Some doctors have decided to step up to the plate to lead their colleagues toward automation
By Greg Gillespie, Managing Editor
Health Data Management Magazine, October 4, 2004
Clayton Hudnall, M.D., just couldn't take it anymore. His practice, Urology San Antonio, comprises 18 physicians spread out across six clinics and a surgery center. A few years ago Hudnall and his peers realized that the old ways of doing business weren't working.
Patient records were being transported by hand to multiple clinics, creating a paper trail that was difficult to track. Urology San Antonio also was bleeding money via high transcription costs and subpar coding.
What the practice needed, doctors decided, was information technology. But their project needed a flag-bearer to champion the cause and lead implementation across the political and financial battlefields it had to cross. That champion was Hudnall.
“I became a champion by being just stupid enough to stick my neck out there,” he recalls.
Leader. Taskmaster. Translator. Rainmaker. A physician I.T. champion has to wear many hats when they're riding in the saddle of an I.T. implementation. CIOs and other I.T. professionals typically are the technological “face” of I.T. implementations. However, the catalysts for I.T. progress often are physician I.T. champions who, sometimes reluctantly, sometimes fearfully, put their reputations on the line to guide an implementation before, during and after software is installed.
The reason that some have decided to advocate I.T. is simple—someone has to do it. The success of I.T. implementations hinges on whether doctors will accept new technology. And most will not listen to anyone else but a peer.
“You can ask physicians to look up results on a computer, but if you're trying to install an electronic record or order entry system, you must have a physician I.T. champion—it's not worth it to even try without one,” says Melinda Costin, vice president of implementation services at Houston-based HealthLink Inc., a consulting firm. “Doctors follow no one. But they will listen to their peers.”
But who in their right mind would volunteer for such a role? With all the risks involved, it's a fair question.
Ironically, physician I.T. champions often aren't the techno-geeks who would seem to be a natural fit for the job. Many are “Average Joe” practitioners who, through one experience or another, have become convinced that information technology is critical to the future of their organization—and profession.
“Any kid is a whole lot better with a computer than I am,” says Bud McDowell, M.D., a partner at Middlesex Cardiology Practice, Middletown , Conn. McDowell spearheaded the group's implementation of an electronic medical records systems—from New York-based Amicore. “I'm 52 years old, and this is all new stuff to me. But I have seen how technology can make a difference. Yes, it can be hard at first, but if you're willing to learn something new it can make your life a whole lot better.”
In fact, being a technology guru can be a hindrance rather than an advantage for a physician I.T. champion, some experts contend.
However, being an I.T. champion does require a basic understanding of software and the lingua franca of technology, says Nathan Beraha, M.D., medical director of Anchor Medical Associates in Lincoln , R.I. Beraha led the practice's initiative to implement a Web-based practice management system and use online claims transactions services from Waltham, Mass.-based athenahealth.
“I'm not walking around wearing a pocket protector, but as a physician I.T. champion your peers are going to look to you to translate the language of technology, because it really is a foreign language to them,” he says. “So while everyone here is reading about the Red Sox, I'm reading through information technology trade magazines. Which is not so bad, really, because I'm not a big baseball fan.”
The role of I.T. champion requires McDowell, Beraha and other physician I.T. advocates to convince their peers that I.T. can be their friend. Succeeding at that task defines their role as an I.T. champion.
Nowhere is success in greater peril than at the group practice level, experts say. Hospitals typically have a structured, committee-driven approach to I.T. initiatives. In addition hospital physician executives exercise persuasive powers over their peers. But at group practices, it's a whole different ball game.
“When I was championing technology at a hospital, I worked through committees and focused on the quality of care advantages,” says Neil Stollman, M.D., a gastroenterologist and part-owner of a San Francisco-based ambulatory surgery center. Stollman has pushed the implementation of software—from Minneapolis-based ProVation Medical Inc.—that helps physicians create an electronic note of each procedure and automatically codes the procedure based on the documentation. “My practice partners are interested in that issue, but you're asking them for money out of their own pocket. And when you're spending someone's money, they hold you accountable.”
Many physicians are reluctant to step into the glare of that particular spotlight. Those willing to do so say that being an effective I.T. champion demands a thick skin. Information technology rollouts are never perfect, they say. Technological and process glitches, like death and taxes, are a certainty.
So champions must be prepared to take it on the chin from their colleagues. But they also must be prepared to stay the course throughout an implementation.
“During the rough patch after we first went live, one of my partners told me I had ruined his life,” McDowell says. “There are going to be some rough times, and your peers are going to hold you responsible. But after a few years of using our electronic records system our physicians are unanimous in feeling it was the right thing to do.”
Potential physician I.T. champions need to appreciate at the outset of their odyssey that a software implementation is not just about technology, Stollman says.
Oftentimes, the biggest upheaval caused by technology is how it can rearrange the power structure in a hospital or practice, he explains.
