Health Care Analysis and Evaluation

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HCA 448 Case 1

Introduction

Saint Vincent Health System is a large academic medical center based in Bolder

Colorado. Saint Vincent Health Systems is associated with the state university, and includes

three hospitals, a medical clinic facility, a medical research complex, and affiliated primary and

specialty group practices spread throughout the region. Saint Vincent University Hospital is the

main hospital campus with 500 inpatient beds and equipment and facilities that are considered

state of the art. Saint Vincent Health System is well known for its cancer and rehabilitation

service lines, and has recently expanded its cardiac service line in an attempt to keep up with the

increasing demand.

Despite strong clinical services lines and an excellent reputation, Saint Vincent Health

System has been reluctant to adopt new clinical information technologies (IT) such as

computerized provider order entry (CPOE) systems or a more comprehensive electronic health

record (EHR) system. Instead, Saint Vincent Health System’s services are mainly supported by

paper-based processes, and a strong team in the medical records department that has been able to

expand with the health system’s growth.

Changing Health System Leadership

Dr. Craig Johnson has just been appointed CEO of Saint Vincent Health System, and

has come to the Bolder area after serving five years in his previous position as CEO of a 200-bed

community hospital. Dr. Johnson’s predecessor, Jeffrey Ash had retired after serving 20 years as

Saint Vincent Health System’s CEO, while the announcement of a new CEO was not

unexpected, this change in leadership has left the organization unsettled, and staff and affiliated

physicians are anxious about the new changes Dr. Johnson may bring to Saint Vincent Health

System.

Assessing the Situation

Dr. Johnson is a definite fan of EHR and electronic medical record (EMR) systems, and

is enthusiastic about the potential for incorporating an EMR system with CPOE capabilities into

Saint Vincent Health System. In particular, he is aware of the opportunities to use an EMR

system to improve Saint Vincent’s ability to provide care according to evidence-based

guidelines, and to capitalize on patient safety improvements that are possible with an EMR

system. Dr. Johnson knows that his daughter, Ellen, uses a handheld computer, or digital tablet,

to help her keep track of her patients, check medications, and access important clinical

information in her internal medicine practice, and has seen these tablets in the pockets of many

of the Saint Vincent physicians as well.

Yet Dr. Johnson is aware of the likely resistance he will face in his efforts to introduce an

EMR system throughout Saint Vincent. He has followed some of the IT implementation

literature, and knows that common barriers to implementation, such as physician resistance to

changes in workflow and a reluctance to use practice guidelines or “cookbook medicine,” may

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create challenges at Saint Vincent. He also predicts resistance from the strong and capable

medical records department. Given that successful EMR implementations are associated with a

reduced need for space and personnel in medical records, it is unlikely that such changes will be

warmly received.

Dr. Johnson schedules a meeting with Ms. Leigh Rice, director of information services,

because he suspects Ms. Rice might have some ideas about how to proceed.

Meeting with the Information Systems Department

Once Dr. Johnson scheduled his meeting with Ms. Rice, excitement grew in the IS

department. Ms. Rice and her department had been enthusiastically following all of the changes

in the EMR systems, but had met with resistance when they suggested that Saint Vincent

consider adopting a new system. The previous CEO had been decidedly “old school” and had

little interest in leading the charge to put Saint Vincent on the EMR map. Instead, Ash chose to

placate the established physicians and the director of medical records, Ms. Amanda Chapman.

Even though he was aware that the newer physicians were all carrying tablets and iPhones, he

had no interest in rocking the proverbial boat at Saint Vincent.

Ms. Rice knew this was her opportunity to make the case for a system-wide EMR

introduction at Saint Vincent. She had full confidence in her IS team’s ability to carry out this

initiative. Ms. Rice had the group compile the information they had collected from different

vendors about the various systems and capabilities, and summarize everything in an “issue brief”

document that would be easy to skim. She also had her summer resident, Austin Mitchell, collect

some of the key articles from the research literature that highlighted the potential and pitfalls of

such a system-wide implementation.

Ms. Rice’s meeting with Dr. Johnson went even better than she had hoped. Armed with

the evidence, Ms. Rice laid out the various issues, pros and con, for a system-wide

implementation of an EMR, and then explained the different vendor options that might be

appropriate for Saint Vincent. Already convinced that this was a good idea, Dr. Johnson gave

Ms. Rice the green light to develop a formal proposal for presentation to the Saint Vincent board,

and directed her to Chase Aukland, Saint Vincent’s CFO, to make sure the cost proposal IS

developed would be appropriate for Saint Vincent.

A Hallway Conversation

Dr. Johnson left the meeting with Ms. Rice smiling, but his smile faded when he was stopped in

the corridor by Amanda Chapman, who was leaving the Medical Records Department.

Dr. Johnson: Hi, Ms. Chapman. How is everything going in Medical Records?

Ms. Chapman: Not well, Dr. Dr. Johnson. I heard a rumor that you were considering bringing

an electronic medical record system to Saint Vincent, and that makes me very concerned.

