Avery Cloud is CIO at New Hanover Regional Medical Center in Wilmington, NC.

Tell me how your Project S is structured, what it’s designed to accomplish, and your thoughts on portfolio and service management.

Project S is exactly that. It’s a service management initiative in disguise. I’ve tried to move away from this idea of talking in a language that means nothing to my customers. We basically took service management concepts and repackaged it into something that was explicable and digestible by our audience.

What created the need to do this in the first place was an analysis of where we stood and our ability to meet service levels or to create customer satisfaction, also to build an infrastructure that would support the coming strategic initiatives that we saw down the pike.

For example, we’re moving rapidly into full-function EMR. We knew that we have to have a structure that supports remote ambulatory care environments. We have to have different service levels for that.

Analysis showed that we just weren’t set to work quite ready for that. We had a maturity study done and we had about a 1.2 level maturity against a maximum of 5. It also revealed that we need to move somewhere around a 3.2, 3.3 maturity level in order to provide the kind of services that would be required to make our organization successful. That gap represented the tools, skills, policies, standards, procedures that are necessary to deliver high levels of service.

Our goal was to create stability: stability in our systems, stability in our service, stability in our satisfaction levels. That’s four Ss and that’s how we coined the term Project S.

Is the maturity level you mentioned CMM or is there something other that you measured that with?

IBM has a customized version of ITIL. They have a service level maturity or service maturity index.

How rigorous and involved was it to get that number back to tell you where you stood?

It was pretty rigorous. It was about a two-month-long analysis.

You got some help from Compuware in putting this together. What did you find you were lacking in terms of knowledge and abilities? Were there any new things that they insisted you bring to the table that you didn’t already have in your shop?

That’s a great question. One thing we lacked was a repeatable process. That’s where adopting ITIL came to bear.

Another we lacked was skills in the right areas. We had plenty of skills, but not necessarily the presence of the right skills for the right job.

We were also lacking tools. Tools essentially mean that we weren’t in a position to automate ourselves so that we could provide higher levels of service. As you well know, you can’t do everything in a manual fashion and be efficient and effective.

Those will be the areas that pretty quickly emerged, and that’s what led us to an analysis of what our toolkit should be.

We believe in the idea of integration. Integration is something that is quite absent in many IT organizations. We tend to be the worse, we’re much worse than our customers when it comes to buying one-off tools for every problem. What we try to do is buy an integrated toolkit that helps us run the business of IT.

That, in fact, was our mantra. We wanted to manage IT like a business, and therefore put in the business systems required. A good example is that we wanted to mimic our financial department, financial and HR. We have one product that manages finance and HR, and that’s Lawson. It has materials management, and then it has payroll, it has financial reporting, accounting, general ledger — you get the drift. It’s a well-integrated product which redoubles its ability to produce efficiency than if you had individual products for each of those foci.

We wanted to help this integrate into one product set, our monitoring initiatives or monitoring processes, our early detection and warning processes, but also our project management, change management, problem reporting, our time management, our budgeting process, our IT governance reporting process, our automated workflows.

That was really important to us. The system lets us embed the knowledge of experts and the systems, therefore driving a repeatable process. I said a mouthful there, covered a lot of territory, but I hope you get some sense out of that.

I don’t want to ask you what it cost, but how much of an effort and investment was it to move from where you were to where you are?

It’s probably the biggest thing this IT organization has approached since its inception.

How did you get the support to undertake such a project in these times?

It was simply outlining the gaps between customer expectations and our ability to deliver and matching a solution to those gaps. The organization wanted those gaps filled enough that the sale was much easier.

It’s kind of interesting. I had to highlight my failures, [laughs] which really is a risky and uncomfortable approach, but in fact, it is the right thing to do. I had to highlight the fact that I had a 30% drop call rate at the help desk. I had to highlight the fact that nine out of 10 problems that we encounter are called in to us by our customers rather than us notifying the customers of the existence of the problem. In other words, they find it before we do.

So you begin outlining all these things, and then you start talking about what’s coming in the future, and you’re going to have doctors who are going to need the services of that help desk with that low performance. You’re going to have doctors who don’t want to have their systems to fail when they’re in the middle of a surgery. You’re going to have nurses that can’t administer medications to patients in pain if the barcoded med system is down.

We were able to use kind of Walt Disney’s “imagineering” approach, just tell a story about how things are and how much better things could be.

ROI was not as necessary when you looked at it that way, because when you really looked at it, the case we were making was a case of staying in business. [laughs]

Overall, is the end result that you have restructured the department and changed the staffing mix and staffing levels?

Yes. We’ve done two substantial re-orgs through this process, continued to evaluate our staffing plans, and brought on a chief technology officer. We made some major staffing changes, major training changes. Our organizational processes don’t even resemble what they used to be.

If you’re talking to your CIO peers, what would you tell them is the key to know that you need to have this done and the thoughts to entertain before they start?

