Jamie Welch is CIO of the Louisiana Rural Hospital Coalition, linking 24 northern Louisiana community providers with Louisiana State University Health Sciences Center in Shreveport. Its goal is to make member hospitals the "medical home" for all members of the community. Grant-funded, it's already changing the way care is delivered in the poorest counties in the state. Recently, HCI editor Daphne Lawrence had the opportunity to talk with Welch about how the RHIO was set up and how it will sustain itself.
DL: How quickly did the hospitals adapt and how receptive were they?
JW: They’re actually incredibly receptive. I knew the hospitals themselves would be receptive because it’s a time and money saver but I wasn’t sure of the patient population because high tech stuff for people who are not used to high tech is a big unknown. We get probably at least ten requests a day from patients who are like ‘wait, I can do this?’ And they’re excited because they don’t have to leave home.
DL: What system are you using for the telemedicine system?
JW: We did put it out to an open bid and we contracted with WireOne, but all the equipment is PolyCom.
DL: And this was completely funded by the RHIO?
JW: That $13 million covered all of it. We were very tight with our money.
DL: Did you have to do any training?
The staff were really good about it. Telemedicine systems are not complicated, you know it takes half an hour max to be training on it. They’re very intuitive and obvious and the remote control that comes with it leaves no guessing. It says what every button does. Outside of that, as the physicians use it more and more they get used to things like how to put the earscope in, if it’s the first time. It’s practice.
DL: Are you tracking data that see savings, ROI?
JW: The hospitals are tracking that. And the only one of them has really gotten to a place where they can give us those numbers is BunkieGenerall. One of the things we covered for them was a PACS system so they could do electronic imaging, and they immediately calculated some of their costs. And they calculated the cost of the film printed out, the stickers, the envelopes, and just all these things and they estimated their immediate ROI with the PACS. That’s not even taking into account that that PACS is integrated into everything else and so patients don’t have to get printouts and walk around with them, and overnights are not happening. Just the PACS system saves them $12,000 a month.
DL: Whos’s paying the upkeep on that?
JW: Remember their start-up costs are paid for this and we covered 18 months of maintenance for the whole system. And they know that once those 18 months are up they know the maintenance is their cost. But that $12,000 a month they’re saving on the PACS more than covers the cost on the electronic system and actually winds up saving them $4000 a month. Which in the world of a 60-bed critical access hospital, $4000 a month is huge.
DL: So this will be able to sustain itself as a business model when the grant money runs out?
JW: Yes. However much maintenance we could cover for them, we would pre-buy. Once that’s up that’s on their back to take that cost.
DL: Can you speak to the technology you’ve invested in?
JW: Sure. Carefx sits on top of all these other things as an integration engine. We did a contract with CareFx, CA (Computer Associates) and Initiate and they’re doing the integration. Initiate is doing the master patient index, and all it is, is they have a direct secure connection into the actual hospital system at all the facilities, and so they keep those patient records and keep that index for where to go find the information for each patient.
Then CA is doing security infrastructure, they provide the authentication, the user provisioning, the secure proxy servers, the entire security platform. Then CareFx comes in and they partner with IBM, using the IBM infrastructure and they take that and they build portlets, a web portal that’s made up of smaller windows. These portlets are the views in the PACS system and pharmacy system and doctors notes and all the things that are available inside the hospital system.
DL: When you put this all together were you following any type of model, anyone else’s model or did you develop this on your own?
JW: I did not pattern this after anything and it’s simply because there’s a really lot of really good effort happening and anywhere I look it seems to take years to do anything. And I refuse to get into any game that’s going to take a long time. That’s just not how I operate. I talked to some of the other RHIOS but it’s high level conversations. There’s no talk of joining together or anything like that. One day in the future, sure. We’re not trying to be a silo, closed off to the world, it’s just I don’t think it’s time for anybody to start connecting.
DL: Anything you thought were unique challenges for your RHIO?
JW: I think I look at what we’ve done here as an inside out approach as opposed to an outside in. From all the things that I’ve seen happening across the nation, for the most part, they’re trying to get competitors together and then have those competitors agree on how they’re going to not compete in that arena. And I honestly think that’s why it takes so long. The healthcare industry is what it is, it’s a fierce competition and hospitals are always trying to get doctors and patients and they’re very protective of that patient data because that’s their revenue stream. So when you get competitors together and you start trying to get them to agree on what I call this in my hospital is what you have to call this in your hospital, the deal’s off. It’s not going to happen. That’s why you’re going to spend years setting up governance, because they’re competitors and they’re always going to say ‘no, my way is better than yours way.’
