Editor’s Note: The following has been edited for clarity and concision.
Implemented EHRs and telehealth in multiple states
Chief Information Officer/SVP of Planned Parenthood of the Great Northwest and the Hawaiian Islands
Robert Napoli is a healthcare leader with over 20 years of experience in strategic development, business transformation, and technology innovation. In his current role as CIO/SVP of Planned Parenthood of the Great Northwest and the Hawaiian Islands, he is responsible for the technology and information systems serving users and patients in Alaska, Hawaii, Idaho, and western Washington. Within the past year, he has overseen the successful merger with the Hawaii affiliate, the deployment of the organization’s first mHealth app, and the expansion of the organization’s telehealth services.
Napoli holds a master’s degree in Information Technology Management from Franklin Pierce University.
On a technical level, how difficult was it to bring an EHR into an area for the first time?
Comparatively speaking, not nearly as difficult as the other merger and acquisitions I’ve worked on. When we merged with the Hawaii affiliate in February 2015, they had tried for several years to implement an EHR but didn’t have the infrastructure or the leadership to get it done. So there clearly was a desire to do this, and there was a lot of support and enthusiasm for the project. My affiliate had merged with Alaska a few years before and understood the logistical and workflow challenges this would present. We also had the expertise and financial resources to support this expansion. I helped lead acquisition initiatives at two medium-size acute care hospitals and had seen the complexity and challenges of both a rip-and-replace approach, as well as a full-scale integration between existing systems. In our case, the EHR and practice management platforms were already in place, so we didn’t have to go through a formal software selection or mapping process to define functionality or requirements – this reduced the complexity considerably.
Was there initially a lot of pushback from providers?
No, not at all. As mentioned, the Hawaii affiliate had struggled with their EHR deployment for some time, and they were eager to get this off the ground. We were very collaborative with them during our planning process and wanted to make sure that their concerns and questions were fully addressed before proceeding with the implementation. We knew that our end-user adoption was dependent on providing a system that worked best for them. Only after our providers and clinical leadership were comfortable with the approach, and clearly understood the deliverables, did we order equipment and begin our deployment.
Were you responsible for bringing telehealth programs into Planned Parenthood of the Great Northwest and Hawaii? Is telehealth something Planned Parenthood is using regularly now, at least under your watch?
When I was hired in July 2013, our telehealth strategy wasn’t very robust and was limited to a handful of providers that could service our patients with access barriers in Alaska. One of the biggest challenges of utilizing telehealth solutions is making sure that your services are covered and that you will be reimbursed, which varies by state.
In our service area, only Hawaii and Washington provide both Medicaid and private-payer coverage for telehealth services. Alaska and Idaho will only reimburse telehealth services for Medicaid patients. These inconsistencies and other restrictions have stifled our ability to land on a more cohesive and comprehensive telehealth strategy in the past. This is starting to change as we explore other opportunities offered by telehealth technologies.
Over the past six months, we’ve expanded our use of telehealth in some non-traditional ways – at least for us. One of our challenges was meeting demand for walk-in appointments, especially at our busier clinics. Appointment scheduling could also be problematic for a variety of other reasons, including patient arrival time and service time variability. We realized that we could address these issues by redirecting our non-surgical patients to health centers with greater availability. However, this wasn’t feasible in a geographic service area that spanned hundreds of miles – telehealth technology was the perfect solution for this. By installing telehealth workstations in each of our Washington health centers, training our providers how to use the system, and redirecting these overflow patients to the telehealth option, we’ve been better able to meet the needs of our patients while utilizing staff that might otherwise be idle. Given the success of this program, we plan on expanding it further in 2016.
Can you provide details on the mobile health program? Are you using health apps to aid in providing care?
In August of 2014, in partnership with the Minnesota affiliate, we launched the federation’s first mobile health app. Originally dubbed Planned Parenthood Care, the technology allows patients, either through a smartphone or computer, to have a secure, real-time, online visit with one of our providers. Our initial deployment was intentionally very measured with only a couple of different services offered. We wanted to make sure that the technology could support a myriad of devices, connection speeds, and workflow changes – things that are difficult to simulate in a test environment.
