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CIO Leadership, Part II: Marshfield Clinic's Bob Carlson on electronic records and preventive medicine

Robert Carlson
Marshfield, Wis. - This is Part II of WTN's CIO Leadership interview with Dr. Robert A. Carlson, director of applied sciences and CIO of Marshfield Clinic. Part I ran on Jan. 19.

WTN: Even with all the EMR functionality that was outlined in the recent New York Times article, is there still something immediate that you'd like to do with the record that you can't right now?

Carlson: We feel, at least at Marshfield, that we cannot simply rely on the retroactive, reactive mode of medicine. We have to be much more proactive. We've got to be able to identify patients at risk and intervene before they end up with either a catastrophic, a high-cost, or a bad outcome.

WTN: Why kind of a reaction has Marshfield gotten to that New York Times article? Are other facilities calling you and asking for advice?

Carlson: It's been great press. To have a positive article come out of the New York Times, I'm not going to complain about that at all. I think it touched on do we have the silver bullet? I think one of the most important points that article did highlight is that IT is not a silver bullet. It is a very important tool to help move medicine where it needs to go, but it can't stand by itself.
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WTN: Does the condition of the economy and its impact on your revenues make it tempting to offer CattailsMD (a commercial version of Marshfield's electronic medical record) beyond the Midwest region, which I believe is where you'd like to start, or do you need to finish building the infrastructure first?

Carlson: We're still building infrastructure. Our focus has been on the region. We've got a couple of clients now that we're building infrastructure around. I think our goal long-term is to go outside of the region, but we're real selective with opportunities. If something came up outside of the region, we'd have to look hard at it, but if it requires significant changing of our direction, that really isn't something we're looking to do.

WTN: Why did you choose to offer Cattails in a software-as-a-service model?

Carlson: You think about the fact that 80 percent of medicine outside of the state of Wisconsin is practiced in those one- and two-physician practices, I think software-as-a-service - particularly wrapped up in an ASP model - is an interesting model to go forward with.

WTN: When we spoke to you recently, you mentioned the accuracy of the EMR is a potential pitfall when applying business intelligence in the healthcare realm. In terms of EMR accuracy, where does healthcare typically fall short, and what can a CIO do to drive improvement there?

Carlson: Part of it is trying to walk through the crosswalk of a paper record into an electronic record. When you start looking at free text and where do you put the field of diagnosis, is it a field or do you map it to the necessary criteria? I use diabetes as a good example because it's relatively simple and it has nice, analytical definition. If you are doing your data mining on the term diabetes mellitus, you're going to get things from accurate diagnoses to things that are mentioned in the differential diagnosis.

As a CIO, one of my responsibilities is really taking and putting in place ways to capture the information simply but accurately. For example, take ink over digital forms, changing the ink forms to discreet fields and then providing real-time feedback to refine that particular entry - while the provider is making his or her decisions - helps instill accuracy on the back end. That's maybe a simple and off-mark example, but those are the kinds of things I would see helping to improve the accuracy.

WTN: Forget about presidential edicts about everyone having an electronic medical record in five years, which may or may not be possible. Will the declining Medicare reimbursement trend, the aging population, and the fact the government will no longer pay for certain medical errors in hospitals really be the biggest drivers for healthcare IT deployment?

Carlson: Let me tell you what I think are going to be bigger drivers for healthcare and then will trickle down into where IT needs to help. Certainly, as the Baby Boomers age, the increasing incidence of chronic disease is going to break the system. Just looking at where healthcare dollars are spent, there are some studies that say 80 percent of the almost $5 trillion in healthcare the next several years is going to be wrapped around chronic disease.

What we see that we have to do as a healthcare provider is to be a lot more efficient, and a lot more effective. What are the things you can do to make that happen? We've talked about one of them. Hospitalization is an expensive place to provide healthcare. If you have somebody with congestive heart failure who ends up spending time in the hospital, that's very expensive. If I could have intervened two weeks prior and noticed that the weight was going up and that the shortness of breath was increasing, I may have had a chance to intervene and perhaps adjust the medicine or get him in for an office visit, and instead of spending $14,000 to $100,000, I could have spend $1,000. That's the kind of stuff that we're going to have to do.