I think, you know, customer’s king. The key is to evaluate the customer’s level of satisfaction with services being provided. You can’t do that without getting very involved and face to face with the customers. So that’s number one.

Also, the study of where your organization is going is vital. You’ve got to forecast what are the strategic demands coming into your organization, and what are your current abilities to support the future.

One of the things I’ve said quite often in team meetings is we have to future-proof IT. We’re not future-proofing it against outside attack; we’re future-proofing it against internal demand. The whole idea is to create an IT organization that is not a constraint to business decisions.

Did the evaluation find that the IT department was underfunded?

Oh, yeah. There were some adjustments made there also. Probably another way to look at it is funding is not in the right places. It was not just underfunded, but the distribution of money and funds — are we spending our money on the most important services and problems?

How much larger did your operational percentage of total budget need to be to meet these standards that were laid out in the evaluation?

Let’s see … what was that percentage increase? I don’t want to guess at it. Suffice it to say that it went up modestly. [laughs]

And you had that commitment going in, knowing that there were things to be accomplished that might cost money, that the folks writing the check would say, “Yes, we’ll buy those recommendations and fund them?”

Right. You have to prepare an organization to accept that. Obviously, marketing the project as goals and describing what it takes to meet those goals helps prepare an organization for an additional cost.

I believe we really did an excellent job on not making those costs burdensome. If you really look at our budget, we have stayed at just about the same expense percent revenue. It has gone up slightly, but not enough to sound alarms. [laughs]

What are you doing to establish relationships with your physicians?

One of the things we’d done is strengthen our governance process. We have a group of physicians that are integral to our governance and decision making to represent physician needs. We’re also looking for better support models for docs. We know service levels required for docs are far different than anybody else in the organization. They don’t have five minutes to hang on on the phone.

We’re looking for easier ways for them to communicate to us that there is an issue. They might want to simply let us know one of the keys is sticking on a keyboard. You’ll never hear about that from them because they’re far too busy to stop and tell you if you don’t make it easy for them to do that. They’re not going to pick up a phone because they don’t like being put on hold.

All those things we’re doing from a clinical perspective. We continue to enhance their portal. We make that their one windowpane to clinical information, or one pane of glass to clinical information is what I’m trying to say. We continue to enhance the speed, we set service level agreements for response time on the full transactions that represent 80% of their work. We are spending a lot of time right now prepping up for computerized physician order entry. That’s going to be a big one for them. Those are the big things.

In summary, the two most important things if you were to ask a doc is that the systems fail a whole lot less, and they run a whole lot faster.

Are you doing anything specific to stimulus funding?

Yeah. CPOE is going to be part of the “meaningful use” definition. We’re working with our physicians not only in the hospital, but with community docs that are affiliated with our hospital, and even extending our reach to all the counties that we serve, and collaborating with other hospitals and their physicians to start talking about health information exchange and how we can better share information, and how we can help them achieve the maximum stimulus dollars available.

What kind of things are you doing with the physician practice EMRs and practice management systems? How are you tooling up to get them prepared and to get your integration strategy with the doctors going?

Boy, I tell you, it’s essential to have a meeting before we talk about that. [laughs] It’s probably one of the more interesting things I get to spend my time on.

Anyway, here’s our strategy in a nutshell: we are going to standardize on one system, one physician EMR that we will recommend, and we will pre-build any necessary interfaces back to our hospital systems. Therefore, if a doc agrees to select that system, and of course we can’t make them do it, but if they agree to select that system they know that they automatically are going to be joined in the information sharing with the hospital.

This is also where HIE comes. We are looking for our own kind of mini-HIE for docs that might not agree to purchase that particular system, and at least provide some way for them to participate in information sharing with the hospitals that they have admitting privileges to.

We’re differentiating very clearly between docs that we employ and docs that we have affiliations with, and trying to provide those two levels of service. We’re really trying to work out the kinks on what is going to be our support model. Are we going to be the ASP, or is there going to be a vendor ASP involved? Might there be a hybrid model? There’s still a lot of unanswered questions, but we are right in the middle of trying to sort all of that out right now.

What would your credibility have been before you did Project S as opposed to now?

They would have run me out of town for real. Don’t you write that. [laughs] They would not have even considered it because our service levels were so abysmal that there was no confidence. There was a crisis of confidence in our physician staff with IT. Rightfully so.

What had happened was the needs of the organization had grown faster than the IT of the organization’s abilities to support those needs. That’s not unusual. That is the reason you have these clearly defined and measurable maturity levels for IT organizations, because you have to match up your IT organization’s capabilities with your internal customer’s demands.

Last question. If you look back at the last couple of years, what are the smartest things you’ve done as CIO?

What a great question. Smartest thing I’ve done as CIO … probably dealing with IS as an internal business. Allowing that perception to govern how I make decisions helps me make the right decisions. That would be one.