At present, patients have the option of receiving a birth control or sexually transmitted disease (STD) consultation. A virtual visit starts with the patient downloading the free app for their Apple or Android device or by going to our website and entering their state of residence. The patient is then invited to an office visit with a medical provider that takes an average 15 minutes to complete.
Patients receiving birth control consults are given a choice among three options, which is discreetly and conveniently mailed to them. Patients seeking treatments for STDs are sent an at-home test kit, which requires them to return a urine sample through the mail. Depending on the diagnosis, patients who test positive are either sent medication or urged to visit one of our health centers for more advanced treatment.
Since our initial launch, the program has been adopted by our California affiliates, with more affiliates coming onboard this year. Currently, we are in the process of redesigning the platform to include additional services and more robust features.
What does it take to get approval and funding for any new technology-based project?
Having a seat at the executive table helps a lot. I am very fortunate that the executive team, or what we call the Strategy Team, values what our group brings to the organization and considers technology an integral part of our strategic plan. They also have a lot of faith in me and my ability to recommend the right solutions given our business objectives.
Our governance process is less formal than many organizations, but it works. Technology requests, whether they come out of our Strategy Team discussions or from somewhere else in the organization, are summarized and discussed at our annual year-end capital budget meetings.
Prior to these meetings, I meet with my leadership team to get their perspective so that I have a thorough understanding of all the potential risks and benefits of each request. My team’s track record of delivering these projects successfully with real, measurable value is excellent – so I have a lot of credibility with the Strategy Team, and they place a huge amount of trust in me when we meet.
At our governance meetings, I outline the submissions and walk the Strategy Team through a discussion that maps the request to our strategic plan. Naturally, we talk about the risks, rewards, and benefits of each particular project, but ultimately the request needs to be aligned with our strategic plan. If it is, and we have the funding, it gets added to our project portfolio.
We don’t consider many requests mid-year if they haven’t been discussed at our governance meetings. This process helps keep our project portfolio on track and our technology spend within a predictable range. However, we also need to be nimble enough to pivot when the unexpected happens – the Hawaii merger, was one such project.
Is it difficult to work for Planned Parenthood with so many extreme criticisms placed upon the organization?
I try to stay out of the politics of our business. The most controversial aspect of what we do is an extremely small part of the services we provide. Although smaller in size and scope, my current role is not much different than my experiences in much bigger healthcare organizations. At the end of the day, I know that the work we’re doing is improving the health of the people in our communities, and this is the driver that motivates me.
Connected medical devices to the EHR
M.D., Senior Vice President, Clinical Improvement and Chief Information Officer, WellSpan Health
Dr. R. Hal Baker has been with the WellSpan health system in York, PA, since 1995, serving initially as associate program director for their York Hospital’s internal medicine residency program. Presently, in his role as CIO, he is one of the leaders at WellSpan responsible for the implementation of new technologies. In 2011, WellSpan Health earned an award for its patient safety connectivity measures, when they successfully connected infusion pumps and other care devices directly into the EHR.
Dr. Baker holds a bachelor’s degree in biology and received his M.D. from Cornell University
Can you detail the connectivity project you worked on at WellSpan Health?
We are, I think, the first hospital in the world to utilize bi-directional interfaces with our IV pumps. We did that with Cerner. We had this closed loop established where the doctor is putting in the order, the pharmacist is verifying it, the order is going directly to the IV pump, and then the pump would run – it then feedbacks to the electronic health record the timestamps of when it ran and when it was paused. It also gives details of how much of a drug was administered.
We have this full closed loop where human beings are removed from programming pumps or documenting what pumps did. We thought that was a really nice safety integration, and we have subsequently done this with a lot of our different devices – our balloon pumps, ventilators, telemetry monitors all feed into the electronic health record. And even our vital sign monitors are connected on certain floors, which has really sped up our input of data, because it removes some of the clerical errors – a computer inputs data much more reliably, and it does it much more quickly.
What types of measurable improvements have you seen?
We have seen significant improvement in our sepsis mortality rates. We’ve seen reductions in our observed sepsis mortality year to year and, while our severity-of-illness documentation has gone up, our observed have gone down. We told our board, we think there are over 70 patients in our community who have survived based on the improvements we’ve made, compared to what would be expected.
