Hospital Beds: The Antiquated Metric

There was a time when the military was the role model for waste and backwards thinking, but in the last 15 years, the US military became a role model for lean optimization and innovative thinking. This new $451M healthcare facility at Camp Pendleton is an example-- only 62 hospital beds. Why? Because the whole motive of healthcare should be to keep patients out of the hospital with preventive care, and when necessary, treat them at home and in clinics. The military gets that. Says Lt Cmdr Stephen Padhi, "People always ask me, 'How many beds do you have?' That's an antiquated question." 

There are boatloads of commercial healthcare executives who, over the past 5-10 years, have continued to build giant "five star resort" hospitals, shrines to themselves and their outdated thinking. The railway executives in the early 1900s did the same thing with grandiose railroad stations that are now mostly museums, as the center of transportation in America shifted to the automobile and airplane.

Hospitals are not going to be the center of care in the future; hospital beds and inpatient treatment will be bought and sold as commodities on the stock exchange, while the center of care moves to ambulatory clinics and the patient's home.

Way to go Navy.  And that's from an Air Force guy.  :-)

Optimizing Cerner: Looking Back (Part 1)

Three years ago, I wrote the blog below to describe our intentions and aspirations for improving the current state of affairs for our Cerner applications in the Cayman Islands National Health System.

The phrase “EMR Optimization” is now the common term to describe our undertaking; fixing a very bad implementation is the more frank description. I half joked with full truth to my Cerner account team that they should have paid my salary.

A component of this optimization strategy included recompeting the existing Cerner contract. In part, we were motivated to recompete the contracts as a means for evaluating other options — to scout for greener pastures. Aside from that, we were required by government policies and regulations to compete the contract upon its expiration. Eight vendors submitted responses to the RFP:  AssistMed, Cerner, IBM/Alert/Stockell, Keane, MEDITECH, Populus, RazorInsights, and Siemens.

In my next blog, I will summarize the journey of that optimization and recompeting the contract. For now, here’s a repeat of that blog from three years ago. In the blog, CayHealth referred to our version of what amounts to an Accountable Care Organization.

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Cerner and the Cayman Islands (June 2010)

The Cayman Islands purchased Cerner Millennium (PowerNote, CareNet, PathNet, RadNet, PharmNet) and ProFit financials in 2005, before I arrived as CIO. Both Cerner and the Cayman Islands have been struggling ever since to make the implementation a success. For the most part, the clinical applications have been relatively successful, even though the physicians are reluctant users; data access and data analysis is torture; and the implementation lacks many added-value features — notably medication order entry.

The ProFit implementation has been only slightly less than a disaster. Practicing medicine is, for the most part, a fairly consistent experience between the US and Cayman Islands, but the Caymans are considerably different in their management of financials and interactions with insurance companies. Cerner admits now that ProFit was a misfit, and we still have a long way to go to make it reliable and functional.

To Cerner’s credit, Talbott Young, the VP who covers the Latin American Region, and Lisbeth Fabiny, our Customer Results Executive, are phenomenal partners in improving the value-add from Cerner products in the Cayman Islands. Neither of them was involved in the initial implementation or contract, so pride of ownership is not an issue.

In my first eight months here, we (my IS team and I) have been focusing on remodeling the neglected technology infrastructure — basic issues like antivirus software, new desktop computing, new printers, cabling, networking, data backups, etc., have kept me very busy. But in the next few months, I will start to climb my way up the technology stack and focus more on the data content and application configuration of Cerner.

Improving the cost-benefit ratio of Cerner is my prime concern. We spend almost $3M per year in Total Cost of Ownership on Cerner, which consumes about 90% of our IT budget. Our IT budget accounts for 4.5% of our total operating budget for the health system, which is much too high, especially given the lack of perceived benefits from Cerner. Our Cerner TCO equates to an overhead of about $41K per employed physician per year.

The Role of Cerner in the Success of CayHealth

If software functionality and design is a reflection of the processes it supports; and if we all agree that our US healthcare process is flawed, then Euclid would conclude that the functionality and design of our current crop of EMRs is also flawed, and Cerner is no exception. In order for CayHealth to be successful, we must partner with Cerner to make some fundamental and major changes to their products’ implementation in the Cayman Islands.

Like all market-leading EMRs in the US, Cerner’s products are a reflection of a healthcare documentation application — not a healthcare delivery application. The design of Cerner was fundamentally motivated by a US market driven by:

• Defensive Medicine: Protecting the physician from spurious lawsuits and billing compliance violations.
• Maximum Billing: Documenting care in such a way that it aligns with the insanely complicated billing rules in the US, but yet also ensures the highest level of payment for services rendered.

We have the opportunity in the Cayman Islands to reengineer our Cerner EMR and surrounding ecosystem so that every mouse click, every function, and every user interface will support and be judged by its contribution to a different set of motives with more sensible origins, including:

Next Generation of EMRs: Improved Motivations of Design

1. Clinician Workflow Efficiency: Enabling clinicians to practice the best medicine possible, in the least amount of time and lowest risk.
2. Evidenced-Based Medicine: Patient-tailored and dynamically generated follow-up appointments, order sets and patient health optimization plans.
3. Economics of Care: Informing the patient and the physician of Total Cost of Care–to the patient and the insurance company–at the point of care, so that treatment options can be discussed within the context of cost and benefit.
4. Patient Engagement: Enabling patients to be more involved, if they are capable, in their own healthcare through personal health records, social networking support groups, financial accountability, and patient-specific health optimization plans.
5. Patient Safety: Providing user interfaces and decision support that enhances the delivery of safe medicine.
6. Paperless transactions: Among clinicians, patients, employers, and insurance companies.

In Part 2, I’ll report on the procurement and progress of the optimization, in particular our headway towards the aspirations listed above.