Another one would be taking no prisoners when it comes to hiring the best. I’ve got to have a team of people who better and more ideas than I do. I want to be the idea vetter, not the idea creator. Surrounding myself with good people — it takes a while to finally get that figured out, but if you do that right, the rest of the job gets easier.

In terms of information systems, specific or technical things that I’m proud of — I kind of don’t know how to say this, because I don’t know how to say this and make it print right, but I’ve spent time with a particular vendor and greatly influenced their product direction. We use a product here, a bed management system that a particular vendor and I drew on the back of a napkin, and he turned it into a product. So I’m pretty proud of that. I didn’t get a doggone thing out of it, but I’ve got a doggone good system.

Maybe another way to put it is I’ve always worked very hard to match a technology to a problem, and not just push technology.

I’ve got to share this one, too: putting in strong governance. If you want to succeed, have strong IT governance.

I always liked somebody who’s got a really firm vision on what needs to change without getting so wrapped up in the minutiae like hospital folks so often do, so it’s refreshing to have somebody with a plan who actually made it work, especially when you get into stuff like infrastructure and staffing and IT governance, which is usually kind the Vietnam of CIOs. [laughs] You get wrapped up in all the stuff you really can’t get closure on.

That’s so true. I tell you, my boss and I had a long conversation. He said, “Avery, what you’re very good at is the visioning part of being a CIO,” and he said, “I really like that about you, and what you’ve got to do is make sure that you have a structure around you and manage the details.” Because what happens to a lot of CIOs is they get pulled down into details and never get up the 30,000 feet to see what’s going on.

Is that inherent in their background, though, when you’ve got a lot of folks who worked to move their way up through IT, which is the argument of “are you better off with someone who’s risen through the IT ranks”, or better off to get a visionary who just lets other people worry about the nuts and the bolts?

That’s an interesting debate. I’ll just tell you about me: I came up through the technical ranks. I hold an MBA, but more importantly, I have an affinity to business. When people ask me about me and my job, I tell them I’m a business person who just happens to know IT.

I’d like to think that I could run any of the departments in this hospital. A good example is that nobody is surprised when the CFO runs the pharmacy department, or the CFO runs materials management. It should be no big surprise either that the CIO can do the same, or does the same. A very good friend of mine in another hospital — he’s the CIO there — runs the pharmacy down there. Another friend of mine who’s a CIO runs the home care division.

So a chief information officer is not a propeller-head. A good one is a business person. You think like a business person, and you recognize the importance of your specific trained professional discipline, which is IT, but you don’t let it rule you.

I think there are advantages to having a technical background because it does help you understand when your people are talking to you. I’ve seen the other side of the thing where the person did not come up through the technical ranks. It must be horrifying to be a person who has a strong grasp of the business but has no clue about technology, because the language we IT professionals talk on can be scary.

That’s why, frankly, a lot of CEOs are uncomfortable with IT reporting directly to them. If you’re not the kind of CIO who’s a business person, your CEO is not going to take to you. CEOs don’t want to hear about the bits and bytes and stuff.

I’m going to share this with you real quick. One of my crusades is to make my organization think about what we do from the customer perspective. Don’t tell me that the systems are up 99% of the time. Tell me how many hours you were down, because that’s how the customer looks at it. Don’t tell me that the server 214 is down. Tell me how many patients are getting backed up in the ED. Tell me how many fewer registrations I’m going to do per day because of this. Tell me what my impact’s going to be to the bottom line.

Part of our monitoring effort here is to cause our monitor to tell us what’s happening in the business based on what’s happening in IS. You’re not seeing a whole lot of IT leaders thinking that way, and that’s a problem.

I really want to pick up my phone and say, “You can probably expect a two or three percent decrease in collections today because we have some stress on one of the segments on the network that prevented as many bills going out.” That’s a different phone call than if I called my CFO and said to him, “Just wanted to let you know that your people are going to be a little frustrated because systems are running slow today.”

So I think that is really what IT leaders have got to strive for, the user viewpoint, the user view of the services that IT provides.

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From Chi Lover: “Re: Eclipsys. Eclipsys is having another round of layoffs today (9/10/09). How can they sustain their implementations with so few staff?” Unverified. Another rumor making the rounds is that Allscripts is thinking about buying Eclipsys, but I mention that purely for entertainment rather than business value since lots of signs point to the likely inaccuracy of that speculation.

From Bobby Orr: “Re: Cerner. I’m disappointed in your thoughts that Neal would do anything that is not motivated by money. Cerner would compile a massive database of patients that could de-identified and sold to the pharma companies for research, trending, etc. Go with the cynical version because it is great business idea that big pharma would be willing to pay big dollars for. The stock is not blowing everyone out of the water because Neal has bad business ideas.” You’re probably right, especially with all the non-proprietary ways the government could get surveillance data (I let my cynicism down for one moment and got busted!) One reader commented on the article, asking how Cerner would deduce H1N1 given that there’s no ICD-9 code for it; another replied that they would simply be looking at ED admissions in which the patient has a temperature that’s a certain amount above normal. If that’s all it does, then it’s worthless.