We think there’s improvement there, and a lot of it comes from leveraging the electronic health record. I think the reason you have a doctor and other clinical leadership leading these initiatives at WellSpan is because we view the electronic health record as not something that solves problems, but as a tool that can be used to deliver better care. It’s not the tool itself that improves care; it’s the desire to place that tool in the right combination of people, process, and opportunity so that it can make a difference.
From a technical standpoint, how difficult was it to get your EHR to connect with all of these devices?
The IV pumps were a very complicated effort. We did that in conjunction with Cerner and Hospira at the time. We have since moved to Alaris pumps. But we were at the forefront, so you had to have a lot of collaboration. We actually received a collaboration award for barcode-enabled patient safety at the 2011 UN Summit. Barcoding was the key for us to linking the machine to the patient and to the record. We got what’s called a Way-Paver Award for our collaborative efforts.
I really think we had great collaboration between the medical vendors and our team. It was not easy – any time you’re doing something brand new, it’s never easy. Fortunately, it’s now going to be easier for everybody after us.
Where did this idea stem from?
It was the brainchild of a lady named Eva Karp at Cerner – she’s one of the senior vice presidents there, and she approached us with this as a development opportunity. It’s been nice. We’ve had people come from multiple countries to look at the connectivity workflow for themselves.
For us, this was a chance to really do something interesting, but the real value was that it changed a process that involved a nurse poking at a computer and took that aspect away – so now if there’s a cardiac arrest, we can focus on the patient. It allows people to get away from having to tell one computer what another computer is saying, and it automates that process and frees up time for staff to talk with patients while the computers talk to each other behind the scenes.
Was the connectivity hard to sell to the board?
Actually, no. Our board has challenged us to leverage the electronic health record to improve care – not just put it in, but to really leverage it for better care. I think the idea was sold as the right way to put in smart pumps, and a chance to do something innovative and creative. This was a commitment to improving quality, and the value came from increased patient safety and a reduction in errors.
As an M.D. and a CIO, why is it that we keep hearing that physicians have an aversion to a lot of medical technology?
I don’t think doctors have an aversion to tech; they have an aversion to tech that interferes with what they’re doing. For example, we deployed Nuance Dragon Medical voice recognition for our doctors, not because we wanted to reduce the cost of transcription – though it did do that. We implemented it for two other reasons: One, doctors don’t type well, and this would allow them to put their words into the notes. And another reason is we wanted notes that could be read and easily understood.
The written notes we would traditionally get from doctors may be good for billing, but they don’t always tell the patient’s story well. We wanted to use spoken language to tell a story in the record, so the person reading it could know the background and maintain that continuum of care we’re aiming for.
So, this Dragon strategy was not something we built or rolled out; there was a demand for it from the clinicians. We funded it by making the argument that this will allow us to produce notes worth reading. And because Dragon fit right in with what the doctors were already doing, they took to it pretty well.
As far as doctors being averse to technology – when I have a da Vinci robot or some new surgical tool, I have no problem getting the surgeons to use that! They’re not averse to technology; they’re just averse to technology that slows them down or interferes with their ability to provide the care they aspire to for their patients.
What does it take to make sure you have the right leadership in place to take on these projects and make them a success?
If you look at WellSpan’s core leadership in IT – of the four of us, three of us are clinicians. The senior leadership at WellSpan is full of clinicians. Our CEO is a physician, and several of our senior vice presidents are also, and I think for healthcare that makes a lot of difference.
What’s the next project you’ll be undertaking at WellSpan?
Our next plan is to implement Epic and to do so in a way that improves care. We’re calling it “Project One,” because we are seeking to come together as one. If you look at our motto on our Web page (“Working as one to improve health through exceptional care for all, lifelong wellness and healthy communities”), it’s about working together. And so, this project will allow all of the parts of our community to be on one shared record, so that patients who touch us at any point will feel like they’re connected – and wherever they go, they feel like we know them.
Where we are distinguished from others is our connectivity and transparency – we have an open patient portal that’s focused on what patients want and what doctors can get comfortable with. Our success has come out of strong clinical leadership with an imperative to leverage technology to make care better, not just leverage technology for its own sake.