The role of IT is to help identify and facilitate those kinds of interventions in a way that brings the high-risk patients to the forefront, sorts through the massive amounts of regulations and paper work and differential diagnoses, and helps the physician and providers make the right decision at the right time before it gets expensive. I don't know of any other answer.

WTN: In five years, given everything you know about the opportunities and barriers, where do you think the nation will be regarding EMR adoption? Enough to start having a positive impact on quality and cost?

Carlson: Well, implementing an EMR can be a very dangerous thing. There are studies that show that given the complexity of healthcare, it's easy to miss steps in processes and delay important information; in essence, instead of a positive impact on healthcare, if done wrong it may actually be a step backward. That being said, EMR is the first step toward moving healthcare where it needs to go. Once you're in the electronic format, now you have the ability to take all the tools, the technology, the intelligent assistants, the data mining and trend analysis, and the outcomes and start bringing them to bear where the rubber meet the road - at the point healthcare is being delivered.

You're in a doctor's office sitting on that cold, hard table, and a doctor has a stethoscope in his hand. What information do you want that doctor to have? Whether you are in Ladysmith, Wisconsin or Madison, Wisconsin, or New York City, the technology piece can make geography less important. The EMR is rightly identified as a critical first step, but again it is only a first step and is woefully inadequate by itself to take medicine where it needs to go.

In five years, it really depends on how much money you put at it. If they put $50 billion on it, and depending on where they put it, there will be a lot of interested companies trying to gear towards that. The thing that people need to understand, though, is that you're going to have to be able to get down to that one- or two-doc shop because that is still the way medicine is practiced, for the most part, in this country. They are not going to be able to afford a $10 million system. It's not going to happen, so whether the country chooses to subsidize the $10 million system or whether there is another niche for other players to come out with a simpler product, I think we'll probably see a blended approach.

WTN: What do you think will be the first priority of most healthcare organizations once they've established an electronic medical record? Will it be to finish the process of adopting other healthcare IT that feeds data into EMRs, or will it be business analytics?

Carlson: It really depends on what they see as their need to accomplish. If all implementing the electronic health record does is replace the paper system, it isn't going to do a whole lot. It's going to depend on what other tools are brought to bear. Can you put best practices in front of providers as they are seeing the patient? Can you do the trend analysis? What is the ability, instead of having to duplicate laboratories, to share records appropriately across the institution so as patients move through a system, they have a complete health record to go with them?

The electronic health record enables that but it certainly doesn't complete that kind of process. [Marshfield Clinic CTO] Carl Christensen had it right - it's the race to the starting line. Once you've got it, you at least have the ability to begin to address what I see as the more important problems.

WTN: How much federal money do you think it's going to take to move EMRs toward full adoption?

Carlson: My guess is there are going to use the carrot and the stick - the carrot being they will fund some of this stuff. The stick being if you want to get reimbursed, you're going to have to play along certain lines and provide certain structures.

WTN: The Governor of Wisconsin is talking about re-introducing the hospital tax. Is that a good thing or a bad thing?

Carlson: It all depends on how it's implemented. The devil is in the details. What we see is that there is a disparity between who is seeing the Medicaid patients and the fact that that reimbursement is less than other fee-for-service providers and if the tax is put out in such a way to level that playing field and increase the reimbursement for those systems that are seeing more than the populations within their area compared to other providers, I think it could be a good thing.

WTN: Do you have any recession survival tips for CIOs?

Carlson: [Laughs] Make sure what you're doing is of value to your organization. It really means getting out of your office, understanding your company, and what are the needs? You can either be a very valuable asset and tool, not only for survival but success, or you will be looked at as another one of those departments with a high budget and not much output.

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