One-on-One with Atlantic Health CIO Linda Reed, Part II

Part I

AG: I’ve heard, even within a company like McKesson, even one that’s grown through acquisitions, sometimes you buy two applications from McKesson and they can be merely interfaced instead of integrated. Tell me about that.

LR: That’s absolutely true, because they are on different platforms, different databases. McKesson’s working on that with their 10.1 release, to try and marry things up, to put them on the same platform. But it’s absolutely true, we had an instance where, if you documented allergies in the OR application, or in the nursing application, either/or, they didn’t test through to the other.

The difficult part for our end users, and it’s always the part that you really have to be aware of, is are we causing them more work? We’re putting in these systems that are supposed to make life better for them but, in the end, we’re either creating a handoff or a work around where it didn’t exist before, or we’re creating double documentation. So, sometimes I think what we have to take a look at is, is the manual process or the manual documentation still better than putting in additional work arounds. I think it’s something we struggle with all the time. Do you put in a system with that additional work, or do you just wait?

AG: Do you have a formal mechanism in place for looking at those kinds of questions?

LR: We do, actually, we do have a system review and our end users are very much involved. They’re also very much involved with creating our technology road map. We have sessions with all of our end users — key clinical folks, key financial folks, and we all get together and talk about where the organization is going, what are the needs from a clinical or financial perspective, and then we map out what we think we’re going to be doing over the next three years. It helps us plan for capital requests, and it helps our operational folks really understand what’s coming and when. It helps us understand what to prioritize because one of the things that has been the issue is that IT has always done what IT wants to do, or IT thinks needs to happen, and then you’d always miss the target with what’s going on in the business.

AG: I’ve heard it’s hard to find the right level of user involvement when selecting a system. You don’t want too many voices but you need the right representation so people feel like they have a stake in the system’s success. Is that correct?

LR: I agree, I very much agree. I think you have to have the people who are the influencers. But I think you’re absolutely right and EMR, I have to tell you, I think the whole EMR quagmire is a very complex and ugly topic because, you probably know, there’s probably somewhere around 200+ EMR vendors out there, from very, very large, to very, very small mom and pop in a garage somewhere. The issue is that is if you have 15 physicians, you’ll get 16 different needs, and everybody wants the one that’s either done by this one, or their brother-in-law is selling an EMR. So, I think our issue is that the government said that EMRs are required, it will be good for the continuity of care, and they changed the Stark Law so that people with deep pockets like hospitals can help physicians. The problem is that I’m not always sure that we help them. Originally, I think we were very naïve, especially the CIO market, saying, ‘Okay, the Stark Laws are going to change, we can go out, we can pick an EMR, we’ll host it, we’ll do all the back end, we’ll take care of all this stuff for the physicians, and they will come and they will love it and they will love us.’

In speaking to my physicians over the last three years, that whole conversation has evolved. You start with the fact that physicians have very long memories and their memories start with every little sin or every little thing that they think a hospital provider has done to them over the years, or has not done to them. So you start off with a slightly negative perception of who you are and what hospitals can provide to them. Then you lay, on top of that, the fact that we’re telling them that we’re only going to go with one EMR and they either have to take it or leave it, and if you don’t take it, you don’t get that 85, or whatever, percentage benefit. It just makes for a very ugly situation.

Our physicians have also started to become more in-tuned to what that really means and more physicians have said, ‘Wait a minute, do I really want you housing my data?’ and, ‘Wait a minute, what if your network goes down,’ and, “Wait a minute, will you steal my patients?’ So for us, the thinking of what we’re going to offer as an EMR subsidy has changed significantly over the last three years.

AG: What is your current thinking?

LR: Our plan right now is we’re going to offer three, probably a choice of three. We will subsidize it. We’re looking at primary care only for right now. We’re going to pay for a part of the software license and the implementation only. Anything that has to do with maintenance, or subscriptions, like the prescribing subscriptions, will be the cost of the practice.

I think what we also learned is that, if you don’t make the physicians put some skin in the game, they won’t use it, or they don’t appreciate it. I think we’ve had the opportunity of seeing others go first to have some of those lessons learned. The other thing that we’ve also learned is that we have to provide our physician practices with a very, not severe, but very realistic warning of what it takes to implement an EMR in an office. I think a lot of them go in thinking, ‘Where’s my free EMR?’ and they don’t realize nothing is ever free.