Upgraded the ER with voice recognition
R.N.-BC, PMP, CHCIO, CIO, and Vice President, Clinical Informatics and Transformation, Western Reserve Hospital and Health System
Pam Banchy currently develops and leads the implementation of all IT solutions across the Western Reserve Health System in Cuyahoga Falls, OH, with a stated mission to support hospital and physician practice-based business needs. Banchy has recently unified IT teams to provide support within an integrated service delivery model. She has also provided oversight and leadership for all regulatory incentive programs for both hospital and eligible providers for Stage 1 and 2 Meaningful Use.
Recently, Banchy and her team undertook a project to implement voice recognition into the emergency department workflow at Western Reserve Hospital. Doing so involved coordination with local fire departments and ambulance companies to ensure all technology used to send information was compatible and patient focused.
What technology did you leverage to make this emergency room project a success?
It was a large-scale project the IT department recently undertook to implement our organization’s C.A.R.E. One EMR, including voice recognition, into the emergency department workflow. For the project, we used McKesson Paragon – the existing software which is utilized for our inpatients and across our organization.
What types of fears are associated with adopting new tech, and how do you address those concerns?
Technology on its own creates apprehension, and it’s always a challenge to get buy-in from the staff. You have to convince them that new technology will help them do their jobs better – we focused on that aspect to gain support. We showed the ED staff the benefits of the new technology and how it would improve patient care, improve safety, and ultimately make the department more efficient.
As this process would change the previous workflow, we also had to consider the impact of that change on staff, and the potential decrease in time for direct patient care to both learn the new technology and to enter data – something the clinicians and patient access staff had to do in new and, at the outset, what seemed to be duplicative ways. The demands of the implementation – namely data entry – could also create delays in treatment. We considered patient impact first and foremost, and created a staffing plan that would ensure safety and quality would not be impacted during the transition. This was complemented by a robust education and support plan – lots of “boots on the ground,” so to speak – to make the ED staff feel confident there were trained users close at all times to rectify errors and ease tension.
Are you seeing measurable improvements?
The implementation has led to a number of positive, measureable improvements that support our patient-centered mission. With the new technology, two key metrics were paramount for us: There has been a decrease in the time from door to doctor for patients entering our ED, and we have a marked increase in patient safety as evidenced by the decrease in both medication events and mislabeled lab specimens. Another interesting result of implementing the new technology was our increased ability to see more patients in the ED. The technology didn’t impede the speed of care or operations – instead it allowed for a more efficient process of registering, triaging, treating, and releasing patients. It eliminated some before-then unknown bottlenecks in the workflow.
How did clinicians react to the changes?
As a physician-owned hospital, we have a strong clinical leadership team that understood the ultimate benefits of the new technology and helped drive the project from the outset. Those doctors partnered with key nurses and other clinicians in the ED and, with guidance and support from my team, really championed the project. It was vital to have these end users show that kind of support, and it made every aspect of the implementation – from funding to vendor contracting, to training, and everything in between – that much easier.
As a CIO, how do you assure you’re building a winning team to work with?
I think it is important to lead by example and be sure your team reflects that same mentality. I wouldn’t expect them to do anything that I wouldn’t do myself, and our patient-first mission fuels everything we do. I work hard to ensure those on my team share this vision and our long-term direction of creating opportunities via technology that allow us to improve patient safety and satisfaction daily. My team gains my respect for their hard work and forward-thinking approaches, and I show that respect through my support. I make sure they have the tools and resources to do the best job possible, and I encourage their growth and new ideas.
Built a large-scale private health information exchange
M.D., CMIO, Baystate Health and CIO, Baycare Health Partners
Dr. Kudler received his medical training from the NYU School of Medicine and completed his residency training in primary care internal medicine at the University of California – San Francisco. He continues to provide primary care for HIV-infected individuals as a member of Baystate Medical Center’s division of infectious diseases. While serving at Baystate, Dr. Kudler helped to establish a large health information exchange (HIE) that would allow patient data to be shared freely between any provider office or hospital system that wished to join – free of charge.
The goal of the HIE is to reduce duplicate patient records and improve the accuracy and speed of care. Once implemented, it would cover over 1 million people in the larger Springfield, MA, area.
