One-on-One with North Shore-Long Island Jewish CIO John Bosco

In September of 2009, 13-hospital North Shore-Long Island Jewish Health System announced it was subsidizing up to 85 percent of the cost of implementing Chicago-based Allscripts' ambulatory EHR in the offices of its more than 7,000 affiliated physicians, constituting a $400 million investment. Specifically, the plan calls for North Shore-LIJ to provide physicians with individual subsidies of up to $40,000 over five years. To learn more about the project, HCI Editor-in-Chief Anthony Guerra recently talked with John Bosco about the strategy behind this massive tactical move. To read the interview it its entirety, please visit http://www.healthcare-informatics.com/john_bosco.

AG: You've signed quite an interesting deal.

JB: Yes, it is. We recently we had our first community forum, and we brought together a bunch of community physicians. I think 50 or 60 of them made it, and we're going to be doing this twice a week for the next few months. At the first one, there was a lot of excitement and a lot of interest. There were good questions, so it was very positive.

AG: What are your goals for these meetings?

JB: There were three main things that we spoke to. The first was - and these are our credentialed physicians, voluntary physicians, the ones who could participate in this program - to educate them about the program itself and the vision for the program, so that they could understand what we're trying to accomplish and why.

Secondly, for them to actually see a demonstration, and so we had Allscripts there and they actually walked through a lot of those screens and did some workflows based on sample patients.

AG: It's always fascinating when you have to convince people to let you buy them something, isn't it?

JB: You know it really is. We first had to do all of the demos to our own internal committees and medical executive committees and medical staff societies and all the various groups that are internal to us. We did that to make sure that within our own health system, all of our physician leadership and others are aware of what we're doing. We've also identified, and we have a phase for, early champions, so we've been running around doing demos for them also.

We've been pretty good at predicting what the big questions are going to be, but it's interesting to see that they're waiting for us to tell them what the trick is. They come in with a certain level of suspicion, wondering, “What's really going on here that I'm not catching yet,” but I think by the time it was over, we did a pretty good job of making them understand what it's all about.

AG: What were the major concerns?

JB: Data ownership and data access I think is the big one. They want to understand what data we will have access to, do we own the data, can we do anything we want with it, can we send it to payers, can we use it to judge their productivity or judge them against their peers or all of these different things. And I really think that was a big question, and we've specifically designed this whole program in a way that we are removed from their relationship with Allscripts.

So the way our program is set up is that they are contracting, not with us, but with Allscripts, and Allscripts is selling directly to them the licensing and implementation support, hosting, ongoing support, the whole deal. They're getting all of that from Allscripts. Our involvement, as far as the physician is concerned, is that they are signing a subsidy agreement with us, and they are agreeing to the exchange of clinical information between patient care settings electronically and between EMRs, between our acute care setting and emergency department setting and various EMRs that are part of this initiative.

AG: You're offering them a 50 percent subsidy if they don't agree to share performance data and 85 percent if they do. Can you talk more about that?

JB: Sure. The two programs are exactly the same with the exception of what you just said, but in both of the programs, what we're calling the Connected Model and the Integrated Model, the physician agrees they will allow for the electronic exchange of clinical data for patient treatment purposes only between the EMRs that are part of these initiatives, and also through our local RHIO.

And so we're just saying to them that only for the purposes of treating the patients, for example, when a patient shows up in our ED, we will pull any information that's available from the office EMR so that we can understand more about the patient. We'll also move data to the practice when their patient is discharged from the hospital. We'll push a discharge plan and a discharge summary out to the primary care physician.

Now, in the Integrated Model, they agreed to participate in the development or the refinement of clinical practice parameters or care guides that are built into the Allscripts system. We are trying in a very collaborative way to allow them to come in and meet with the people who are going to be tweaking these things. Right now, we're focusing on six or seven of the major chronic diseases, and we're reviewing those care guides in the Allscripts system and, as necessary, tweaking them a little bit. We haven't really even done that yet because the care guides that are in there are based on nationally recognized standards and NQF.

And so what the Integrated Model says is you can participate in the management of these care guides, you'll follow the care guides and, on a monthly basis, you're willing to report back to us your performance data anonymized but you agree to report that quality data to us so we can use it in the aggregate to measure the impact that we are having on the population health. That gets you the 85 percent subsidy.

AG: Are you getting a sense of whether they're generally inclining towards the 85 percent or 50 percent?

JB: They are, for the most part, inclined toward the 85 percent, as we get them comfortable with the data we'll have access to and how it will be used. I think there are some who just think it's worth the money.

AG: When we're talking about pulling in the ambulatory data, how do you pull data that's hosted with Allscripts or at the practice?

JB: We are working with Allscripts to create that level of integration and, in fact, they have software called Connect which has that ability. That software had been out for a year or two. It's not fully matured yet, but we do know of at least one other local health system that's already doing exactly that, pulling in information from the office EMR.

AG: Can the practices host the data themselves?

JB: The way we've built the program, the way we're building the infrastructure, the pricing that we've been able to come up with is, in some part, based on the economies of scale that we get by them all being centrally hosted in a common infrastructure. And so right now, it's an ASP only model, with Allscripts hosting the data.