One-on-One With North Shore Long Island Jewish CIO John Bosco, Part III

April 10, 2013
At the end of September, 13-hospital North Shore-LIJ Health System announced it was subsidizing up to 85 percent of the cost of implementing Allscripts ambulatory EHR in the offices of its more than 7,000 affiliated physicians in New York City and Long Island, constituting a $400 million investment.

At the end of September, 13-hospital North Shore-LIJ Health System announced it was subsidizing up to 85 percent of the cost of implementing Allscripts ambulatory EHR in the offices of its more than 7,000 affiliated physicians in New York City and Long Island, constituting a $400 million investment. Specifically, the plan calls for North Shore-LIJ to provide physicians with individual subsidies of up to $40,000 over five years. To learn more about the project, HCI Editor-in-Chief Anthony Guerra recently talked with CIO John Bosco about the strategy behind this massive tactical move. (Read a related interview with Allscripts CEO Glen Tullman)

(Part I, Part II)

GUERRA: In terms of your deal, where will the practices get the change management advice, the information about implementation best practices? Will they get that from AllScripts?

BOSCO: I think, for the most part, they’re getting that from Allscripts. I think we’re going to have some level of involvement. I mean, Allscripts is contractually going to do the installation. The package that we worked out with Allscripts contains onsite training at the office location and onsite activation presence. This is our name and reputation behind all of this, so we tried to do those things that we really thought were going to make it successful.

Contractually, Allscripts has a lot of responsibility, but we are behind the scenes working to make sure we’ve designed a successful program. We have our quality group at the health system, called the Institute for Clinical Excellence. We have a couple groups in that institute, one that we call the Evidence Based Medicine Group and another one that is focused on workflow. And so they’re behind the scenes working with us and Allscripts to say, “You know what, the system that we’re going to put out in all of these offices, we want to make sure that the Evidence Based Medicine Group is looking at clinical content and the care guides, the clinical practice primers, as we’re calling them,” so we’re going to be looking at these care guides and making sure that they make sense.

And then we also have a group that is looking at the basic setup of the system, and the work throughout the system, to make sure it’s adequate, and that it’s efficient, and that it’s one that we think will suffice for a large majority of the practices without having to tweak it. So we’re doing everything that we can. We’re not just saying, “Allscripts, go in there and do whatever the heck you want.” We’re trying to work together with them so this is successful.

GUERRA: What’s the current best practice for getting the old paper records into the EMR? Do the docs ask about that?

BOSCO: They always ask because that’s always high on their priority list, this overflowing chartroom that’s taking up so much space. Since there’s only so much we can cover in a demo, we’re not really giving them complete information about it because we only have them for a couple of hours. What we do tell them is that there are some best practices, that if they decide to sign up, that’s one of the first things Allscripts will do. Again, they come and they do an assessment or a readiness assessment and they do an implementation plan with the physician, and that precedes access to the software. So during that assessment and plan, they start looking at their current workflow, bringing best practices to them, talking about what to do with charts, talking about how to best setup the workflow – whether, for example, there are medical devices that you’re going to want to connect to this or to hold that off for a later phase – but we discuss all of these things and that includes what to do with the charts.

So I mean, I guess there’s best practices, but it’s individual to everyone because what a solo practitioner might do is going to be different than what a 75 physician practice does. It all comes down to, “Do I want to scan all the charts or only a portion of them? Am I going to scan the whole chart or just abstract certain data elements and attach those to the records?”

You have to decide how much of these charts you really need to get electronic and what’s the cost/benefit. Those are tough challenges, and I think that Allscripts, with this being their primary line of business, does have best practices and does have ideas to bring to these guys. And as I even said to them recently, this gets very expensive in terms of what to do with your charts. There are some things that we’re not allowed to subsidize, such as hardware and people and charts scanning and all that stuff, but we will certainly help them think through the best things to do.

GUERRA: I know Eclipsys is now your major inpatient system, and you have Allscripts in the ED and some practices. Just take me through your overall software environment.

BOSCO: Sure. We made a decision five years ago to use the Eclipsys Sunrise Clinical Manager as our EMR, and we are still on the process of rolling that out. We’ve got pieces of it up at five of our 13 hospitals, and that project has proceeded along really well. It has been very well-received by the physicians and other clinicians who are heavily involved. And then I have to make clear it’s not an IT project, it’s a major enterprise initiative. I mean, I really feel lucky that I’m in a place where everyone is bellying up to the bar to do this, and it’s not IT dragging everybody through it.

At some point, we realized that the Eclipsys ambulatory product wasn’t the right match for our ambulatory physicians, that it wasn’t necessarily designed and intended for the very small physician practice. I don’t think Eclipsys would disagree with that. As a matter of fact, they went out and acquired the product they’re now calling Peak Performance, the MediNotes system, as their offering to the small physician office. We made our decision right before they did that, and so that wasn’t really in the picture.