From Who Pays For EHRs? Patients: “Re: Cerner. People might have forgotten that Cerner already is selling patient data to pharma and there really isn’t any such thing as anonymized data. I guess no one is buying Cerner, so they need to do something.”

From Sr Health Integration Tech: “Re: Cerner’s H1N1 surveillance tool. I believe the CDC already has the capability, known as BioSense. It takes HL7 messages, which are made anonymous prior to transmission, and the aggregated data is analyzed for the region to determine if a ‘biological incident’ exists.” That brings back a memory that UPMC had developed a biosurveillance tool for the CDC or NIH years ago (I remember downloading it). I don’t know if it’s the same one.

From Cal Worthington: “Re: HIEs exchanging data. From what I’ve seen at many of the state-wide HIE conferences being put together to respond to the HITECH act, only the PhD/MDs are salivating over the HIE to HIE exchange because of the research they are doing. Most are professing my patient imperative, ‘the closer to the patient the faster the information is needed’ — which I believe cannot be done in a cost-effective way as you get farther and farther away from the patient’s home turf. However, I do believe that certain CMS, CDC, SSA, and research data could be exchanged in that manner, making reporting a behind-the-scenes activity to healthcare delivery. Once that happens, we’ll get better data without the administrative overhead. HIEs are effective collaboration tools in a community of healthcare providers with significant overlapping patient populations.”

From Mike Mills: “Re: iPhone emergency apps. I bike a lot, so I bought the Road ID, a wrist bracelet with my wife’s name and number and an 800 number and PIN. The system ‘talks’ to the EMT and tells them my name, blood type, any medical conditions, meds I am on, allergies, etc. That is much better and easier than a phone app, easier to find, and they make one version of the wrist band that is nice looking so you can wear it all the time.” Pretty cool for $9.99 a year. EMTs call the phone number or go to the Web page on the bracelet and a text-to-speech app reads off the information.

From Colorado Kid: “Re: Steve Hess. He left Christiana Care and joined the University of Colorado Hospital as CIO.” Thanks to the several readers who passed that info along. I feel like John Walsh for tracking him down publicly.

From The PACS Designer: “Re: wait times. As we digitize more health information, we start to see more innovations migrate to the Web. Middlesex Hospital (CT) is one institution that is going digital in their Emergency Department when it comes to posting wait times on the web for treatments which exclude real emergency situations.”

dbMotion, Allscripts, and Initiate Systems will host a Healthcare IT Executive Summit later this month in San Francisco. The topic is, of course, ARRA, which has dislodged every other topic from every HIT event (maybe HIMSS will be nothing but people talking about Meaningful Use and getting government money). It’s invitation-only, so if you didn’t get one, join the club.

Readers have added quite a few events to the HIStalk Calendar in the last few days, so check them out or add your own events for free (I keep saying “for free” since I don’t think everyone has caught on).

Listening: brand new from Phish, who shows they’re more than spaced-out live jammers. Lots of little 70s prog bits in there. Meanwhile, the music industry’s only possible savior is a group whose last album was recorded in primitive tape equipment nearly 40 years ago, the 50%-still-alive Beatles. Quality really does last, apparently.

Midwest Orthopaedics chooses SRS after taking its free EMR free trial.

Dell gets into the PM/EMR business, offering a sponsored solution to hospital-affiliated doctor groups that can include hosting, HIE services, a monthly lease payment, onsite services such as practice and workflow assessments, and 24×7 hardware and software support. Tufts and Memorial Hermann were early adopters. Partners include eClinicalWorks and Perot. That’s bigger news than the Sam’s Club announcement, I think, since Dell is offering everything for one monthly payment and practices need a lot of support. We’ll have our interview with Bill Shickolovich, CIO at Tufts-New England Medical Center, posted shortly.

The Dell story made The New York Times, which dug deeper to see what other vendors are doing. GE will roll out a hosted version of its systems in a few months, eClinicalWorks has 10 data centers for hosting, athenahealth will announce a marketing drive and technical assistance program within the next three weeks, IBM is creating a cloud-based service for EMRs, and Verizon started a 500-employee healthcare unit that will offer hosting and data sharing.

Construction will start soon in Wyandotte County, KS on an 18,500-seat soccer stadium and a 4,000-employee Cerner office park with 600,00 square feet of office space. The $414 million project, funded by bond money, covers the two organizations that Neal Patterson and Cliff Illig own most of — Cerner and the pro soccer team there. Not shown: the pizza delivery man observation platform atop the giant ticking clock.

The CRIMSON Initiative, a physician profiling system sold oddly enough by The Advisory Board Company who bought the company last year, announces that it’s being used by over 200 hospitals. One hospital CEO is quoted strangely: “If I had the ear of President Obama, I would tell him that we need two things, a national fishing holiday and the CRIMSON application.” He also calls it “a diamond in the rough,” implying there’s something “rough” about it.

