the system user-friendly enough that an MD can order directly through the HIS, without requiring a nurse or unit secretary to intervene? This capability is the ne plus ultra of an HIS, separating the physician-friendly from the physician-unfriendly. Figure B illustrates the difference in process engineering terms, showing the steps required for a physician to order through nursing, versus directly through the HIS. It also points out how without direct physician entry, the prime users of most HIS systems are Unit Secretaries, among the lowest-paid and least technical members of the clinical team!

 Alerts - Hard costs savings are available if the HIS can trigger physician alerts when certain medications or procedures are ordered. Figure C documents a study done recently on H2 Blockers, which might be given either orally (PO) or intravenously (IV). For one hospital's volumes, the potential annual savings are in six-figures for this one item alone. Multiply this capability across the hundreds of items in the typical charge master, and the potential savings from such alerts are enormous.

Figure C: Potential Cost Savings Through System Alerts

To determine the effectiveness of physician alerts in its HIS, our hospital conducted a study of the use of H2 blockers. It has been determined that these medications are as effective when given orally as intravenously, enabling a significant potential cost savings. Of 140 patients admitted to the ICU during July, 1996, 136 charts were reviewed, and 34 patients had been prescribed with IV administration of H2 blockers. Based on the patients NPO status, it was determined that 314 doses of the drug could have been administered orally. Switching from IV to PO medication routes would have realized a direct medication cost savings alone of $1,800 that month, or an annual savings of over $20,000 for the ICU. With 16 nurse stations in toto, the potential savings throughout the hospital are in six figures for this one drug alone. Below is the alert that we have since designed to appear on order screens whenever a physician inquires into a patient whose drug administration route should be re-considered

Display Costs - If your HIS does not have the sophistication to handle such "artificial intelligence" or rules-based decision making, it surely can simply print the price if each item on the ordering screen to constantly remind MDs of the economic impact of their actions. In this member-per-month capitated world, physicians are extremely cost-conscious, and such a simple modification can reap rewards for both patients and providers.

KNOWLEDGE BASE

Deciding among alternative procedures and medications is a complex decision, especially considering the vast amount of new procedures and medications, and the pressure on a physician's time keep up with the hundreds of medical journals describing the latest research. To assist your hospital's MDs in prescribing the optimum treatment for their patients, an HIS should provide ready access to a number of knowledge-base resources and publications:CD-ROMs - exist for over 300 medical texts and data bases usually found only in the medical library (MicroMedix, BiblioMed and the Physician's Desk Reference are among the more popular titles). Modern technology can expand the access to these library resources, as electronic media break down the four walls of the library, enabling physicians to access its resources at any HIS device throughout the hospital. Relatively inexpensive "juke boxes" store the CDs, Local Area Networks transmit them, and the same PCs that act as HIS terminals display them via "hot key" inquiries.Internet - access is the ultimate knowledge-based tool, as the World Wide Web has literally thousands of medical web sites with:

• libraries of radiologic images of various media, eg: the Visible Human Project at the National Library of Medicine (www.nlm.nih.gov) or MRI and CT scans at GE's 3D Medical Reconstruction site (www.ge.com).
• "UseNet" groups where MDs can post conditions that patients present, and receive responses form colleagues around the world with potential diagnoses and suggestions.

Although daunting security issues (i.e., viruses, hackers, patient privacy...) preclude Internet access directly through an HIS (firewalls merely reduce such risks, rather than eliminate them), a few dedicated PCs in the Medical Library and Physician lounge can enable Internet searches in a controlled environment at a very low cost (about $20 per PC per month for unlimited access).Networks - IntrAnets or even simpler E-Mail networks can facilitate communicating among physicians for such mundane matters as staff meetings, published minutes, policy memos, etc. Although only a minor cost saving to the hospital to automate, they can be a tremendous boon to a paper-burdened MDs who receive, file and must retrieve dozens of such documents each day. 

