Mastering IT matters

A series to help you get a handle on this increasingly essential part of medical practice.

By Peter J. Polack, MD, FACS

Welcome to the first installment of my five-part series on getting your IT house in order.

IT adoption, my practice learned while going down this road, has four stages. Part one of this series summarizes how my ophthalmic practice transitioned through these stages.

A major discovery: each stage required that we hire IT expertise differently.

Another huge discovery: Excellent IT management is the most critical success factor in using technology in your practice.

The goal of this series is to educate and entertain you with lessons learned, to show you what pitfalls to avoid and which best practices to adopt, and hopefully to share how to stay sane as you navigate the choppy waters of IT management. At the end of this first article, you’ll get a sneak peak into the first of four milestones.

My hope is to give you the facts so you can hire more appropriately for your practice needs. My approach will be to tell you a story that combines elements from my own practice’s journey and pepper that story with situations and outcomes from other practices.

The genesis of this journey, and this article, was to answer this question: How does a practice hire an IT manager or director?

Like a horse and carriage

For you, the challenge to correctly answering this question will depend on your practice’s current level of IT adoption. Where you start dictates where you’ll end up. That’s why this story addresses both IT hiring and technology adoption. With the commitment to use IT comes the need to manage it.

When we began getting our own house in order, we had no IT management talent — no one in-house, nothing outsourced. What we did have were ‘drivers’ for adopting IT (EMR adoption was just beginning) and internal IT “champions” (partners with an affinity for technology who were already using PCs at home). These drivers became our starting points as we began looking into the human side of IT management.

This was in 2004, years before there was a Medicare incentive to reimburse medical practices for EMR adoption. We were classic early adopters. The promise of EMR intrigued us, but to pull the trigger, we needed more justification.

We wanted this new technology to ease our challenges of paper charts. The square footage required to store them, knowing our storage requirements were doubling every 18 months, weighed heavy on our wallet.

We wanted an IT person who knew IT — but what we understood about “knowing IT” meant this person knew how to back up a server, pull cable and replace a hard drive. Looking back, we understood very little.

We discussed our hiring options. One, train someone from within — pick a person who’s geeky. Or pick a partner who loves technology, and make that person the IT hero by expanding certifications, competencies and capabilities with training (basically build versus buy).

The second option: hire a full-time manager already fully trained who would be productive from day one. The third option: hire a consultant whose expertise would fill in IT management gaps. The issue with the consultant option is that we would still need an IT operations person for day-to-day tasks.

We could have a mix of these. But that option was the most costly and least likely to be implemented properly. The goal was not to add overhead but to reduce it. IT talent that met our nascent requirements at that time was mainly get an EMR running, maintain it for uptime, availability and data integrity (keep it running) and monitor system growth needs as we implemented more and more IT beyond the EMR purchase.

The transition through four stages might not map your exact journey, but it should establish some guideposts. If yours is a similar journey, then I hope to align wherever you are with some information that you may not have, or with perspectives you have yet to acquire.

Learn from our mistakes

Not surprisingly, the stages we learned were through trial and error. May our trials and errors flatten your learning curve Here is a quick rundown of what is to come.

If Stage 2 (Keep it running – becoming a Meaningful User) were a book, its opening line would read, “We don’t need no stinkin’ badges.” Becoming a Meaningful User to qualify for reimbursements is the goal of the current incentive program. The push toward interoperability across IT systems with a goal of unimpeded access to patient health information has led many of us to adopt this technology.

Yet we don’t understand the true complexity of managing these information systems, once they are running, after the EMR vendor has left the building. The incentive for EMR reimbursement is not simply the purchase of an electronic medical record application; the incentive is to become a Meaningful User of medical record technology, and the reimbursement requires attestation and data evidence collected by an EMR.

Becoming a Meaningful User is not easy. Many EMR adopters find themselves on the horns of a dilemma today because they gave little or no thought that IT management would play into their EMR adoption. Because they chose too quickly without factoring in the challenge of managing complex technology, they are now contemplating ‘ripping and replacing’ instead of choosing an adaptable system this time around.

If Stage 3 (Get legal/stay legal – maintain continuous audit readiness) were a book, its opening line would be, “If you come to a fork in the road, take it.” Thanks to more regulatory mandates, IT management has expanded into compliance management and extends well beyond “keep it running.” The challenge for IT managers is how to interpret mandated regulations relating to the practice’s individual and unique IT footprint.

Your IT footprint extends well beyond the walls of your practice and includes all external connections where the exchange of information takes place. In addition, key service providers whose exposure to patient information occurs as part of their service delivery must also be managed as sources of risk and noncompliance. There is no prescriptive method for attaining and maintaining compliance of your IT systems. This is because every implementation has its own IT decisions, every legal interpretation of the mandate is conducted by the partners with strategic counsel (hopefully) and every IT manager brings his own level of expertise unique to his profile.