The Physicians’ Drug Reference (PDR) is merging with the Health Care Notification Network to form PDR Network, offering the online drug reference and FDA provider alerts. A reader reported in May that something was up with Medfusion and Medem, Medfusion bought Medem’s health services business in July, and former Medem CEO Ed Fotsch is now listed as CEO of the new PDR Network.

The cost to McKesson to provide security to John Hammergren: $402K per year, the fifth-highest cost in the Fortune 100, way more than the cost of protecting the CEOs of ExxonMobil and the car companies.

Rockingham Memorial Hospital (VA) chooses NextGen’s PM, EMR, imaging, and community health solutions.

I missed this: Medicity CEO Kipp Lassetter, MD spoke Wednesday at the Robert W. Baird Health Care Conference.

Who believes this? Delnor Hospital (IL) says it hasn’t had a medication error in 15 months. I guarantee I could snoop around for an hour and find several, although maybe they really meant medication-related sentinel events.

Halo Monitoring announces that its home monitoring and personal alert system can send data to Microsoft’s HealthVault.

Informatics Corporation of America brings on three new regional sales directors for its ICA CareAlign data sharing and portal solution.

The State of Kentucky opens registration for its e-Health Summit, which is Wednesday at the Hyatt in Louisville. John Glaser is on the agenda (warning: PDF) representing ONCHIT.

GE Healthcare announces its plan to develop wireless monitoring systems it calls Body Sensor Networks, replacing hard-wired medical monitors with wireless versions that could be used anywhere in a hospital or at home. The company has also petitioned the FCC to create a dedicated frequency band for low-power, short-range monitoring systems. That sounds like a great alternative to moving patients around in the hospital just to get them to a monitor-covered location.

Insurance company WellPoint apparently has cleaned up its much-publicized software glitches that nearly drove the company out of business, receiving notice from CMS this week that it can resume selling its Medicare insurance plans.

Mediware announces Q4 numbers: revenue up 4.3%, EPS $0.07 vs. $0.04.

E-mail me.

HERtalk by Inga

Fall River Health Services (SD) alerts patients they are converting to Meditech Client Server EMR this week, a change that will allow them to connect with Rapid City Regional Hospital.

The DoD signs a contract with CliniComp to deploy its Essentris inpatient clinical documentation package at 36 additional military treatment facilities.

West Park Healthcare Centre (Toronto), Northeast Georgia Health Systems, and Hunterdon Medical Center (NJ) are awarded 2009 QuadraMed User Excellence in Software Technology awards. The award recognizes success in maximizing operational efficiencies and delivering high quality through QuadraMed technologies.

Weeks after MetroSouth Medical Center hosts a first year anniversary barbecue, the Blue Island, IL hospital lays off 120 employees. Just a month ago the Chicago Tribune reported things were looking up at the former St. Francis Hospital & Health Center. Now administrators are blaming the decline in patients for creating additional financial pressures.

E-mail Inga.

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Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

Healthcare Clearinghouses
By Skip Tumalu

You’re asking the right questions about X12 and clearinghouses. The answers, as is sometimes the case with EDI issues, may lie beneath the surface. And bravo for insisting on transparency. But do take the time to investigate, measure and test. Do not let the inability of your business partners to approach transparency trap you into a corner with no exit. Let’s take a quick snapshot of the surface issues and “what lies beneath.”

Eligibility on the surface
Provider transmits data elements per payer requirements. Payer responds with Eligible or Not.

Eligibility underside
The more non-required data elements the provider transmits, the more likely the payer will falsely respond Not Eligible. Why? There was a keystroke or other error in one of the data elements. The data set did not match. Not Eligible. Or, the payer eligibility system is old, cranky, or attempting to comply with governmental program rules and “just says no.” Don’t worry — false negatives on eligibility are usually less than 15%. Remember this when we discuss how much you might invest to get YOUR own revenue cycle to Six Sigma, as measured internally.

Claims on the surface
Provider transmits complete claim and “scrubs” the data elements or pays for “scrubbing.” Payer accepts and pays some claims, but a double-digit percentage are rejected or pended. Providers don’t like to reveal their percentage of claims that are sent in a second time. Want to see real discomfort? Just ask about the percentage that must be sent in a third time. It is not always a single-digit number!

Claims underside
Payers have massive legacy rules tables for claim editing/adjudication. A payer might say they have XX thousand rules they apply to filter and route claims in their processing silo. If you run enough claims and keep track of results, it is not hard to show that the payer is wrong. It is not XX thousand rules, but perhaps 150% of XX thousand rules.

