Virtua is a multi-hospital healthcare system headquartered in Marlton, N.J. A non-profit organization, it employs 7,900 clinical and administrative personnel and has 1,800 physicians as medical staff members. Virtua is an early adopter of clinical and digital technologies, led on the IT side by CIO Al Campanella. Recently HCI Editor-in-Chief Anthony Guerra caught up with Campanella to see if HITECH was changing his strategic plans.
GUERRA: Can you give me the 10,000-foot overview of Virtua?
CAMPANELLA: Sure. Virtua has four hospitals with a little over 1,000 beds. We have a little over $1billion in revenue. We own 150 physician practices. We also have two nursing homes, a very large home health agency with 400 nurses, and we have two large ambulatory care centers.
GUERRA: And I would imagine there’s a large population of physicians down there that are independent and refer to the hospitals?
CAMPANELLA: Yes. We have 1,100 office-based physicians who are completely voluntary, and then we have another 600 that are employed by other health systems that also admit here, or they are hospital-based physicians such as anesthesiologists and pathologists, so roughly, 1,700 altogether. And then, separately, we have 150 employed physicians.
GUERRA: The employed physicians – the office-based physicians that are owned – are they allowed to refer patients to other hospitals or do they have to refer inside the Virtua network?
CAMPANELLA: No, they don’t have to refer to us. If we offer the service, then they’re encouraged to refer the patient here, but if we don’t offer the service, then of course, they can refer elsewhere.
GUERRA: How long have you been CIO of Virtua?
CAMPANELLA: Just 18 months.
GUERRA: Eighteen months, and were you a CIO before that somewhere else?
CAMPANELLA: No.
GUERRA: Did you come up in Virtua?
CAMPANELLA: No. The eight years prior to Virtua, I was a consultant.
GUERRA: But you’ve been in the industry for awhile?
CAMPANELLA: Yes, I’ve been in the healthcare industry for over 20 years. I guess 10 of those years I was on the operational side. I worked really at two places, John Hopkins Hospital and the University of Pennsylvania Health System. I did hospital and physician practice operations and some IT, and then I worked for the last eight+ years as a consultant, and the last year and a half here.
GUERRA: You certainly have been involved with the market for a long time. How would you describe the difference between the pre-HITECH world and the HITECH world we’re living in?
CAMPANELLA: I think, in the post HITECH world, there’s definitely a greater awareness that technology can be one of the enablers of true healthcare reform, and secondly, that there’s no question there’s a great need for data to be shared amongst disparate providers to truly provide patients with the high level of care they deserve. I think that the goal of the bill is really the sharing and the exchange of data between different healthcare providers – that’s the essence of it. The true end point is really sharing data across a continuum for more efficient quality care. The EMR itself is simply a means towards that.
GUERRA: What is the most difficult part of making that happen?
CAMPANELLA: I think the most difficult part is overcoming physician concerns about their workflow and productivity. Physicians in a community are paid on a pay-as-you go basis. So anything that is perceived as a barrier to their daily productivity directly effects their income. So they’re concerned that the use of a computer is, in some respects, minute by minute less efficient than just talking or speaking, such as dictation, or even just telling an employee in their practice to do something, to place an order, for example. That human voice is a very efficient tool compared to typing or using a stylus at a computer.
They do agree fundamentally that structured data, and having electronic availability of data, is very valuable, but it’s at the price of slower workflow for them. I do not think the cost of EMRs is really the barrier. It’s really the effects on their personal workflow. If they just lose a few minutes per patient because of working with a computer, that translates to having to work one to two hours at night to catch up – or seeing less patients – and to them, that’s unacceptable. If they found that computers made their life personally more efficient, then I think they would be buying them very easily, very readily.
GUERRA: Would you agree that currently the systems on the market do not make them faster?
CAMPANELLA: I would say they make them marginally faster, if they really know how to use them well. The systems have to be usually customized to meet their style of practicing medicine. Every physician has a slightly different style in how they practice medicine, how they obtain information from the patient and, in turn, how they record it.
Some systems lend themselves to a particular personal style and others do not – and I think they’re something to overcome in the industry. Now overall, their staff can pull charts more quickly – I mean, in fact, there is no pulling of charts – their staffs don’t have to pull charts for prescription refills, they can be alerted about possible drug interactions when they’re ordering prescriptions, they can have the chart accessible in the off hours when they get a phone call from a patient, so there’s a lot of other efficiencies outside the immediate office hours.
But within the office hours themselves, when they’re literally walking from room to room quickly and verbally recording what’s happening, as opposed to typing what’s happening, they feel their workflow can be slowed down.
GUERRA: Blumenthal says it’s not about making more money. Is that a winning argument with the docs?
CAMPANELLA: Well, I do think physicians, by and large, go into medicine to take care of patients and to help other people. They don’t want use EMRs to make more money, they just don’t want to use an EMR to make less money. They feel as though there’s a certain trade off that’s made between having data electronically available and having clinical decision support available as you’re documenting, versus being able to see the requisite number of patients that your practice needs to keep up with patient demand.
I’ve had a physician tell me, “I’m seeing 30, 40, 50 patients a day, and sure I want the data to be electronically recorded, but if I’m going to have that, but can see 10 percent, 15 percent less patients, then I have a lot of patients who aren’t happy, who can’t get to see me.”
GUERRA: But isn’t that exactly what you have to tell them? Isn’t that the reality of it?