Dr. Johnson: Well, Ms. Chapman, nothing has been decided yet, but there is a strong push

nationwide to introduce EMR systems in all hospitals and we don’t want to be left

behind.

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Ms. Chapman: I understand that, Dr. Dr. Johnson, but I just don’t think we want to do any of

this too quickly. Mr. Ash had been very consistent in his message that Saint Vincent had

no reason to be an “early adopter” of such systems. As he repeated said, “Let all those

other health systems make the mistakes first. Then we can learn from their mistakes and

make our own decision. And in the meantime, we can keep doing well what we already

do well.”

Dr. Johnson: I appreciate that perspective, Ms. Chapman, but I have to admit, I am a bit more

likely to push the envelope than Mr. Ash. I believe an EMR system would be a great

boost for Saint Vincent, helping us to track everything electronically, and potentially

helping us to reduce medical errors in the process.

Ms. Chapman: But don’t we already have the ability to track everything? I’m just not sure

what’s wrong with paper. Out medical records team is very capable and responsive. I

certainly haven’t heard any complaints about our ability to access patient records.

Dr. Johnson: That’s true, Ms. Chapman, but I don’t think that we are looking far enough ahead.

As other hospitals and health systems go digital, we’re going to be left behind. I truly

believe we do not have a choice in this situation. It is not a matter of “whether,” but a

question of “when.” I think it would be in the best interests of Saint Vincent to get this

going on the sooner side so that we can take advantage of the capabilities of an electronic

medical record system as soon as possible. Also, Ms. Chapman, before we select a

system, a task force will be created which is charged with the analysis, selection, and

implementation of an EMR system.

Ms. Chapman: Well, Dr. Dr. Johnson, I disagree. I tend to believe “If it isn’t broke, don’t fix

it.” And the Medical Records Department “isn’t broke.”

Dr. Johnson: Thanks so much, Ms. Chapman. I appreciate your time.

As Dr. Johnson headed back to his office, he was once more reminded that none of this

was going to be easy. Even though Ms. Rice and her IS department seemed fully capable and on

board with the idea, there were plenty of others throughout the health system who might not

share their enthusiasm. He was especially concerned about resistance from the physicians. While

he was a physician himself, that did little to improve his credibility when he was making a case

“from the dark side” of administration. He decided to seek out Dr. Jody Smith, the chair of

internal medicine, to begin to gauge some of the sentiments from the physicians. He headed to

her office to see if he could catch her for a moment.

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A Physician’s Perspective

Dr. Johnson (knocking as he enters Dr. Smith’s office): Hi Jody. How’s everything going?

Dr. Smith: Craig. Just the person I wanted to see. I heard a rumor that you were considering an

EMR for Saint Vincent

Dr. Johnson: Well, Jody, the rumor is actually true. I just met with Ms. Leigh Rice, the head of

IS, to get her and her team to begin to develop some estimates and plans for what an

EMR adoption would mean for Saint Vincent .

Dr. Smith: But Craig! Have you been following the latest research? Despite what the vendors

claim, every place that puts one of these systems in reports that it actually takes the docs

more time to do what they used to do on paper. Even after having the system in place for

a while, the docs are still spending more time doing record-keeping than before – and that

time is time that they used to have to care for patients! Also, when they put in a system

somewhere in Pittsburgh, the EMR system was actually associated with an increase in

the number of medical errors!

Dr. Johnson: I have followed that research, Jody, but I think there’s a bigger picture to consider

here. While it’s true that EMR systems do require the physicians to spend more time

entering data and so forth, there’s also evidence that with an EMR it is actually the right

people who are entering the data – not some non-clinical person trying to decipher a

physician’s notes about what was done, or trying to figure out if a visit was long or short.

Also, evidence is beginning to build that when EMR systems are coupled with decision

support logic such as order gets with CPOE systems, this type of systems can actually

save time. Instead of going through multiple screens to find all the meds and tests that

need to be ordered, the physician can just click on the asthma order set, for instance, and

review the options there.

Dr. Smith: But what about patient-centered care? Who says that every patient is alike? For

heaven’s sake, what if your patient needs something different? How long does it take to

find that when everything is based on a standardized order set? And how about the

resident physicians? Maybe they will stop thinking about making patient-specific clinical

judgments and just click the standard order set for everyone! Have you really thought this

through?

Dr. Johnson: I know there are issues, Jody, but I truly believe the future of medicine is in

electronic records. I’m guessing you’ve been following what’s going on at the national

level, and there are policy-type folks involved making a strong push toward expansion of

EMRs into outpatient settings as well. Policymakers are concerned that hospitals and

physicians have been too slow to adopt these systems, which they believe will improve

both patient safety and the quality of care delivered, and they are beginning to propose

incentive systems to encourage adoption. As I just mentioned to Amanda Chapman, the

director of medical records, I don’t think this is a question of “whether” any more – it’s

just a question of “when.” Saint Vincent is a terrific system that should be at the forefront

of medical and technological advances, not waiting to see what everyone else does.

