Three decades of evolution in healthcare IT, seen through the eyes of CIOs who led their organizations through some of healthcare's most dramatic changes.
Editor's Note: This is part two of a two-part series. Part one was featured in the September issue of
Health Management Technology; it can be viewed at www.healthmgttech.com.
Best technologies deployed
Horror stories aside, what stands out as the best technologies these CIOs deployed over the years? For Denis Baker, vice president and chief information officer for Sarasota Memorial Healthcare System in Florida, it's a centralized data storage system from EMC. He notes that if they followed conventions of the day, each system would have its own data storage — and its own process for accessing, monitoring, maintaining and backups.
“As we prepared for our EMR implementation, the concept of the longitudinal patient record was emerging,” Baker says. “We decided we wanted a system to keep everything, on every patient, forever — not simply the seven years that would meet regulatory requirements.”
Monday-morning quarterbacking makes that decision look easy. But it was tougher then, Baker indicates, partly because their other system vendors, including a major PACS seller, complained. “They wanted us to buy and use their storage and backup system,” says Baker, “so they indicated their system couldn't accommodate storing and retrieving images from the EMC solution we were planning.”
Baker warns that even today, with each new system they consider, the vendors pitch their own backup and storage. Hospital CIOs should be willing to say no and be ready to use their own storage system. At Sarasota, after a two-year battle with its imaging system vendor, the hospital succeeded in doing just that — and it was the right choice.
“Especially when you recognize that the cost of a terabyte of storage is 10 percent or less of what it used to be, and still coming down,” Baker says. “More important, look at the utility: We can pull up data, images, everything on a patient we saw 12 years ago. The docs love it. They say it takes a little more time to sign on, but the system provides so much better access, they're very willing to swap out the time they used to lose calling medical records to pull an old chart, and waiting.”
For George “Buddy” Hickman, senior vice president and chief information officer for Albany Medical Center in New York, one of the best solutions they've put into play was building a Citrix server farm, about five years ago.
“We looked at all the applications we had running, all the remote connections we were supporting,” says Hickman. “Our staff was connecting on devices from so many locations. We had more than one VPN in place. The Citrix farm allowed real centralized management; it was almost like being back in the mainframe days again.”
The boom years
The late 1990s were the boom years of healthcare IT. Hospitals began investing in IT in a big way as they shifted from the narrow concentration on revenue cycle optimization. Enterprise-wide information warehousing began to take root for clinical as well as financial decision support. Health systems began to supply systems to support line management and employees at all levels, not just senior management. The early clinical information systems were arriving. New “best practices” in clinical arenas emerged, and information technology began to show its potential to help reduce mortality rates.
The big challenges were “integration” and “interfaces.”
John Hummel, founding member of Certification Commission for Healthcare Information Technology (CCHIT), IS consultant and former senior vice president and chief information officer for Sutter Health, recalls work on implementing one of the industry's first comprehensive EMR suites, from HBOC, later acquired by McKesson. “Their pitch at the time was that their system was completely integrated,” Hummel laughs. “Sure, HBOC's system had one of everything, but the individual modules weren't integrated. It was just a collection of programs. While connections were available, each module ran on separate databases. Massive integration engines were needed.”
While HL7 was available, and accredited by ANSI in 1994, Hummel points out that vendors treated them more like guidelines than standards. “HL7 was supposed to 'standardize' the interfaces so that we could all share info; except that almost all vendors had their own view of HL7.”
That left Hummel with a lot of interface work. His team included more than 20 programmers who had to write the messaging for all the interfaces — over 100 million message segments each year. “We had little choice,” Hummel says. “We had to do it if we wanted to ensure connections and correction transactions.”
According to Hummel, when you go looking at healthcare IT expenses, look at the people and equipment that kind of monitoring and vendor management require. It may also help explain the IT paradox — an era characterized by little or no correlation between investment in technology and the return on that investment, in terms of profits, improved efficiency or other measures.
“We decided we wanted a system to keep everything, on every patient, forever — not simply the seven years that would meet regulatory requirements.”