How can this be? Payers edit their adjudication tables. They do it frequently. The process may be less than Six Sigma, folks! Over time, they have a table full of best efforts — not a Six Sigma system. And no, you won’t get any payer to agree that this is remotely possible. This also means that if you measure diligently, your payers won’t be very responsive to this issue. Why? Can you imagine the consequences if they stepped up to solving this one?

I met with a provider who admitted to having most claims submitted more than once and many claims submitted a third time before payment. I said, “Gadzooks – your Days Revenue Outstanding must be really large.” They said, “No, it is less than two days.” I asked how that could be. The response was, “We deposit payer reimbursement checks the same or next day — we have about 1.5 Days Revenue Outstanding.” I said that we need to count from the day the claim dropped and had my head handed to me — I was yet another false expert with no understanding of how the revenue cycle really works. This type of “unintended conspiracy” of weak partner systems and small misunderstandings can indeed cause some major pain!

It is interesting to note that with big ERP installations down, the large systems integrators are selling a lot of engagements for “total Six Sigma healthcare revenue cycle reengineering.” I’ve chatted with some nice folks about the view above regarding eligibility and claims, the surface view, and the underside view. They’ve said, “So what, our re-engineering is underway and we are not Six Sigma yet.” I’ve asked the about the cost and payback for total re-engineering and heard of many projects investing more than $10 million with paybacks greater than one year.

Cheeky bloke that I am, I’ve asked what the “process quality” of eligibility and claims might be, based on local estimates of the “surface” and “underside” issues mentioned above. Folks will readily agree that process quality on eligibility may be 80% on a good day and claims process quality may be 60% on a good day. I then ask what happens when the middle of the 80% and 60% goes to Six Sigma. The response is, “Please don’t mention this to anyone — it was an important investment that we were counseled we had to make urgently.”

If you’re still doubtful, there is a test you can perform to understand “aggregate process performance” — not of your provider systems, but your total environment. Got Self-Pay? Got Unpaid Self-Pay? Sending any Unpaid Self-Pay to Early Collections? Screen your output file heading to Early Collections a day in advance — ONLY if you’re prepared to see 5% or more of the accounts with valid current eligibility that will pay the claim! If you get 7.5%, 10%, or more, be prepared to call it “an anomaly” and do re-testing over an extended timeframe. 

You can do your own math on the implications this has for what payer eligibility responses and payer claims adjudication are doing to YOUR revenue cycle, regardless of your standalone process quality. Besides, don’t you think there might be a compliance issue you’d rather avoid in heading towards collections with folks covered by Medicare, Medicaid, or a commercial payer where you’re in-network? If you don’t have resources to do this screening, then it might be worth paying to get it done. And remember, this is hardly your fault. Even if your “process pipes” are Six Sigma, if you’ve got “gray water” in the eligibility data incoming and “gray water” in the claims back from payers, you are simply using a pristine Six Sigma solution to “pump gray water.” At least don’t promise that the new Six Sigma system will reach process levels that your business partners don’t support and have no capability of reaching. Prepare to measure and report the “grayness” of your business partners’ water.

OUCH!

What are the implications of these possibilities? (I don’t expect them to be real for you until you check it out in your environment with your own payer mix, systems and data results)

1. Ignore processing charges at first. Instead, focus on process performance. If you’ve gotta pay to get process quality end-to-end, pay for performance before you get trapped chasing “false economy.”
2. Expect weak results on eligibility and focus on making it as easy as possible for staff to check eligibility when and where it makes sense. Unless it is absolutely EASY, your results will only be worse than the typical “gray water result.”
3. Expect >> 90% of claims to be accepted and paid as submitted, first time in. Impossible? Ask around. Quality solutions are not free and they are out there. Don’t settle for “we send the claims on as quickly as we can” or “we check each data bucket, for sure.” Use process metrics and announce that your headed for excellence. You’ll be surprised to see the world change around you. And yes, you may need to pay some small fees. Those are small compared to the cost of carrying one or two months of needless Days Revenue Outstanding at a time when banks and revenue bonds are “not behaving normally.” Your Treasurer can provide updates on that issue. Only ask if you have time to listen to a true tale of woe.

The Value of Clearinghouses
By Jim Denny

Scott Bayou’s Sept. 2 commentary on healthcare clearinghouses raised some good questions — and ultimately was dead-on.

In theory, there should be no necessity for transaction or interface fees. The intent of HIPAA was to provide, and ultimately enforce, an interoperability standard. In reality, however, that hasn’t happened. This means that practices and hospitals must force the issue by refusing to do business with vendors that charge these fees. They must instead insist upon free and unlimited access to X12 transactions.

Within this imperfect environment, it’s also wise to recognize the value that clearinghouses bring to the current marketplace — hospitals and medical practices alike — through standardization, efficiency, and leverage.

First of all, if electronic transactions were truly standardized as noted above, today’s typical clearinghouse might indeed be redundant. But the truth of the matter is that different payers transfer files in divergent formats with varying content, supported by a wide range of service levels. Providers are saddled, in other words, with a myriad of technical challenges when it comes to claims and revenue cycle management. Advanced clearinghouses serve as an “EDI translator” that can streamline submissions, provide meaningful visibility into claims status and adjudication, and reduce days in A/R.