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Dr. Smith: I’ll bet Ms. Chapman was thrilled with the prospect of losing control of her medical

records area. I understand your desire to help Saint Vincent, but I don’t think you’ve been

here long enough to appreciate how great we already are. Our docs are content with

paper, we have a functional and responsive medical records department, and I’m not sure

I sense any burning need to be the “most digitized” or anything. This isn’t Boston, after

all. A lot of us chose to practice here because we could what we do best – provide

excellent clinical care – without the distraction of a push to be number one in the world

or something like that. I’m just not sure you can make a major like putting in an EMR

and keep everyone happy like they’ve been for so long here.

Dr. Johnson: I realize I haven’t been here at Saint Vincent very long, but I’ve been working

very hard to get a sense of this place before I propose and major changes. I also realize

that introducing and EMR system to a place that is completely paper-based is no easy

task. At this point, I know there is still considerable work to be done to better understand

both Saint Vincent and the opportunities and risks associated with implementing an

EMR. However, I strongly believe the future of medicine will require the electronic

capabilities associated with an EMR system, and I am not willing to “watch and wait”

much longer. I’d like to make an EMR system implementation a major goal for the

coming year, we will form a task force which will be charged with the selection and

implementation of an EMR system.

Dr. Smith: I think this is crazy. I agree Mr. Ash. We should wait and see what happens at other

hospitals and health systems and learn from their mistakes. There is no reason to stick our

necks out on the “cutting edge” of EMR system implementation. And by the way, I’m not

alone in my beliefs. Lots of other physicians agree. What we do here works just fine, and

the people who work here are happy doing things the way they are done now.

Dr. Johnson: Thanks so much for sharing your thoughts.

Dr. Johnson left Smith’s office with his mind reeling. Was Saint Vincent truly content

with paper-based records and letting other hospitals pass them by with electronic capabilities?

Regardless, Dr. Johnson knew he was right about the future. He knew Saint Vincent needed to

get on the EMR bandwagon, and the sooner the better. However, he now knew the

implementation challenge was even greater than he had anticipated. Not only were the member

of the medical records department threatened, but apparently physicians weren’t all that

interested in changing their practice pattern either. His only allies appeared to be among Ms.

Rice’s IS team.

Considering the Resistance

Dr. Johnson recognized that in addition to uncovering some attitudes toward EMRs, he

had learned quite a bit about Saint Vincent’s organizational culture during these exploratory

conversations about EMR adoption. It appeared the predominant culture was comfortable

clinging to the status quo, and that few individuals were open to considering the possibility of

change. He had felt resistance from Ms. Chapman and Dr. Smith, and knew that resistance to

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change was a major hurdle he would have to overcome if there was any hope that an EMR

implementation process could succeed.

Yet Dr. Johnson sensed that this resistance was not merely resistance to change, but

resistance to change that would result in a loss of control for the individuals involved. As he

reflected upon his conversations with Ms. Chapman and Dr. Smith, he thought about some of the

unspoken messages they had sent. Ms. Chapman and her group felt threatened by the loss of

control they would have over the medical records process. With electronic systems in place, they

would no longer have a major role to play in health systems operations, and their jobs might even

be at stake.

Dr. Smith’s comments suggested that the physicians were uninterested in changing their

practice patterns because they would lose some of the control as well. The introduction of

standardized order sets and other decision support tools could truly change the way physicians

practice medicine thus leading to less discretion for individual providers with respect to viable

treatment options. As both Dr. Smith and Dr. Johnson knew, with electronic medical records,

there would be a searchable digital trail, which could be used to monitor those providers’

practice patterns. While Dr. Smith mentioned her fear that newer physicians would to rely too

much on decision support systems and stop thinking for themselves, there was also an unspoken

fear that if a physician did not do what the order set had defined as the “right things,” they might

face problems.

Learning More

Dr. Johnson knew of several IT implementation failures that had occurred over the past

several years, with the most notorious at Cedars Sinai in Los Angeles. There the hospital had

rolled out a CPOE system across both the inpatient and outpatient settings and the process was

deemed an utter failure. Physicians revolted and the hospital had to retreat, going back to paper-

based processes while they decided what to do. On the other hand, he had also heard anecdotal

stories about implementation successes, such as an incremental implementation that had been

taking place at Children’s Hospital in Columbus, Ohio. While the Children’s physicians were all

hospital-employed and thus had little ability to “just say no,” as the physicians at Cedars had, the

process at Children’s had been carefully planned and seemed to be proceeding according to

schedule – without alienating the entire provider population.

Dr. Johnson had to plan his next steps carefully. He knew doctors valued evidence, and

he had to build a good case for moving forward with an EMR implementation, and he had to

build a good case for moving forward with and EMR implementation. He suspected there might

be value in learning more about implementation successes and failures, but he also guessed there

was other information out there he was not aware of. Dr. Johnson decided to recruit Ms. Rice’s

summer resident to help him expand his search for evidence and help build the case for EMR

adoption.