CAMPANELLA: Initially, what my research from past years has shown, and what I tell my physicians, is that productivity will slow down anywhere from three weeks to three months, and then after that you should be at least on par with your pre-electronic days. Many physicians actually improve productivity by approximately 10 percent, to say nothing of all the off hours conveniences.
I’ve told them, “The learning curve is going to be three weeks to three months and then all of a sudden you will find yourself actually being more efficient at certain things and actually seeing more patients.” Almost every physician I’ve ever met who uses an EMR, after one or two years, says, “Absolutely, I would never go back to paper.” But it’s a huge, massive learning curve for the industry.
GUERRA: Do you think we are going to be successful overall as an industry?
CAMPANELLA: Absolutely, absolutely. I equate this to major transitions in modern history, going from the horse to the automobile, going from the telegraph to the telephone. I mean, we’re seeing a major sea change in how, in this case, medical documentation is done. There’s a learning curve for the industry, and there’s the normal resistance to change.
The younger generations who are entering medicine and nursing and other clinical fields absolutely have no resistance whatsoever to using electronic tools for their profession. You see the same thing in law where you still have an old generation of lawyers who still dictate, don’t know how to use email, really don’t know how to use any of the modern desktop electronic tools, whereas all the younger lawyers wouldn’t think of not drafting their own materials straight onto the computer. So I think this is very much a temporary thing. I think this will be a non-issue in about 10 years, a total non-issue.
GUERRA: But a painful transition for some.
CAMPANELLA: Yes, absolutely. There are physicians who feel as though they’re very successful and provide quality care without this tool, and that it’s being imposed on them. They have the right to those feelings.
GUERRA: Have you heard any physicians saying they will forgo the incentives, suffer the penalties, but stay on paper?
CAMPANELLA: I haven’t heard it like that. I mean, I think there’s concern. To address part of your question; I don’t think the incentive payments truly have an incentive effect. The incentive payments, first of all, are taxable income. So for most physicians, that means they’ll receive 40-50 percent less of what’s granted. There are also unknowns about the definition of meaningful use, as well as what reporting requirements will be necessary to qualify for the payments. So with all those uncertainties, physicians, I think, do not see those payments as an incentive. I think, instead, they just see that this is closing in around them and now’s the time to get on the bandwagon, but I don’t think the payments themselves are the incentive.
GUERRA: What about the penalties? Is anybody even thinking about those?
CAMPANELLA: They’re not even thinking about the penalties. I think the physicians are more concerned about the 20 percent Medicare cut that’s predicted. I mean, every year congress always repeals the Medicare physician office payment cuts, and this year I don’t think that’s going to happen. It was in the news just in the last few weeks. They’re very concerned about Medicare, the normal Medicare funding stream for that population, let alone any other long-term penalties for EMR lack of use.
GUERRA: Let’s talk about the lack of healthcare IT talent in the workforce. Have you come up against that yet?
CAMPANELLA: Well, two parts: one is I am very fortunate here at Virtua to have an extremely talented IT team. So I have not personally felt that. Nationally, I think that what you described is the case. Certainly, there’s this huge growth curve, and it requires individuals who can blend workflow and technology into a meaningful combination of tools to improve patient care in the office.
You have to have someone who really understands what healthcare delivery is about in ambulatory settings, and what the culture is in a physician office and working with patients. They also must understand how you can adapt technology appropriately. The others that surround informatics in a classic sense, such as people understand coding, understand the value of structured data, but do they understand how to create metrics for evidenced-based medicine – I think there’s a lot of work to be done in those areas to create people who have those skills.
You need to have the knowledge of the industry, as well as knowledge of analytics and data management. So I think there is a shortage of those people, especially in the larger health systems that are obviously investing lots of money in acute care, especially acute care EMRs that want to do evidence-based medicine based on all the structured data they’re collecting as part of the EMR process. Do they have people who value and understand the life of a health system but also can translate that into queries and analysis that make sense and are meaningful and then can then be used for evidence-based improvements within the organization.
I think those people are a lot harder to come across. Now, I think you see more and more physicians and nurses getting Master’s degrees in MIS, and it’s becoming a bona fide of a specialty within the medical and nursing world. And just so you know, we have at least five (officially, three) nursing informaticists, and I have two medical informaticists, and they’re both physicians, and I have at least seven nurses who are now in the IT world. I don’t call them informaticists, but they’re very much like that. So in most larger IT departments of healthcare, you will find expatriates from nursing and medicine who now live in the IT world.
GUERRA: Do you have a strategy to protect your staff from poachers?
CAMPANELLA: Virtua has what we call our BEST PEOPLE program which involves compensating individuals at competitive rates. We also highly encourage and financially support educational development, and we also support career growth within the organization. So it’s very common for us to promote people within the organization and plot a career path. Those statements can be true for any kind of well-run organization.
The other thing we do is really around our culture. And to stress that, the advantage of working for a health system – as opposed to a software vendor or consultant firm – is that you can really see the fruits of your labor and really become part of the fabric of the organization. My department is not viewed as just a support department, we’re viewed as an operations department. People see us as critical to the operation of the organization; as much so as nursing would be.
So it’s important for executive leaders in the provider healthcare world to make sure that their IT folks are really valued and promoted as critical to the organization’s mission. With that, I think you’ll generate a lot of employee loyalty which, quite frankly, is more important than just monetary compensation. It’s critical they really feel part of something very important in their community.