MIS DEPARTMENT

Although not a daily occurrence, on many days, a physician may need to interact with the hospital's MIS department, an experience that can be as rewarding or frustrating as interacting with the system itself:

• RNs - at a minimum, every MIS department must have one of more RNs assigned as clinical system analysts, to spare MDs the trauma of deciphering the "computereeze" spoken by most computer programmers and operators. At smaller hospitals (<100 beds), there should at least be an "Informatics" specialist in the nursing department acting as an ombudsman for physician problems or questions concerning the HIS. At medium sized hospitals (100 to 300 beds), one or two RNs should be assigned full time to MIS to address clinicians needs and concerns. For the largest facilities (>300 beds), an exciting new trend is appearing:
• MDs - physicians themselves are being hired in many MIS departments, usually recruited from among the more computer-literate on the medical staff. In smaller facilities, they would be, at best, part-time, serving on selection and implementation committees, but at larger facilities, representing the medical staff permanently on MIS steering committees and in ongoing inservice and screen design capacities. Reimbursement for their time is an added but worthwhile cost to the hospital, as Managed Care has adversely impacted MDs' earnings as much as hospitals' precluding such work to be pro bono. The largest and/or most progressive facilities are hiring a physicians full time, either as CIOs or staff members of the MIS department, an admirable trend that costs the most but can pay back enormous dividends in intelligent screen and pathway design.

MD OFFICES

At this point in the typical physician's day, let us follow her from the hospital to their office, and see how additional links to an HIS can benefit both parties. Indeed, this introduces a new player in the story: the physician's Office Manager, as important to a physician as anyone except either depending on several key features of an HIS:

• Physician Billing - 1500 claim forms are as near to an MD's heart as UB-92s are to a hospital CFO's, and there are several key ways in which an HIS can facilitate their production:

- face sheets (admission forms) for inpatients contain information vital to professional billing, such as patient demographic, insurance and employer information (that's why they disappear so frequently from the front of patient's paper charts!). The ideal HIS should automatically print or FAX a copy of every one for the admitting physician's office manager, and greatly facilitate their re-printing for consulting MDs.- CPT4 and ICD9 codes are even more crucial to professional fee billing than hospital billing, with a diagnosis code required for every procedure, not just one per stay. Transmitting these codes, often assigned by Medical Records coders after discharge, whether electronically or via paper, can save office managers much time and trouble.

• Communications - Surprisingly, some hospitals inadvertently make it difficult for a physicians office manager to send them business:

- Scheduling outpatient procedures can be a nightmare of calls to multiple hospital ancillary departments, each of which operates autonomously, placing the office manager on hold, demands they repeat the same patient demographic data over and over, while they hand-write appointments into paper books. Woe to the office managers who has to re-schedule an appointment because the last department called in a day can't squeeze the patient in; one must then call each department all over again, be placed on hold, ad nauseam... The ideal HIS has a central scheduling module where a single phone call to a central location quickly searches for available slots and easily accommodates cancellations or re-scheduling.- Inpatient admissions are a similar bottleneck, depending on the nature of the MPI in the HIS: a good design enables the quick identification of past visits and re-calling of patient demographic information through such techniques as phonetic searches. A poor HIS causes a frustrating catechism for office manager: "How do you spell "Paderweski?"" and "What was their grandmother's maiden name?"

