Michael Bakerman, MD, gives a physician leader’s perspective on the successes and shortfalls of the industry ongoing high-tech revolution.
Michael Bakerman was a practicing cardiologist for many years and moved into health care leadership roles, never veering from his sideline interest in technology. As progress would have it, computer systems are now the glue holding together most modern industries — including health care.
So Bakerman, now chief medical officer at St. Elizabeth’s Medical Center in Massachusetts, had a front-row view of the paradigm shift over the past two decades. As far back as 2005, he was on the forefront of electronic health records, working as chief medical information officer at Perot Systems (founded by H. Ross Perot, a billionaire through EHR systems before his U.S. presidential runs in 1992 and 1996).
“Really interesting character,” Bakerman says of Perot. He “had a very large footprint in outsourcing for IT and his company had some of the larger health care systems in the United States … and they were all trying to implement electronic medical records at the time. Some spectacular failures, so they determined at that point it might be helpful to have clinicians help with these implementations.”
Bakerman says his team “actually helped translate the clinical side with IT. So that was my first introduction into IT.”
After Perot, he worked as quality director at Partners Community Healthcare on how its providers could translate data in quality care. “Partners was one of the first places in the country who could say they were 100 percent computerized,” he says.
Beginning in 2011, as chief medical information officer at Massachusetts Memorial Health Care, he “really got involved in technology, integration with physician workflow, quality of care, meaningful use.” There, he was introduced to several EHR systems, becoming certified in the Epic system in an ambulatory environment.
A member of the faculty of the American Association of Physician Leadership®, Bakerman moved on to St. Elizabeth’s, a large teaching hospital in the Boston area. “Here, I sit a little bit above the CMIO role and look really at how the medical staff integrates with technology from a data perspective, quality of care perspective, workflow perspective.”
Workflow is among Bakerman’s chief concerns. At many facilities, he says, providers don’t receive the proper training, so “we haven’t realized really the benefits of the systems yet.”
“If I had one plea or goal, it would be to simplify the workflow for the providers and to really understand the interoperability requirements for moving data around,” he says. “Those are the two things that will ultimately realize promise, but we’re still kind of stuck at the beginning.”
We tapped into Bakerman’s vast experience as a clinician, technologist and physician leader on questions related to health IT and its implementation in health care organizations. Some answers were edited for brevity.
Q From your perspective as a physician leader, how do you think health care IT innovation can be focused to assist and educate the patient in their health care journey?
A I think there are more and more tools now that are available as applications, either from Apple or Androids, or high-def that are useful in instructing patients about their clinical cores, about helping them understand what the values and data are, from simple blood pressure to blood sugar, to videos about … what a bypass surgery is like, what the expectations are for colonoscopy, sigmoidoscopy, any procedures. But I think it requires each of the specialties to be able to have a resource catalog so that they have the ability to recommend it, pull it up, get a web address, show it on the iPad. There are a lot of resources that are coming available to be able to do that.
Q Are there barriers that would prohibit these suggestions?
A There are some from the provider side or health system side. Being able to have the equipment, the infrastructure, Wi-Fi, all that available. It costs money to make an iPad available, to have the resources so when patients come in they can see that information. It’s resources, attention, focus and money for that.
On the patient side, it’s the diversity in education, resources, socioeconomic levels. It depends on where you live in the United States. We did projects out in West Virginia, where they barely had running water, so to expect them to be computer-literate, or have a computer at home, or an iPad, even an iPhone was challenging. Other places, in the suburbs of Boston, you can’t go anywhere without Wi-Fi or a computer or things like that. So diversity and the socioeconomic patterns of your patient populations are a huge barrier.
QHow important are IT solutions to health care organizations in the move from volume- to value-based care? Are physician leaders investing enough in people, hardware and software for the transition?
A That’s a complicated question. I think IT is an enabler for that, but it’s not the actual solution. A lot of it is about workflow, community resources, understanding how you move information from one place to another.
A good example: In an academic medical center in the past, the discharge process would be we identify that the patient can go home today, tell the residents to do a discharge summary, and then I wait until it comes to my inbox at some point in the future, and then I read it and sign off on it. Most medical staffs have 30 days to complete documentation before they are out of compliance with policies. Many of our value-based purchasing goals now are to transmit documents within 48 hours. So I can’t just wait for my residents to get around to it whenever they want, I have to own that discharge. I have to say, “That patient is going home today,” I want the discharge summary in my inbox tomorrow morning, I’ll review tomorrow morning and sign off tomorrow afternoon. And then it gets done. I had to change my medical staff policies to a 48-hour turnaround time, not a 30-day turnaround time.
