Ante Up

June 24, 2011
Throughout time, ambitious people have studied how best to effect change: How can they get others to do what they want? A popular school of thought

Throughout time, ambitious people have studied how best to effect change: How can they get others to do what they want? A popular school of thought goes something like this — if you can show the other person that what you want them to do is really in their own interests, the battle is largely won. But what if, despite such “carrot-like” efforts, the desired change doesn't come about? What if the object of influence is so intransigent that no degree of cajoling will work? According to many, that means it's time for the stick.

Partners HealthCare in Boston decided in March 2007 that it was definitely stick time. The integrated health system — founded by Brigham and Women's Hospital and Massachusetts General Hospital, now including community hospitals, specialty hospitals, community health centers and a physician network — stipulated that all its network physicians had to agree to adopt an EMR by the end of 2007. To make sure they followed up, Partners further stipulated that the physicians had to be up and running on an EMR by the end of 2008 (dates are for primary docs, specialists have another year).

Failure to meet these milestones results in removal from the network. For physicians in Boston, no longer being able to refer patients to Massachusetts General or Brigham and Women's is serious business.

Evolution of a mandate

The process started in 2003, says Cindy Bero, CIO of Partners Community Healthcare Inc., when the organization formed a committee to look at different paradigms for requiring physician EMR adoption. PCHI is the network for Partners which includes about 2,500 affiliated community physicians (who are not employees of Massachusetts General or the Brigham physician organizations).

In 2004, Bero's boss, PCHI CEO Thomas Lee, M.D. (reporting to Partners Healthcare CEO James Mongan, M.D.) was in favor of mandating such a deadline. But Bero demurred, noting that only about 9 percent of the network physicians at that time were live on an EMR. A mandate, she said, would be premature and counterproductive. Carrots were needed first, then sticks. “If you come out with a heavy-handed message too early in the process, you will alienate everyone,” Bero says. “We wanted to be one step ahead of the network, not five or six.”
(left to right) John Glaser, Ph.D., VP and CIO, Partners HealthCare System Cynthia Bero, CIO, Partners Community Healthcare Inc. Th omas Lee, M.D., CEO, Partners Community Healthcare Inc.

Those carrots took the form of incentive-laden managed-care contracts, negotiated between Partners and the largest area insurers, that offered higher payouts to docs using EMRs.

Today, insurer incentives aren't the only method for inducing EMR adoption. With recent clarifications to the Stark regulation, why hasn't Partners chosen to pick up the tab for the physician EMRs (through reimbursing docs for up to 80 percent of the costs)? Partners HealthCare CIO John Glaser, Ph.D., says that's not a model to promote continued usage once implementation is over.

The Stark relaxation, he says, is a good and necessary first step, “but it's incapable of getting us to the next step just by the way it's put together, so going through the plan route (for incentives) is certainly the better long-term move. Sooner or later, even those who have taken advantage of the Stark provision will have to move into the incentive realm if they want to take that next step.”

Complementing the managed-care incentives, Partners strategy had another tenet — primary docs first. Primary doctors have the most managed care patients, and thus the most to gain financially from using EMRs. Specialists, Bero reasoned, would soon follow, so as not to be disconnected from the primaries who feed their referral pipeline.

“That strategy worked out beautifully,” Lee says.

One, two, or many?

Telling physicians that they must adopt an EMR is one thing — but ordering them to adopt a particular one is another. Health systems around the country are now facing the same decision Partners did in balancing EMR freedom of choice with the realities of ambulatory EMR/inpatient hospital information system integration.

On the extreme side of the freedom scale, the health system even toyed with the idea of putting out functionality guidelines, then letting practices go from there. Bero was concerned about a “you choose” approach. “If you go with multiple or dozens of products, our ability to function like a network will be limited. I think that message resonated,” she says.

On the other end of the spectrum, Lee explains, “The idea of telling everyone that they had to use the Partners electronic record was a non-starter, because a number of people were wary that they would then be married to Partners forever.”

Some timely guidance came in the form of a Boston Globe article. The article, which came out on Feb. 3, 2005, days before an important Partners board meeting, ranked nine of the area's integrated delivery networks, with Partners coming in at number two. Not happy with anything other than first place, the team closely looked at the number one player, Harvard Vanguard Medical Associates, to find out what they were doing differently.

