients is becoming higher and higher.
GUERRA: So do you think this will happen as a result of the community docs not being able to embrace CPOE?
DEVENUTO: It will be interesting to see how it ties into meaningful use, because while we said we wanted CPOE in the new hospital because of the opportunity to have it from the start, I don’t know that we’ll turn around and say that when we start rolling out CPOE to the other hospitals it will be 100 percent mandatory to practice medicine there. Plus, your ability to mandate it depends on your environment. We tend to be in a very competitive environment, so there’s some leeway and latitude that you’ve got to provide physicians just to deal with that.
GUERRA: You mean to keep those physicians practicing at the hospital?
DEVENUTO: Yes, because referring physicians are who bring in revenue to the hospital.
GUERRA: Do you think there will be physicians who choose to practice somewhere more accepting of their paper-based habits?
DEVENUTO: There may be a very, very small minority of doctors that do that. Like I said, it is the future, and unless you’re not reading anything about your industry or what’s going on, you’ve got to know it’s coming, and you’ve got to see it’s coming. So maybe some of them will try and figure out if they can retire before they have to comply.
I think the hardest job right now would be a small rural CIO that’s got to implement all this stuff to be ARRA compliant, and they don’t have the revenue or the operating dollars to actually buy any of the systems.
GUERRA: GE Healthcare IT just came out with a program where they are offering no-interest financing for their EHR. And they are tying the repayment schedule to when the hospital will receive HITECH funds. I thought that was very interesting.
DEVENUTO: Right, but it goes back to the question of whether an organization will receive enough ARRA funds to actually pay for it.
GUERRA: Well, of course they said that whatever shortfall there may be between the cost of the system and the reimbursement is the customer’s responsibility.
DEVENUTO: Yes, imagine that (laughing). Or you turn around and see Sam’s Club selling eClinicalWorks, which on the surface is a decent deal, $25,000 for the first doc, $10,000 each doc after that, but that’s just the entry fee/admission fee, then you still get into all the interface costs, the implementation costs, etc., etc.
GUERRA: What’s the hardest part about being a CIO today? Does it have to do with working with the board and making the CEO and the CFO understand the large sums that need to be spent? Is it dealing with the HITECH issues? Is it dealing with the doctors and getting the clinicians to embrace IT?
DEVENUTO: That’s a good question. I think educating leadership in the organization around the value of IT is actually the fun part, being able to translate technology into business, operational impact. I think the frustrating part is there’s a pool of people who just assume that if I buy technology then it will solve all of their problems.
And so when you start to get into this, you learn it’s really people, process and technology. If I’ve got a bad process and it’s automated, then I’m just going to be bad faster and more consistently. If I have bad people who aren’t doing what they’re supposed to do in a paper system, well, they’re probably not going to do it right in an electronic system, unless somebody is managing them and overseeing them appropriately. Technology just for its own sake is not going to take care of what needs to happen.
GUERRA: Is there a fear among the CIO community that people don’t realize that and therefore they’re going to come back and point the finger at the technology and, thus, the CIO?
DEVENUTO: It’s always my fault (laughing). I’ve talked to peers and asked them if that was the deal with them as well. But I think there has got to be some point at the end of these four years or five years when all this money has been given out and spent when, if we’re not any better off, it’s going to be perceived as a failure of the technology.
There’s a Gartner term that I use a lot: digital natives versus digital immigrants. I think part of it is we’re in that transition between the digital immigrants who know they need technology but don’t necessarily get it, and the digital native population that know they need technology and know exactly how it fits what they want it to do. While I’m in a digital immigrant generation, I guess because of my job I tend to look at things more as a digital native. And so I see technology for what it is, I use it for what it does, I don’t expect it to do more. It’s like when I have a senior executive complaining because his laptop has issues every once in a while. And I think, who guaranteed you 100 percent? I mean, stuff happens.
GUERRA: Are you saying that people expect more out of the current clinical technologies than they are suited to achieve?
DEVENUTO: I think if you just slap in technology without looking at everything around it, I think you’re going to be disappointed. And the analogy I use is if you’ve ever driven in Boston, the roads are all over the place. And the story I’d heard is that they paved the cow paths because that was where the traffic patterns were. In newer cities, they laid out grids. I think healthcare has done that same analogy; we have always just automated what people did without taking that step back. The question should be how do we use this technology to be better than what we were doing before? We should be truly looking at doing process redesign until it’s married with the technology.
GUERRA: Is there a key person that the CIO should be working with within the organization to make sure that they’re not just laying technology on top of bad process? Is it the CMO? Is it the CMIO?
DEVENUTO: Well, I can’t identify that it’s just one person. It depends on your organizational structure. But I think definitely tight alignment with the chief medical officer and the chief nursing officer is key. And then the CMIO, in my own mind, he’s part of the IS team. I mean, in our organization, he reports to the CMO but the CMIO is three doors down from me. So he comes to my direct-report meeting. He is a part of IT for all intents and purposes.
So he is part of the solution but is connecting with the CMO and the CNO to say, for example, “I was on a call earlier today, we need to deal with care management to redo their process so we could track some referral information better than we currently do now.” That involves working with the CNO because she owns care management, while the CMO owns other aspects. So it’s those two people from a clinical use perspective. It’s like anything else; if I wanted to redo a finance application, I’d have to work with the CFO to say, “Okay, your payroll, we’re going to automate some of your accounts payable and do scanning versus paper-based documentation. You’ve got to work with your leadership to make sure that we do that process effectively.”
It’s more of who is the primary business driver for that perspective and that’s who we need to work with to leverage and get their buy in.