Sadly, continuous audit readiness by your IT department will be “A Bridge Too Far’”for many practices. We will explain why in part 3.

If Stage 4 (Continuous improvement – become a Process-Centric Practice) were a book, its opening line would be, “The long and winding road,” and its ending would be, “And miles to go before I sleep.” Stage 4 is where all of us hope to end up. It includes:

• Adopting technologies beyond an EMR

• Automating and building the practice beyond paper-based workflows

• Using technology to amplify competitiveness through improved productivity and performance (it helped us become a premier practice in the area).

The first discovery

Our foray into acquiring IT talent began with the decision to hire an IT manager, which worked well initially.

With our EMR implementation project, we figured we would only need “traditional” IT talent: hardware or server setup and maintenance, network and firewall service and support, and so on. But we discovered during the process of evaluating and selecting the EMR that what we needed wasn’t IT management alone but also IT project management talent. We needed someone to sit with us while the EMR vendor’s project manager sat on the other side of the table. We needed an advocate who would keep suppliers honest and hold them accountable.

If our practice had not had both types of IT managers in place, we would’ve been hoodwinked. This will be a major point of emphasis throughout this series: Depending on your IT maturity level, know that only looking at the “keep it running” competencies puts you at risk. Other management competencies will be required.

Remember the question and answer we first posed: How you hire an IT manager will depend on where the practice is in terms of its unique IT needs. A simple recipe or a checklist won’t do.

It can be costly to hire an IT manager from a checklist, then realize that the checklist isn’t complete. Another way a wrong hire can be costly is in terms of IT compliance management. The HIPAA Security Rule will rock your world regarding IT. If you’re not hiring with this in mind, it might lead to unpleasant surprises.

Stage 1

For the next article, we drill into Stage 1 – EMR adoption. Since most of you have or will have EMRs, this will be expanded beyond discussing initial EMR adoption and include recommendations when faced with a decision to replace an EMR, AKA “Rip and replace EMR adoption.” Many of you could be considering replacing your EMR or forced into it because your EMR is no longer certified under Meaningful Use, or your cost to upgrade, according to your vendor’s requirement, is so expensive that you want to comparison shop.

Key takeaways for Part 2

Key takeaway #1: IT management’s mission is to improve productivity and performance through effectiveness and efficiency. Effectiveness is doing the right things. Efficiency is doing things right. Productivity is a word that everyone tosses around, and it sounds good, but productivity can be measured, a fact that escapes most people. The metric often used to measure productivity in businesses outside of health care is the number of full-time employees (FTEs) divided into gross revenue. So the quotient is revenue per the FTE number. FYI, revenue/FTE goals hover around $300,000-$350,000 in other verticals.

The proper enabling technology is acquired from a desire to produce better outcomes. Better outcomes happen due to better process management, better productivity, better performance, better profitability and quality of care.

Key takeaway #2. If you’ll recall, with our first EMR purchase, we hired a full-time IT director to sit beside us as we negotiated with EMR vendors. If you don’t negotiate properly with your vendor, the end result will be a wide chasm between what you want, what you expect, and what you get. In the words of IT contract land, this is often referred to as “Works as promised” vs. “Works as needed.”

Key takeaway #3. IT management is not project management. The two aren’t interchangeable. Even though most IT engagements are crafted as “projects,” most ophthalmic practices have little to no experience in managing IT projects. If your IT manager’s sole expertise is in day-to-day operational processes, you must acquire project management talent.

Key takeaway #4. “Works as promised” does not automatically ensure “works as needed.” “Works as promised” is what I would call the “letter” of the agreement, the legalese of an agreement. “Works as needed” is what I would call the “spirit” of the agreement. This is true with any IT vendor. During negotiations, an IT manager must help the practice create requirements so that “Works as needed” is assured; otherwise “Works as promised,” even though legally fulfilled by the vendor, does not deliver what you expected.

When you and your partners are negotiating, your IT manager needs to tell you about the implications of your decisions and enable the smooth transition. The reason technology fails is not because it doesn’t work: It fails because the users reject it. The users reject it because it doesn’t work as needed. It quite possibly works as promised. IT management talent must be more than just a technically capable person who knows how to get it running and keep it running.

The promise that your technology “works as needed” might not be entirely met if you rely on the three priorities common within the discipline of project management: “on time”, “on budget” and “within scope.” After implementation, “works as needed” is not a concern. A project manager’s job is to go live with the technology by date promised for the dollar amount promised and within scope, per the contract’s requirements. That is why equal capabilities in IT management and project management are the best way to hedge your bet. OM

About the Author
	Peter J. Polack, MD, FACS, is comanaging partner for Ocala Eye, a multi-subspecialty ophthalmology practice located in Ocala, Fla. He is also founder of Emedikon, an online practice resource for physicians and administrators. His e-mail is ppolack@ocalaeye.com.