What was your motivation for establishing the HIE?
Baystate Health is an integrated delivery network (IDN) comprising five hospitals and more than 90 primary and specialty care practices. The organization employs over 900 physicians and advanced practitioners in the three-county region of western Massachusetts, serving some 800,000 residents. In the spirit of Meaningful Use and accountable care, we established a healthcare information exchange (HIE) platform to share patient data and imaging studies with clinicians who are affiliated with our organization – and those who are not. We know patients are coming to our facilities and also visiting other facilities outside of our network. As a result, they are at risk of receiving duplicate procedures and imaging exams. We decided to open up our HIE to other healthcare organizations to better serve the residents of our community.
In terms of the logistics, how difficult is it to establish an information exchange of this scope?
Starting with an EMR and associated applications that provide demographic, claims, and coding data, we elected to deploy InterSystems’ HealthShare platform. In partnering with this company, we built a robust clinical data repository that integrates and aggregates clinical information from Baystate entities and facilitates the interfaces with disparate data sources from other organizations and their respective EMRs. The challenge of standardizing the proprietary code language and data sets of the various EMR platforms had been addressed through our partnership with InterSystems, allowing for a comprehensive view of patient health information.
Were there federal dollars that you could take advantage of to help pay for this?
Under the auspices of Baycare Health Partners – Baystate’s affiliated physician-hospital organization (PHO) – several million dollars were invested to build a private regional HIE without state or federal funding. Like many healthcare organizations across the country, we did receive significant incentive reimbursement funding from CMS under the HITECH Act, based on our use of an EHR/EMR. However, that funding didn’t come close to covering the costs incurred in expanding to a regional HIE. In spite of this financial burden, we made the decision to invite outside hospitals and physician groups to participate at no cost to make our HIE both attractive and effective.
How difficult was it to get your own healthcare organization to approve and take on this project?
Fortunately, the leaders within our organization are very forward thinking. Since we are an IDN, funding an HIE was viewed as a strategic decision that cut across major entities including Baystate’s healthcare delivery system, the provider-sponsored health plan, Health New England, and Baycare, the physician-hospital organization. We knew the HIE would create a platform that integrated and aggregated data from additional sources, which could deliver tremendous benefits to our organization and the communities we serve. Our decision to offer outside healthcare organizations access to the HIE makes it an even more effective tool for enhancing patient care in our region.
In your opinion, what is the reason other providers are choosing not to participate? Do they think the HIE is an indirect way to lure their patients away?
Like other market sectors, when service providers are located in the same geographic area, there is an underlying spirit of competition. However, patients make care decisions based on a variety of factors that range from preferred physicians to location or wait times for urgent care or specific procedures. Since patients are going to be visiting the provider of their choice, we think it’s in everyone’s best interest to share and exchange patient health information across the spectrum of HCOs and providers. We wanted to create a new approach to patient care based on collaboration. Our goal is not to create an advantage for any provider but to create a system that promotes the delivery of high-quality patient care. We realize that sharing patient data and information can be perceived as giving up a competitive advantage, and we are currently working to bring outside providers into the HIE. Another significant barrier to participation is the high cost of professional services being levied by EMR/EHR companies to link each provider’s system with the HIE; these expenses are often prohibitive for smaller physician groups and practices.
What is the real solution to the EHR connectivity and interoperability issue?
For our organization, the issue of efficiently sharing patient records is not about profitability – it’s about patient care. In the midst of an ongoing healthcare transformation, commercial and government-subsidized health plans are making a shift toward accountable care, whereby the cost of care is shared by those who provide the care and those who pay for the care, including the patient. After making a large investment in an HIE, we are offering free access to outside providers because we believe it can enable delivery of better patient care and help contain overall healthcare expenses.
For you, what is the guiding principle behind your business philosophy?
Providers need to focus on the needs of the community and join together to enable a comprehensive view of each patient – regardless of where they are being treated. The reality is that most patients will be treated at a variety of facilities including general physicians’ and specialists’ offices, urgent care centers, and hospitals. Common sense dictates that we share patient records with all the providers involved in each patient’s care. And that’s the goal of the HIE that we have created to serve our community.