Secondly, clearinghouses give providers efficiency (and economies of scale) they otherwise would not have. Let’s say that all providers across the country unerringly run into problems submitting one type of claim with one specific payer. To make adjustments, each provider would have to modify its own system. A clearinghouse, however, could update its edits engine or change processes for all its clients, relieving them of monitoring and “fixing” payer-specific anomalies. This is particularly true for SaaS-based clearinghouses.

Lastly, clearinghouses provide operational leverage. Consider data warehousing and the business or clinical intelligence it can supply to providers. If information is locked in a payer-biased clearinghouse, providers will be unable to extract, aggregate and analyze data in ways that are meaningful — much less beneficial — to them. Payer-sponsored data clearinghouses perhaps provide a more cost-efficient option. But we must remember that their objective is to serve payer interests, not provider interests.

Provider-centric clearinghouses, on the other hand, are able to offer provider-focused information that delivers valuable insight about performance, utilization, and outcomes that allows them to track key measures and gain leverage during contract negotiations.

Jim Denny is president, CEO, and director of Navicure of Duluth, GA.

Follow the Yellow Brick Road
By Craig James

Call me the EHR heretic or the guy whose sister the house crushed in the Wizard of Oz. My comments have nothing to do with how hard everyone is working, their professionalism, or their skills. So much for my disclaimer.

You can’t read a blog or Twitter post without tripping over hopeful accolades anticipating some miraculous intervention by one of the standards committees, the RHIOs, the HIEs, or the Meaningful Use  or Certification Committees. Example:

State CIOs Get ‘To-Do’ List, HDM Breaking News, August 25, 2009 — The National Association of State Chief Information Officers has published a report giving guidance to CIOs as their states implement health information technology provisions of the HITECH Act within American Recovery and Reinvestment Act.

The act requires state leadership in two primary areas: oversight for the planning and deployment of health information exchanges and management of the Medicaid incentive payments for meaningful use of electronic health records, the report notes.

“The HITECH Act placed a significant amount of new responsibilities on states in regards to state oversight for HIE and the planning and implementation grants for preparing for HIE,” the report states. “During this initial planning period, state CIOs must secure a seat at the table to establish themselves as key stakeholders and also to recognize strengths and identify weaker points that require resolution within their own offices relating to statewide HIT/HIE planning. They must ask themselves what they, with their unique enterprise view, can do to support and contribute to each of these areas.”

Let us remember the mission — accurately and timely delivery of your records from A to B. You are 1,200 miles from home, unconscious, and are rushed to the ER in a clinic in Smallville. EMRs from your oncologist and cardiologist, your CT-Scan, and your nuclear stress test, along with a list of your meds, are in the hands of the nurse practitioner as she awaits the doctor’s arrival.

Now let the grownups apply logic. Hundreds of vendors, an equal number of standards — by definition, an oxymoronic statement — home-made EHRs, outpatient EHRs, EHRs serving as RHIOs, IPA EHRs, IPA RHIOs, real RHIOs, and HIEs. Certification and Meaningful Use — another oxymoron.

Here’s a simple question. Who among us can make a reasoned argument that the current plan will enable everyone to get from A to B in 3-5 years? Right now, we call it interoperability. It’s the fly in the ointment and its degree of difficulty and costs are grossly underestimated. If you believe you can, I would love to see it articulated. I do not think the RHIO / HIE / Certification / Meaningful Use plan will work, not do I think anyone who isn’t making revenues from the current plan can make a reasoned argument. Couple that design with the fact that the vast majority of IT projects that cost more than $10 million will fail.

So what? In six to eight years we will have an open, national, browser-based EHR. Maybe we should spend time figuring out how that will work.

TPD’s Review of Semantic Web Concepts
By The PACS Designer

The Semantic Web is a term that some might find confusing when they hear about it from others. The Semantic Web consists of websites that can converse with each other to provide a more robust web experience. Sir Tim Berners-Lee, an English engineer, computer scientist, and MIT professor is the director of the World Wide Web Consortium (W3C), which oversees the Web’s continued development. He is the inventor of the World Wide Web, which was launched on December 25,1990.

Berners-Lee in 1999 had a vision of what the Semantic Web should be. “I have a dream for the Web in which computers become capable of analyzing all the data on the Web — the content, links, and transactions between people and computers. A Semantic Web, which should make this possible, has yet to emerge, but when it does, the day-to-day mechanisms of trade, bureaucracy and our daily lives will be handled by machines talking to machines. The ‘intelligent agents’ people have touted for ages will finally materialize.”