Tomorrow's troubles
Ten years or so ago, the investment in IT was 1 percent or less of a hospital's operating budget, on average. Big initiatives of the last decade, including EMR and CPOE projects, have brought the IT spend up rapidly, to an average of 5 or 6 percent or above in most institutions.
Just revisit some of the staggering sums for major EMR initiatives: Sutter spent $600 to $700 million; Catholic Healthcare West, close to a billion. Kaiser put more than $4 billion into system-wide EMRs. “Spending that kind of money could lead to some difficult times ahead for CIOs and IT departments,” Hummel projects. “Boards or CEOs could easily ask CIOs to cut their 6 percent budgets in half, to do more with less, or just shelve some key projects.”
Hummel also frames the debate another way: “It's only right to expect the question: How much value did we get for this billion? Instead of connected computers, how much more or better care could have been given? And, that's one reason 'meaningful use' is such an important concept.”
There is no doubt that EMRs and CPOE add to the cost of each patient walking through the door. But as healthcare facilities get past EMR implementation, Hummel believes better patient safety and quality of care will be part of the longer term reward. “The EMR work done in the recent past and in the next couple of years will be foundational to so much more value we can't even begin to see yet,” Hummel says. “We're already looking at handheld devices that are more powerful, more useful than PCs were, and the 100-core chip could soon make servers we use so much more powerful than the minis on which we ran our entire enterprises.”
Sarasota's Baker shares another concern that could affect IT operations in the years ahead — a lingering worry about healthcare vendor mergers and acquisitions. With hundreds of IT vendors selling solutions in healthcare, many come into the market without knowing enough about healthcare, or without the resources or commitment to stay.
“Wall Street is a huge distraction, too much pressure on public companies for quick bottom line results. I wish more vendors were private corporations, working on their own missions and timelines,” says Baker. He describes how a takeover affected IT operations in Sarasota, when they licensed with PeopleSoft about nine years ago.
“We were one of PeopleSoft's first healthcare customers, and I was extra cautious in asking for contract language that locked our maintenance fees,” Baker says. “I wanted protection, in case of acquisition. A vice president at PeopleSoft balked, adamant that PeopleSoft would not be acquired. Of course, we know the rest of the story. Oracle bought PeopleSoft, and one of the first things Oracle did was to jack up the maintenance fees by 20 percent.”
Game-changing events
What events most changed healthcare IT operations? The possibilities list is so long: the arrival of the PC, the rise of managed care, Y2K, HIPAA, emergence of the Internet, Sarbanes-Oxley, HITECH.
The easy answer for many CIOs would be the Internet, especially when looking at how deeply it has edged into many aspects of almost everyone's life. But Albany's Hickman thought back to a fiscal issue that began affecting healthcare in 1984 — and still affects it today.
“When the federal government brought Prospective Payment System into play with Medicare, that was a watershed event that significantly restructured the revenue model for every facility, forever,” Hickman explains. “It was actually one of the events that made getting good IT in place so much more vital. Depending on your base year and payer mix, your facility could be well positioned fiscally, or in a very difficult place. It forced us to do different kinds of analyses, focused us on cost-based initiatives and required us to manage by the numbers.
“Clearly, what is happening with healthcare reform now might present us with another major paradigm shift. We'll just have to stay vigilant, to be ready for that change.”
Crystal ball
Healthcare IT has come a long way from IBM punch cards and timesharing on mainframes to tablet PCs, from self-develop hospital info systems to cloud computing.
“The focus is clearly on mobility,” Baker says. “With products like the iPhone and iPad, demand will move even faster in that direction.”
In the past, Baker suggests, healthcare organizations were too limited in the technologies they could put in place, partly because of their conservative nature, and partly because technology vendors put too little emphasis on enhancing mobile devices for use in an environment such as healthcare.
“We've had laptops and tablets for some time, but they came with lots of limitations — short battery life, heavy weight, connectivity issues,” Baker says. “We had to make them work the best we could, but they weren't designed for our environments. They were made for the consumer market, but that's beginning to change. And so are healthcare systems.”
When Sarasota's new nine-story critical-care center and patient bed tower opens in a couple years, Baker will make sure the organization gets away from the personal-computer concept, creating an environment where providers will share computers, but also providing charging stations outside the patient rooms, for the personal devices each professional carries.
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