PHYSICIAN'S HOMES

Finally, long after most people are asleep in front of their TVs, a physician's typical day often ends up late at night in their home/office, with a beeper announcing a patient's condition turning critical or a phone call from a nurse station about an abnormality. Again, an HIS can be a help or a hindrance:· Remote Dial-Up - almost any HIS can allow MDs to dial-in to a bank of modems from a home/office PC to check the patient's condition or test results, but the devil is in the details:- Number and speed of modems - as with terminal devices, spending a few hundred dollars (popular brands are now under $200 per) to avoid busy signals and having new, fast modems available is a must: 28.8 and 33.6 bps are now de riguer; 9600 or 14.4 bps are slugs on the electronic superhighway. Anyone who ever signed on to AOL or CompuServe at such outmoded speeds can imagine the frustration an MD experiences navigating through the numerous screens of an HIS in slow motion.- Security Codes - the challenge here is to balance undue restriction with excessive laxity. Granted one must be cautious about hackers & break-ins, but the number of ID codes and sign-on complexity must be commensurate with the desire to entice physicians access. Also, allow MDs to pick their own ID codes to match ones they use on their office PCs and other systems, which minimizes the number of codes memorized or scribbled on stick-up notes pasted on monitors (how secure are they?).The most crucial areas to improve security with regards to MD usage: an HIS should automatically sign off a terminal if it is left unattended for over 10 minutes, as busy practitioners are thinking more about their patients than the needs of a computer operating system. Also, security codes should be changed periodically (e.g., every "x" months); try signing on to your HIS using the password of "Nurse," "Doctor" or "Test," and you'll see how often anyone updates your HIS' codes.· Automatic Facsimiles - this simple device is common in many ancillary department computer systems (eg: DEC's "VAX to FAX" capability), and it can save a hospital the cost of having clerks carry paper result slips to FAX machines for scanning and then manually dialing an MD's office. It can be a boon or bane to MDs, however, depending on how it is implemented:- FAX all test results for all departments (Laboratory, Radiology, etc.) and sub-departments (Micro, Hematology, etc.), and you will bury the MD and/or their office manager in a blizzard of curly paper.- FAX only abnormals, that exceed pre-determined values for critical tests in selected departments, and it can be a great service.

HOSPITAL CHECKLIST

All of the above physician linkages are recapitulated in the survey form in Figure D . It was designed as a tool to enable financial managers to rate how friendly their information systems are to their physician community. There are no passing or failing grades on the 200 point scale, but rather it represents a quantifiable measurement that enables a facility to take its temperature at a given point in time, implement a program to improve its HIS' physician relations, and then compare a revised score later to the original benchmark. As technology marches on, more lines will be added to such a report card, and a "good" score today might seem mediocre in a few years. However, the risk to a hospital for having a poor score on this checklist might be reflected in the hospital's bottom line far sooner than in a comparative survey or JCAHO report.

CONCLUSION

As Managed Care revolutionizes the Health Care industry, physicians have become business partners with hospitals: the source of income, through inpatient referrals and outpatient testing, and also in control of many expenses, through ordering of tests and discharge decisions. Such critical members of the Health Care team deserve extensive consideration in an HIS, not only in selecting and implementing systems, but in their ongoing customization and day-to-day use. Considering a physician's perspective in making mundane decisions, like the quantity and quality of terminals or printers, can have an enormous impact on their (and ergo the hospital's) productivity. There are some who argue that a hospital's true "customers" are its physicians, even more than its patients, since MDs are responsible for making most clinical decisions for patients. If that is true, then physicians should rank high up on the priority list among HIS users. In most of the criteria discussed in this article, it is not just the programs or features programmed into an HIS by the vendor that make a given system physician-friendly, but rather it is how they are implemented and supported by the hospital. The positive attitude and financial support of hospital administration can make a weak HIS appear physician friendly, while an unsupporting or uninolved hospital management team can negate a multi-million dollar HIS investment.

ABOUT THE AUTHORS

Margaret M. Quinn, MD, FACP, is the Director of Medical Informatics at Jersey Shore Medical Center, a 500-bed teaching facility in Neptune, NJ. She is Board Certified in Internal Medicine with added qualifications in Geriatrics.Becki Weber, CMPA, is Vice President and Chief Information Officer at Meridian Health System, a four-hospital Integrated Delivery System in Neptune, New Jersey. She is a member of NJ's HFMA chapter and the Board of Directors of NJ's HIMSS chapter.Vince Ciotti is a 28-year veteran of the HIS industry, a regular contributor to HFM's Journal and a frequent speaker at industry seminars. He is a Partner with the Information Systems consulting firm of "HIS Professionals," located in Boonton, NJ (www.hispros.com).

Reprinted with permission from the June, 1997 issue of Healthcare Financial Management.

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