The conventional hierarchical structure of a provider organization is one where older, more experienced physicians are running the show. But technology can turn the hierarchy upside down, Stollman says. Younger doctors, who are more experienced and comfortable with I.T., often are leading costly and complex I.T. implementations. Some older physicians for this reason see I.T. as a threat to their status at an organization. This, instead of fear of technology, can be the root cause for their resistance, Stollman contends.
“The biggest challenge to being a champion is getting other physicians to use the software, and that task gets more complicated when older physicians feel their power is threatened,” he says. “All of a sudden, the ‘young bucks' are running the show, so in many cases the struggle to implement technology is at its root a struggle for power.”
However, the fear of lost status and control is not always limited to older physicians, McDowell says. Even young physicians can be reluctant to use computer software and hardware.
“The biggest problem with doctors is that they are smart but only in their areas of expertise,” he says. “They are used to having people rely on them to make a decision. If they don't know the answer or have to ask someone else for help they feel as if they've fallen off their pedestal. They find it very hard to ask for help, and it's ever harder for them to admit they don't know what to do.”
But next comes the delicate part of the dance: selling an application to reluctant physicians. This is a crucial juncture when the physician I.T. activist's skills of persuasion are put to the test, experts say.
This is the point when it's vitally important that a champion has “street cred” with their peers, says Kenneth Fath., M.D., a cardiologist and medical director at Alamance Regional Medical Center , Burlington , N.C.
“You need someone the rank and file physicians will listen to—and that's why it's so important to have a practicing physician as an I.T. champion,” Fath says. “Clinical applications change—disrupt—workflow, but if you're a practicing physician those changes are affecting you too, and your peers know it. That gives you credibility with doctors that a non-practicing physician or an I.T. professional simply won't have.”
In addition, an I.T. champion who is a practicing physician knows what the real issues are in the trenches and can focus on how I.T. will address those issues, Fath explains.
In 1999, Alamance Regional embarked on deploying a computerized physician order entry system, from Boca Raton, Fla.-based Eclipsys Corp. Many experts believe CPOE is the most workflow disruptive clinical application and, as a result, is the hardest to sell to physicians.
Fath's first task was to quell concerns voiced by some doctors that the technology would relegate physicians to a clerical role, he says. Others were threatened by clinical alerts and felt the software acted as a Big Brother who was guiding their every move and infringing on their clinical practices.
But Fath, while trying to ease their concerns, focused on the benefits of increased legibility and the reduction of duplicate orders.
“We talked legibility, legibility, legibility, and we demonstrated how using the application would cut down the number of call-backs from the pharmacy and nursing staff,” he explains. “Improving legibility is an issue every practicing physician can understand, and it was a convincing argument to get doctors to agree to spend the time to learn how to use the system.”
Also, during Fath's CPOE roadshow, the Institute of Medicine released the first of its reports on the frequency and impact of medical errors.
“Most physicians were shocked by the enormity of the numbers, as I was, but the more data that came out the more sobering and convincing the report's conclusions were,” Fath says. “Our physicians could see the connection between increased legibility and reduced errors.”
Connecting the dots between information technology and improved clinical and financial performance is an important component of being an I.T. champion. But it's also important to in some ways share skeptics' concerns about technology, says Larry Judy, M.D., a partner at Wellborn Clinic, a an Evansville, Ind.-based practice comprising more than 100 physicians and nine satellite offices. Judy recently led the clinic's initiative to implement a practice management system from Horsham, Pa.-based NextGen Healthcare Information Systems Inc.
“A champion has to be skeptical about the benefits of the technology for physicians,” he says. “Vendors can tell you all about all the great benefits, but an I.T. champion has to determine if those really, truly are benefits for practicing doctors. A champion has to figure out the advantages from a physician's viewpoint, not the benefits for the business office.”
However, the intertwined relationship between the delivery of care and the billing process is one reason information technology has become a necessity, he adds.
“The delivery of care is getting more closely linked with computer codes—anything we do or provide to a patient has to be documented with a code,” he says. “Part of our interest in technology is a result of this interaction.”
A physician I.T. leader must spend time both convincing and cajoling colleagues into purchasing and using information technology. And by assuming this responsibility, they have painted a big red bullseye on their back, I.T. champions say.
Because they are the “owner” of technology, a physician I.T. promoter often is held responsible when something goes wrong, says Hudnall from Urology San Antonio.
“If one of my partners loses an electronic chart, or the network suddenly goes down, they are going to blame me,” he says. “Sometimes I fear that I'm not as well-liked as I used to be, but you have to be ready to hear criticism. You also have to be ready to accept responsibility.”
For Hudnall, being an I.T. champion meant delving further than he ever had into the world of technology. When his practice installed an electronic medical records system—from Seattle-based Physician Micro Systems Inc.—physicians wanted to use standardized templates to document their care delivery. Hudnall ended up performing six months of “very nasty work” to design customized templates.
“I had no idea it would entail so much work—it was a process that seemed like it would never end,” he says. “ But I kept at it because I felt it was going to be a huge advantage for our practice. We did a cost evaluation that estimated we would save $500,000 per year when we had the records system implemented. Physicians are going to complain about an application no matter what, but they really can't argue with that.” •