I think the original vision was of one integrated clinical system for the ED, ambulatory and inpatient environments, but at some point we realized we were large enough and complex enough that we really needed the best-of-breed product for each one of those environments. And so, really within the past year, we acquired the Allscripts ED system and we’re rolling that out. A few months ago, we signed the agreements with Allscripts, really two separate agreements, one to install the enterprise EHR for our 1,200 employed physicians who are a part of a faculty practice plan, and that was a typical IT contract. And then this community program which is not a typical IT project, it’s very different from that, it was really a unique partnership with Allscripts. We set up this whole program for the community physicians where we have certain responsibilities, as it relates to marketing and governance and strategy and those kinds of things, and Allscripts’ delivery people are doing all the contracting and implementation, et cetera.

So we’re really running, essentially, concurrent EMR programs, and the bags under the eyes of my staff will attest to that because HITECH has really sped up the dates for wanting to get some of this stuff done, if you want to optimize the incentive money. We’re speeding up our inpatient rollout. We were almost going to make it anyway, but we’ve had to speed it up, and now we have additional hospitals that are coming onboard. We’re speeding up on the inpatient side and, for our employed physicians, looking to get it installed so we can take advantage of the incentive money.

At the same time, we’re going out to the ED – which isn’t on any kind of an ARRA timeline – and then this community program, which is, because any of the physicians that can sign up and get this implemented in time will be able to get their incentive money. Those who wait a few years, either they’re going to get less or they’re not going to get any.

GUERRA: Running a healthcare system is getting pretty expensive.

BOSCO: Yes. I mean it certainly is. We’ve never looked at this in terms of a financial ROI, and we don’t even really understand what the return is going to be. This is purely a quality initiative. And as I said before, if we’re able to be successful with A, B, C, D and E, making physicians more efficient in measuring and managing quality, and we reduce unnecessary testing in our facilities and by the physicians and all of these things, we believe we will eventually bring down the cost of patient care, and that everybody will somehow benefit. But we absolutely did not do a financial ROI. I don’t even know how we would do one at this point. It’s the vision of our leadership that made us do this. We need to take on faith that we’re all going to benefit from this down the road, in terms of quality and safety and everything else, that we’re not doing this for financial reasons and there were no calculations.

So it is a really expensive initiative, but we feel that it’s necessary. We don’t believe that in this country the quality is where it needs to be or safety is where it needs to be. We know that New York State is one of the highest states in terms of utilization in the country, and that Long Island happens to have one of the highest concentrations of subspecialists in the country. And so we were one of the first, if not the first health system in New York State, to start reporting our quality data voluntarily on our Web site.

Before there were any regulations about it a year ago, two years ago, our CEO said, “We have to be upfront about what our quality is, we’re going to be putting numbers out there, and people are going to see those numbers. They’re not what we want them to be, we’re not proud of them. We don’t think most places ought to be proud of what their numbers are, but this is the way things are going and payment reform and pay for quality and performance and all of these things are coming down the pike. And so we better start thinking in a new way and getting used to it.” One of the early steps that he wanted to do was to put our quality data out on our public Web site for everybody to see.

And so this is the kind of forward thinker that (NS-LIJ CEO) Michael Dowling really is. He’s looking forward and saying, “As payment reform comes down the pike, we may need to start thinking about bundled payments for episodes of care that are going to cross providers and practitioners, so we need to be ready for this. We’re not going to really move those quality and safety numbers very much without something to enable that to happen, and we believe that the EHR is an enabling technology.”

So I think he’s just looking forward to what the healthcare world will look like five years from now, and he’s saying, “You know, we need to do this. We need to get over this hump, and if we’re going to be a true leader as a health system in this nation, and be able to demonstrate what can be accomplished by appropriate sharing of clinical information, we need to invest in the EHR.”

We have, like most health systems, a capital allocation process and committees and things that look at the best ways for us to allocate and use our available capital dollars. So actually, usually, that process does involve financial reviews and looking at returns on investment and all of that. In this case, we bypassed some amount of that, or certainly the whole financials, but we went in there and we made the case to the capital committees and to our board and everybody as part of the approval process. We made the case I just said, that this is about quality, and this is about a vision, and this is about us being where we want to be a few years from now.

Yes, there probably are some initiatives that we’re going to hold back on. I mean, with the economy tanking last year, everybody got nailed. A lot of CIOs I talked to had their expense budgets cut. They had all of their capital taken away in many cases. We looked at our capital, and looked at where this fits in, and felt that this is one of the most important initiatives we’re going to do as a health system over the next few years, so it went very high on the capital list, even though we have a lot of capital priorities.

We are involved in one of the biggest construction and building programs that we’ve ever had. We’re building a couple of new women’s hospitals. We’re adding towers on our existing hospitals. We’re rebuilding a lot of our hospitals and infrastructure. We had to scale some of that back because of the economic downturn, but we’ve been able to keep the most important things, and I actually think it’s a testament to how important we really believe this initiative is, that even with everything we’ve had to scale back, we still put this very high on the list. So this is something we have to do.

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