“We figured out that they had all their docs using the same electronic medical record,” Lee says. The non-IT folks on Partners board then pushed for the one-and-only approach, “but that was just not saleable (to the network physician community),” Lee says.

A compromise approach seemed the best way to move forward.

Ultimately, Bero and the Partners team chose to allow the use of the health system's homegrown EMR — the Partners Longitudinal Medical Record (LMR) — and one other EMR product. After much research — tapping the knowledge base of organizations like Forrester, Gartner and KLAS — Partners chose GE Healthcare's Centricity Practice Solution.

Looking back today, Bero wonders if the IDN made the right decision. Though it may seem that limiting physicians to two products — one created by the healthcare system itself — would leave room for few integration headaches, the reality is far different.

Bero says, “Being on two products is not as seamless as everyone thinks. The problem is that if we stuck to our guns (in terms of mandating the use of one product), I don't think we would be here today. We would not have gotten the movement. So we gave people the choice of two products, which was a practical necessity. But I will always question whether we sub-optimized what we might have been able to do with quality and patient care.”

Time to deliver

By issuing an EMR-adoption mandate to its network docs, Partners has accepted a huge responsibility to support them, so Bero's group has taken on the role of healthcare IT vendor, with all the sales, marketing, implementation and support responsibilities that go along with it.

Providing such technology services is not completely new to IS departments like the ones run by Glaser and Bero. For one, Partners has been providing systems to the Dana Farber Cancer Institute for years, replete with vendor-like contracts that include service-level agreements.

“We are not here to be a vendor, but if there is a partnership or strategic intent that requires us to act like a vendor, then we will do just that,” Glaser says.

Now, when docs want to learn more about one of the two EMRs being offered, a team is dispatched that can arrange demonstrations of Partners' LMR or set up a demo with GE. Physicians are taken through their options, with no push to take the Partners product.

“We, like everyone who has taken advantage of the Stark stuff, is sort of a mini-vendor within the walls of an IS group, and that has been a transition for us,” Glaser says. “Many healthcare organizations are going through a similar exercise of trying to figure out how to do that, and do it well.”

All aboard

Though they are in the extreme minority, some physicians make the decision not to go electronic, preferring instead to cut their ties with the network. Most, however, have come around, a few at the last minute. Most resisters either don't feel implementing an EMR is financially viable, or see retirement around the corner.

If it's all about business and not about patient care, the short-term outlook may not scream out for adoption, Lee says. “This is not going to increase their productivity,” he admits. “It's going to call for, at the very least, a temporary decrease. I've been telling them that this is more work. This provides a very high return on investment for your patient, a critical return on investment.” Such honesty should serve Partners well in the long run, he says, as anything less could erode trust with physicians in the network.

The bottom line for the health system is that there is no long-term alternative to pushing docs into the electronic realm. “We are not going to become higher performing without these kinds of systems in place," says Lee. “We can bring value to the community by showing leadership through this difficult work. You get rewarded when you do the difficult things that other people know are the right thing to do, but don't feel like doing.”


Partners Network EMR Adoption

*Primary care doctors, end of year














Application Integration: Never as Easy as It Sounds

According to Cindy Bero, CIO with Partners Community Healthcare Inc., even integrating two EMR systems is a daunting task.

“You could do mapping, but it would be a monumental mapping task because the amount and kinds of data that are in an EMR are huge. Then the management of that would be a nightmare going forward — to keep the maps up to date. We have undertaken some of that mapping with some of the fields, but in the back of our minds we are hopeful that industry standards will come faster.”


Bero's Team — A Vendor in the Making

According to Cindy Bero, CIO of Partners Community Healthcare Inc., her team, which supports all network EMR selections and implementations, consists of three groups:

  1. A software-development group that builds and maintains Partners LMR. (60-70 people)

  2. Distributed teams performing implementation, training and support. This group is spread across Massachusetts General Hospital, Brigham and Women's Hospital and the Dana Farber Cancer Institute, which Partners supplies systems to. (40-50 people)

  3. Community-based team. A small sales group that visits affiliated practices, explaining the value proposition for adopting an EMR. (40-50 people)

Missing Piece? Business operations. “I need someone to help me with invoicing and marketing and communications,” Bero says.


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