Regarding the amount of cash it will put into your practice, I think a lot of physicians also think this is a drop-in, and they don’t realize how much work they’re going to have to do or their staff is going to have to do to make it work. At the end of the day, there may be revenue, and there may be patient satisfaction, so those are all the things we’re putting into a document to distribute to our physicians. We’re saying, ‘Here’s what we’re doing. Here are some of the things that we’ve gleaned from some of your peers, so in the matter of EMRs, be aware of these things.’

One of the other things that we’ve done is we’ve offered our physician practices RelayHealth (owned by McKesson). One of the other things that we’ve been talking to some experts about that have done EMR implementations, one of the big stumbling blocks is that a lot of these smaller practices have no automation, so taking them from no automation to an EMR is a wide chasm in functionality. So we’re trying to ease in RelayHealth which would help us build a network but, at the same time, it gives an office almost an EMR-light to work with. It gives them a way to have some patients self-scheduling. It gives them a way to communicate with patients and other physicians. It gives them a little bit of documentation that they can work with for patient performance. So it gives them some of that functionality in a like-manner before they then jump into an EMR.

That’s the progression that we’ve taken. So if we can put you onto RelayHealth first, that’s the way we’re going to go, and then we’ll move into the EMR after.

AG: Isn’t it also a competitive issue around integrating the local docs before the health system across town does?

LR: That’s very accurate, but it’s also a double edged sword because if you don’t do it correctly, you’ve got the ability to disintegrate a lot quicker. I think that’s why we didn’t rush into it. We were ready to do it a few years ago, but the more you read and the more you look into it, and the more you start talking about physician readiness, I think those are the things that you really have to take into account.

AG: You mentioned you could offer as many as three EMRs. Wouldn’t that create an integration nightmare?

LR: Well, to leverage the RelayHealth functionality we’re using something called Results Distribution. What we will do is underlay anything that we put in with RelayHealth. So when we start sending results out, it will go through RelayHealth, through their results distribution network and then up into whatever EMR gets placed.

AG: Do you think that will allay some of the problems that other people are fearing?

LR: We think it will. One of the issues that we haven’t addressed and, I think a lot of people haven’t addressed this, is getting data back. I don’t know if a lot of CIOs want data back from the practices at this point in time. At some point we might, and I think that’s something we’ll have to look at later. I think what the physicians are looking for is getting hospital data into their EMRs and then, if they have to, finding a way to get to their EMRs from the hospital to look at their records.

Those are the things we’re trying to address. I think what we’ve found, though, is if we try to offer just one, we would have a mass revolt. So, we’re just going to do the three, and we’re going to underlie it with RelayHealth as an integrator.

AG: What are the concerns, you said, about the implications of receiving data from the practices? You said you’re not sure CIOs want that?

LR: How do you co-mingle ambulatory data into a hospital record? Where do you put it; what episode do you put it with? Because we’re episode driven and ambulatory is not. So, what do you associate it with? Do you associate it with an episode? Where do you put it? I think for us, it’s more of an issue that we don’t know where to put it, as much as an ambulatory EMR might, when they get results back from us.

AG: If you’re receiving outside data like that, who owns the mistake? Who’s responsible for the quality of that data?

LR: You’re absolutely right, that’s the other issue. That’s one of the reasons the doctors keep saying, ‘We have better data than you for demographics, so you should take our billing information.’ I say, ‘No, no, we can’t do that.’ I think that’s still an issue that’s out there — when people are talking about integration and providing integrative records, I think that’s really difficult.

So for us, right now, I don’t think we’re looking at that integrative continuity of care, as much as we’re looking at giving our physicians a technology tool that will help them. I think the goals for that whole program have also changed across the board.

AG: Where are you on deciding on these three ambulatory vendors you’re going to offer?

LR: We’re pretty close. I can’t build the experience in my own department fast enough, you can’t hire those people fast enough to be able to build the kind of experience, so we’re going to go with a third party to help us do that. So we’ll probably be starting in the next quarter. We’ve got a charter ready, we know what we’re going to offer, we’ve got the physician leadership onboard. We now are putting together a physician steering committee, and then we’ll start doing the selection for those three in the next quarter.

AG: Do you like the ASP or SaaS model, where the docs don’t have to host it?

LR: There’s a lot out there but, since we’re going to actually require the physician to pay for part of that, what we found is physicians don’t really want to do that, some of them still want it in their office. We will give them the choice.

