Vermont in the Vanguard: Catching Up with Fletcher Allen's Chuck Podesta

June 13, 2013
At a time when virtually everyone in healthcare and healthcare IT is incredibly busy, Fletcher Allen's Chuck Podesta is still busier than most. Podesta's role is evolving forward, as his organization expands, establishes an ACO, and participates in two regional HIEs. What lessons are being learned at an organization at the vanguard in healthcare transformation?

At a time when virtually everyone in healthcare and healthcare IT is incredibly busy, Chuck Podesta is still busier than most. As senior vice president and CIO of Fletcher Allen Partners, Podesta’s role continues to evolve forward. Just a year and a half ago, he was SVP and CIO of Fletcher Allen Health, a Burlington, Vermont-based health system with one hospital facility, Vermont’s sole academic medical center. But then in October 2011, Fletcher Allen Health came together with Central Vermont Medical Center (Berlin, Vt.), becoming Fletcher Allen Partners. And then in January of this year, Champlain Valley Physicians Hospital in Plattsburgh, N.Y., and Elizabethtown Community Hospital in Elizabethtown, N.Y., joined the group, creating a four-hospital system caring for patients in both Vermont and the adjacent region to the west in northern New York state.

What’s more, the Fletcher Allen organization in January launched an accountable care organization (ACO) under the Medicare Shared Savings Program for ACOs; and Fletcher Allen is moving full-steam ahead with its participation in two different health information exchanges (HIEs), the Vermont statewide organization known as VITL (Vermont Information Technology Leaders), and the northern New York organization known as HIXNY (Healthcare Information Xchange New York).

Needless to say, Chuck Podesta has been busy. But he took time out of his packed schedule recently to speak with HCI Editor-in-Chief Mark Hagland, to fill him in on all the latest developments in his world. Below are excerpts from that interview.

You’ve had a tremendous amount going on lately! Please share with us some of what you and your colleagues have been up to in Vermont and northern New York.

Two years ago, we were a single academic medical center. Now, we’re a four-hospital system, within two years. And my guess is, we’ll probably add a couple more within the next few years. Two are in Vermont, and two are in northern New York, across the lake. We’re now called Fletcher Allen Partners.

So I’m at the system level now, so now I’m CIO for Fletcher Allen partners; and the IS leaders in the other organizations have a dotted line to me. Altogether, we’re up to about 225 people in IT. The interesting thing now is that it’s not just Fletcher Allen Healthcare that I’m responsible for, but also for the strategy for Fletcher Allen Partners. We had an IT governing council that we’ve kept, to help manage the governance of all the activity. And 99 percent of the agenda is system-wide work, as opposed to Fletcher Allen Healthcare-specific.

For people who have never worked in systems before, it definitely requires a different mindset, because sometimes, you have to give up what works locally for what works for the whole system.

Chuck Podesta

You were already live on Epic for your EHR [electronic health record] at Fletcher Allen Healthcare; are you live on Epic everywhere now?

No; Central Vermont has Meditech on the hospital side and eClinicalWorks on the practice side. CVPS has Siemens on the hospital side and GE Centricity on the practice side; and then Elizabethtown has CPSI. So we really have to work things out. My sense is that we’ll move to implement Epic across the ambulatory space first, and eventually across the inpatient hospitals. And it needs to follow the strategy of clinical integration and alignment as well. You don’t want to do it either too son or too late.

How does fulfilling the requirements of meaningful use affect of all that?

It does from a timing perspective, and so does ICD-10. So you have to line that up as well. The good thing is that all the organizations—hospitals and practices—have already attested to Stage 1.

Does that mean you’ll wait until after Stage 3 to switch?

Possibly yes. My one concern is whether all the vendors can support the hospitals after Stage 3; Central Vermont is on the old Meditech Magic system. And those systems are tanks. Meditech Magic is the one system I’m worried about. I am a bit concerned that GE Centricity might sunset their product.

Is interoperability the interim solution for you?

Yes, absolutely. We have a group called VITL, and it’s a public/private partnership, and it’s the HIE for the state of Vermont. So all the Vermont hospitals have pretty much connected to VITL, as have many of the physician practices. VITL is also the state REC [regional extension center]. And we have a very high EHR adoption rate in the practices, as well; it’s something over 80 percent. So that’s moving along well. And then in northern New York, there’s an HIE called HIXNY. And we’re working with both VITL and HIXNY to use the NwHIN [the Nationwide Health Information Network, now called the eHealth Exchange]. Because I don’t want to contract with VITL and HIXNY and have two separate processes, as around consent issues. We’re looking at both policies right now to see how closely aligned they are. That’ll be the sticking point if the policies in New York and Vermont are different—doctors will go crazy. So we just want one consent process. The great thing is that VITAL and HIXNY want to work together.