DL: Sounds like you’re eliminating the logjam of governance.
JW: Absolutely, and that’s why I say we’re going from the inside out. We are taking the non-competitors of the state, these are small hospitals, they’re all in different areas, they all serve different population streams and we’re taking them and joining them together to their natural referral method . We didn’t pull in some off the wall place that nobody ever heard of. We took the natural flow of what would happen anyhow and automated it and added some additional services to it. So we skip half the governance part.
DL: What else are you doing that you think is different?
Another thing I made my mind up on very early, and this is where CareFx ended up winning the bid -- this is what they won it on, they didn’t win it on price or because they looked prettier—was I refused to go with any product that would take patient data from hospital A and do some sort of manipulation to it and then try and put it in hospital B. Because that’s where you run into issues. You’re going to spend a year getting everybody to decide on the same definitions for the same things. I wanted to skip past that part, I wanted something that was absolutely federated where the hospitals information never leaves their hospital system.
CareFx goes there and gets a real time view of that information and puts in the screen but they never move it they just display it. So as soon as you close that browser it’s over. The information never moved from where it originally was so you don’t have the ‘who owns the data’ problem, you don’t have the issue of ‘OK when I click on this patient and pull it up, who owns it then,’ because I’m viewing it in my hospital. “I moved it over to my hospital so technically it’s my patient”—No! Nobody has time for all that.
DL: What’s the downside?
JW: The downside is that you have to very secure, very high speed, always on connection and that would be the biggest downside and those can get very costly, extraordinarily costly, but we have a couple of things we’ve mitigated that with. Number one is the telemedicine system, we put that on their very own dedicated line so they’re never messing with the hospital internet. Because those suck a lot of bandwidth themselves. We took that part out and put them on their own dedicated T1 line so nothing’s ever messing with that bandwidth. And for the hospitals, we increased their bandwidth and it is not, it’s still, you click on PACS and you want to pull up a 24 slice CTct , you’re still looking at a two minute wait. But that’s a small price to pay when you consider that rural patient didn’t have to leave where they were and we didn’t have to print out these images and stick them in this big overnight thing and it’s fragile and incur those costs. And so two minutes is nothing compared to the larger scheme of what it’s saving.
DL Will you be able to grow using this model.?
JW: Absolutely. The infrastructure we laid was done so it’s not an open source infrastructure for a bunch of different reasons. But the directory structure that we use can pretty much put out any standard directory feed so we can hook into other things or grow when needed. The actual model though, I don’t think you could do it in an urban area. I don’t think that the business model we put together is going to work in any other setting than taking rural non-competitors and bringing them together in their natural referral setting. I don’t think you’re going to be able to duplicate that in any other kind of setting.
DL: What’s next for the RHIO?
JW: Geographically we will absolutely take it to the south of our state. Technically, initially we are covering the functionality of the portal itself. It’s covering discharge notes, any kind of doctor summaries, medications, allergies, vitals, it’s covering quite a bit from the get go. But we will extend that as the hospitals are ready and they get more and more electronic.
We have one hospital that is starting their interfaces to actually pull in some of their electronic instruments into their hospital information systems, like blood gases and heart monitors. And once the hospital has those integrated into their system, then we will integrate those into the web portal. So as we develop the system (and this is probably years off,) Let’s say I live in Richland parish and I go to Shreveport for my surgery. Instead of a week hospital stay because I have to be monitored, now I can go back home where I’m comfortable and where my friends are and where my doctor that I’m used to is at, and the LSU specialist can still view what’s happening on those machines real time through the web portal. That’s still a couple of years off.
DL: Your final thoughts to share about your success?
JW: I think the big thing to impress upon people is don’t try to actually exchange patient information. Just view each others and leave it at that. And even more, I think so many people get so heavy on the technology because that is a huge part of what we’re doing, but at the end of the day, no matter what technology we do or don’t put in place, it is still to bring better patient care to people who would not have access to it any other way. That’s truly what it is.
DL: Where do you think you’ll be in a year?
JW: Give us a year and I think we’ll blow people away. Not because the technology is there or all the great things we’ve done or the computers or the servers. None of that. We’re now taking patients that may have had a heart problem their whole life and never had the money to see the heart doctor, and now they can get the treatment the need. Or diabetics who are suffering can get the expertise they need to manage that disease,. It may take a while. What is that while? It may be ten years, I really don’t know. But understand that the potential of it is that we can affect people early so that we can hopefully prevent the chronic stages of whatever it might be. And that’s a return on investment that we’ll never be able to put on paper, but good God it’s much more than money.