Q Are enough physician leaders recognizing the value of IT leadership in their organizations? Are they recognizing it and keeping pace with the needed technology?
AI’m a little pessimistic at this point that about that. There is so much frustration and failed promises about IT. Epic is the lead dog in the fight at this point, Cerner is a close second, but even in those two large organizations, people aren’t really satisfied with the workflow and the level of training and understanding that the providers have. This still seems to be a frustration. The ambulatory electronic medical records very rarely interact well with the in-patient record, other than potentially Epic at this point. They’re not seemless, it’s difficult.
Q Are the approaches to these barriers different in larger facilities versus small- or medium-size hospitals?
AThere is a difference. Those who have can continue to do what they do. Epic and Cerner are expensive applications, they have much more customization ability, they probably work a little better, but they are hugely expensive. A smaller community hospital is not going to be able to do an Epic or Cerner conversion on their own. My hospital has Meditech. And Meditech works — it’s not bells and whistles, it brings its own set of challenges, but there is a significant difference in the way those medical records work. … Epic is an integrated platform, so if you have in-patient, outpatient [ambulatory] support is a lot better. For us with Meditech, there is no real good ambulatory record that works, so our providers use two or three different ones, which makes this Tower of Babel even more complicated.
Larger organizations have more money to throw at it. The fundamentals are still in workflow, physician training and the flexibility of the organization. If you don’t do the implementations well, don’t require some strict changes in workflow. It still doesn’t work well.
Q What are some smart tech initiatives physician leaders should consider investing in?
A You have to be on the lookout for opportunities that improve care.
Some of the initiatives we’ve looked at:
We have a number of patients that fall. We’ve put in a lot of systems to try and prevent that. We ultimately invested in a solution that provides cameras that can follow the patient, put artificial bars up to show what areas they are OK in, what areas they are not OK in. It can alert an alarm if they are moving around. We don’t have to keep people in the room, and the monitor helps us. We have to have someone watching the monitor, but the monitor can survey four or five rooms. That seems like a good technology.
For patient flow, there are a couple of solutions out there that integrate bed management, facilities management, [and] is able to track and display data very quickly. It’s real-time information once a room is clean, once a room’s reserved, where the patient is at any one time in the system, and that helps with patient flow. … It’s those kinds of add-ons that help with infrastructure and displaying data that is the most useful.
And there are a whole bunch of patient engagement tools that are smartphone-driven, some are wearable products we use on our cardiology patients to check heart rate rhythms. Those are useful products to give us information in the ambulatory environment to see what they look like when they are not in the hospital.
Q What are some ways medical organizations are using data gathered through HIT in clinical and operational decisions that perhaps could not be done in the past? What do you think is the next, most pressing innovation in health IT that should occur?
We have one really good example where we have a device that can be implanted into a pulmonary artery. It measures the pulmonary artery pressures. [With] our patients with congestive heart failure, we get real-time download of what their pressures are at any one time. As they gain more and more fluid or fall out of compliance with their medication, we get real-time information with them at home to adjust their medications and their doses. That is a relatively straightforward catherization implant. Safe. Reliable. And it helps keep those patients well, keeps them out of the hospital, and it’s something you couldn’t have done before. It’s a Wi-Fi driven device. It’s used with the cloud, and we’re able to download the information here [at the hospital].
Similarly, in the last several years we’ve had more and more applications that are able to download blood pressures, blood sugars, sleep-wake cycles for sleep apnea, that kind of stuff. Those are good innovations we didn’t have previously that are very helpful.
The other thing you’ll see more and more of are smart houses, or smart homes; patients can be fully monitored in their house. If they haven’t gone out of their bedroom in 14 or 18 hours, people can be alerted if they are sick or they are hurt. If they are in the bathroom and haven’t come out of the bathroom because they fell and are injured, you can do that. You can have devices in the house that record blood pressure, motion, did they take medication. … Those will be innovations we will see in the next several years.
The stuff they are using today are really smartphone-based technologies. For diabetes, hypertension, for COPD with heart rate and O2 saturations. They’ll have others they can download how many steps they did, ambulatory activity. That’s the stuff we are looking at, more on the ambulatory, primary care, health approach.
Rick Mayer is a senior editor with the American Association for Physician Leadership.