Also, we launched an ACO in January, OneCare; it’s a CMS Medicare Shared Savings Program ACO, with about 40,000 attributed lives. We’re about to get our claims data probably by the end of April, the beginning of May. And we have 13 hospitals in OneCare, including Dartmouth Hitchcock Medical Center. The 40,000 lives are in Vermont only; but Dartmouth Hitchcock, since they’re on the border, see a lot of Vermont patients. So they’re in two, including a Pioneer ACO in New Hampshire, and part of OneCare for their Vermont Medicare patients. It’s nice having two large academic medical centers that are kind of like the anchor stores in a mall; and the rest of the hospitals in Vermont are quite small, including critical-access hospitals. And then we have 58 independent practices across Vermont that have joined OneCare, including two FQHCs. Those are very important, because they see a large dual-eligible population.

So the challenge has become, if you look at how big OneCare is—we’ll have the claims data and will do something with that, but we’ll also have to capture the biomedical data as well as the claims data, to get into the predictive analytics and population health management aspects of all that. And we’re estimating that there are 15 different EHR vendors involved. So we’re working strongly with VITAL on that—about 20 percent of the practices are connected with VITL, while all the hospitals already are. What’s good is that OneCare will be a customer of VITL, so they’ll be putting that on their priority list. So they’re helping us with our integrated delivery network, but also with our ACO. And Dartmouth Hitchcock is working on joining VITL as well, for the Vermont patients; though Dartmouth Hitchcock is an Epic organization as well, so we could actually use CareEverywhere [Epic’s data exchange capability] if we needed to.

So you’ve got the EHR component and the HIE component; the next step is the patient portal. You’ve got 15 different vendors, so you’ve got 15 different portals, then, too, right? And you’ve got to have that patient satisfaction/patient engagement element with regard to your participation in ACO. And to take an example, you have a patient in OneCare; and they’re a Medicare patient, so they can go anywhere for treatment. And their records might be in a number of different EHRs. And they want to see all their lab results, everything. And you can’t give them three or more different patient portals. So VITL will help us to create a generic patient portal; they’re using the Medicity product, which includes a patient portal product. That way, the patient will have a single view, otherwise, it would be a nightmare.

And the fourth part is the big data element. So we’re working with a four-hospital collaborative—the Northern New England Accountable Care Collaborative (NNEACC). [Please see Mark Hagland’s January interview with David Wennberg, M.D., M.P.H., CEO of the Northern New England Accountable Care Collaborative, here.]

I spoke with Dr. Wennberg about the NNEACC in January.

Yes, it includes Eastern Maine Medical Center, MaineHealth, Dartmouth-Hitchcock, and now us. We’re signing on to have them consume our CMS data, and to be able to use their tool set. We’re excited about that; we do have our own business intelligence group, and we will be bringing the CMS data into our own data warehouse as well; because we’re going to end up having an ACO in northeastern New York as well. And NNEACC will have tools as well. But when it comes to predictive analytics, being involved in the NNEACC will help a lot, because you’ll have access to a few million patients’ data, as opposed to a few hundred thousand patients’ data.

So, to summarize, we now have a four-hospital system, operating one ACO, with another ACO probably coming about soon in northern New York. So in terms o the work involved, it just gets crazier and crazier! We know from a foundational standpoint what technologies you need—you need EHR, HIE, a patient portal for the personal health record, and big data; it’s a matter of implementing and optimizing all of those elements.

What lessons have you and your colleagues learned so far in all this?

I’m not sure we’ve learned any yet! It’s a crazy answer, but there’s so much to do. We know we’ll eventually be on Epic, and we can map out a six-to-eight-year strategy on that. But the ACO stuff is just so new. It’s exciting, because there’s no roadmap on this; but it’s also scary, because you have three years before you take risk on that population. By the way, OneCare has been designated as the pilot program for the Vermont single-payer program as well. They’ve created the Green Mountain Care Board, which was tasked by the state legislature to create a pilot program to get us towards risk. The timing was great, because OneCare emerged as a Medicare ACO just as they were looking for a state pilot. So there’s government participation as well.

I think the only lesson learned so far is that, depending on your market and what relationships you’ve established—that to me is one of the keys to success or failure. If you’re a large hospital and are seen as the eight-hundred-pound gorilla, and doctors don’t like you and feel threatened by you, it’s a lot, lot harder. The nice thing is the relationships we’ve had that have allowed us to move faster. And of course, we’re a smaller state, so we can get leaders into the same room pretty quickly. But the relationship thing is huge. And the other element is physician education and communication; that’s huge. They need to know what it’s about; how they’re going to get paid; and also, as we’re changing their information systems and changing their workflow, why we’re doing it. The good thing is that they’re incented to do it. But they really need to understand that. So that’s a huge component. That’s definitely a critical success factor.

So you have to excellent IT governance in all this, or you’ll fall apart, right?

Absolutely. And we have an excellent multidisciplinary team with a CMIO, a CMO, two practicing physicians, the president of the medical group, two chairs (one in radiology and one in anesthesia), the COO, and the CFO, and myself. And then we have representatives from the other organizations at different levels. From different organizations, we have the CMO, CFO, and CIO of those other organizations participating. So it’s a good group. And the relationships were built as part of the process of them joining us. And the relationships were already built, so when we created the IT governance for Fletcher Allen Partners, those relationships were already built; and the hospitals have their own governance as well.

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