The other thing that we’re doing, which I think is a little unusual, is we’re not going to become the third-party middleman. What we’re telling the vendors that we work with is that the contract that you create gets created between you and the physician office. Again, this Stark program ends in 2013, technically, if it’s not renewed. We just don’t want the physicians then having licensing issues and things like that. So the licenses that we want will be done between the vendor and the physician.

AG: Then you just pay a portion of the bill.

LR: Correct, and we will support the implementation.

AG: Besides Stark, what are some of your other main initiatives?

LR: Because of New Jersey and the issues that we’re having in New Jersey with hospital closings, capacity and throughput is a large one for us. A nearby hospital closed and our hospital took over the emergency department as a satellite emergency department. What it’s done to us really is it has increased the capacity — the amount of patients that are seen now. So from a testing perspective, a capacity and throughput perspective, it really puts a strain on us.

I guess I’ve got two things — one is how do you keep the trains running on time, and then what are you looking at from a strategic perspective? From that perspective, if the train is on time is about capacity and throughput, staff efficiency. We know we’re doing some integrating, some calls, things like that. Quality and safety is the other big one, so we’ve got a couple of things. We’ve got medication safety as a program, which includes CPOE, we put in narcotic medication administration. We went live with CPOE, we’re automating, we’ve got a pharmacy robot, we’re trying to figure out the best way to do that. Then we’re doing something with surveillance, it’s called MedMined. Now we’ve put all these pharmacy pieces in there, how do you then use your pharmacy data for surveillance for MRSA, for any of the other things that might pop up?

Business intelligence is a big one, especially from a clinical perspective. We’ve got so many systems and so much data, but how do you use it effectively, and where do you garner the expertise? Because I think we’ve all got data, I think the struggle is how do you turn that data into action? So, what does the data really mean, what does it imply? What kind of expertise can you bring to the table to help you look at your data and say, ‘Here are some of the things that this data tells us.’ I think the struggle is, how do you turn all the data that you’re getting from all these systems into real knowledge?

AG: Do you have any theories? Everybody is asking that question.

LR: Yes, we’ve done a couple of things. We’ve worked with the UHC (University Health Consortium). What they help us do is they take our data then they help say, ‘Here’s some of the things we think.’

One of our hospitals has taken our OR data and some of our financial data, and they’re working with the advisory board Compass Program for OR and that’s also helped them, because now, not only do they look at data, they also get some expertise in deciphering that data.

I think that, working with some of those specialty groups is helpful. When I look at my future, I’m almost looking at it through constituencies. We’ve got our regular clinicians in our hospitals, so how do we make, or help them make, care safer, integrated, make their day easier, ease of use in terms of systems that work together. Then we’re looking at physicians and, if I look at physicians, I’m really looking at how do we provide them with access? How do we provide them with the information that they need, regardless of where they are, so they can provide better care? For us, that’s service.

We created something called a PST (physician support team), an educated group of five people that does nothing but support physicians. What they do is sit in the lounges, they go to physicians’ offices. We help them if they’re looking for EMRs, if they’re working with contracts, we’ve got a lot of contract experience. We’ll sit down, we’ll take a look at their contracts and say, ‘Hey, you know what? Here’s something that you can talk to them about.’ So we’ve got this team that does nothing but support physicians.

Then the last group that we’re starting to really look at is consumers. We started a patient portal; it’s about a year in. We’re struggling with that, as to how to make it viable and workable for consumers. We’re putting out a transparency program to help consumers understand what care really costs. I think what we struggle with is we’ve always traditionally put out on our site what we want to tell patients, not necessarily what they want to hear. I think that’s a struggle right now — how to begin putting out there what patients want and need, or families want and need, versus what we want to tell?

AG: How do you turn things into a two-way dialog?

LR: Right, and that’s what we’re working with right now and, I think, it is bringing more focus groups in. Who do you put on your steering committee? When you start talking about health, you get away from the widgets that you put into your Web site. What is really E-health and how do we define E-health, and then how does it fit into our strategic plan? So that’s one of the things we’re working on now, also.

There’s a couple of things that have changed — the speed of care, and the speed required for care. Up until about two years ago, I think IT ran a little faster, sometimes, than operations. But they’ve caught up and, I think, in a lot of ways, they’ve surpassed us. So one of our challenges as an IT department is how do we provide the services they need as fast as they need it? Agility has become a huge, huge issue for us.