In order to improve the World Wide Web (WWW) with more semantic capabilities, we need to review the current framework of the web. The World Wide Web is constructed using a Uniform Resource Locator (URL), the generic term for all types of names and addresses that refer to objects on the World Wide Web. A URL is one kind of Uniform Resource Identifier (URI).

Another Web term is Resource Description Framework (RDF), which is intended to provide a simple way to make statements about Web resources such as Web pages and other online resources.

Now, at the end of our first decade of the 2000s, we are set to embark on a move to a more interactive Web experience.

One way to improve the Web experience is to improve the linking capabilities to the various web resource storage locations.

The Universal Data Element Framework (UDEF) provides the foundation for building an enterprise-wide controlled vocabulary. It is a standard way of indexing enterprise information that can produce big cost savings through the linking of Web resources.

One of the early linked solutions available that employs semantic Web attributes is called “Twine.” Twine is a new way for you to collect online content — videos, photos, articles, Web pages, products — and bring it all together by topic, so you can have it in one place and share it with anyone you want. Twine can be called a “mashup for the Web 3.0 era” as we move toward a Web 3.0 world. All we need now is for Tim O’Reilly to say it is officially here!

So for healthcare collaboration, if we combine linked resources in a secure private cloud, we can create a place where decisions can be made to treat patients using a broader  base of information sources.

Also, healthcare can really benefit from the move to employ more semantic Web concepts in the years ahead and begin to obtain more knowledge in the war against diseases!

http://semanticommunity.wik.is/
http://en.wikipedia.org/wiki/Tim_Berners-Lee
http://www.viswiki.com/en/Universal_Data_Element_Framework
http://www.twine.com/

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From Cynical CIO: “Re: Cerner. Interesting initiative. What’s in it for them?” Click the graphic above to see the letter from HHS Secretary Kathleen Sebelius to Cerner CEO Neal Patterson, taking him up on his offer to create an H1N1 surveillance network made up of Cerner clients. Attached to the letter was Cerner’s pitch to its customers, asking them to sign an agreement allowing Cerner to distribute HIPAA-compliant aggregated data from their facilities. It sounds kind of cool. Benefit to Cerner? Well, Cerner got face time with Sebelius, did her sort of a favor, and may get unspecified IT vendor benefit someday. Add that to having a former Cerner director as President Carter’s … err, President Obama’s healthcare reform czar and you’ve got friends in high places who are spraying great gouts of taxpayer dollars directly at healthcare IT. Still, I’d say Cerner’s intentions were more noble and focused primarily toward their clients and their patients, so I tend to believe their claims of sincerity.

From Michael: “Re: Texas Toast. A certain high profile technology / billing service company issued walking orders to 30 practice management billing employees at 2:00 PM Thursday. Word on the street is that physicians are ‘heated in Houston’. Silicon Valley VC types have learned that hand-to-hand combat the physician office billing trenches is a different kind of war. The VC types ‘donated’ $13.8 million to a lost cause in March of ‘08. I’m wondering about the physicians, their cash flows, and how many physician-initiated lawsuits are on the dockets.”

From Bells are Ringing: “Re: UPMC. From their site: ‘Alcatel-Lucent, a telecommunications industry powerhouse, has played an important role in delivering innovative communications platforms, including multimedia and data infrastructures, wireless and wireline broadband access, and full network optimization.’ Fact: so-called high tech telecom has been disruptive to care processes at the new Children’s Hospital since inhabitation in May. Shhhhh.” UPMC and Alcatel-Lucent are joint venture partners, so there’s no chance of discouraging words being heard.

From Fred: “Re: Meditech. Their latest technology first was known as Focus (internally), then C/S 6.0, and the latest is Advanced Technology. You wonder how long they spent thinking about this one.” That name makes me think of the IBM PC AT, which wasn’t advanced for very long. Interesting: did 6.0 sound too much like an easy upgrade when it wasn’t, or maybe was it a good marketing opportunity to rebadge a big technology change to impress the market? I have to say I like the strategy even though the name is kind of white bread. I’d have gone with Meditech Optimized FOcus , or MOFO for short. Quick, no peeking — which name do you remember, theirs or mine?

From Mike Mills: “Re: HIEs exchanging data. Maybe the people living in those regions could get stimulus funds for travelling to the other regions, where they could get sick, so that the providers could actually have a reason to view clinical data for someone who lives four hours away!” I tend to agree that the “unconscious in the ED while on vacation” is a stretch, but somehow people always assume that happens a lot. I figure it’s 0.005% of the healthcare that raises the interoperability cost by maybe 25,000 times over just connecting everybody in a single region, but everybody likes irrelevant analogies like those involving cell phone service or ATMs.

From Mick: “Re: Steve Hess at Christiana Care. What happened to him?” Nothing that I’ve heard. His name is still on some recent press releases and his LinkedIn profile says he’s still there.

Listening: relatively new music from David Byrne and Brian Eno, reader-suggested. I’m not a huge fan of either (maybe more of their former bands, Talking Heads and Roxy Music, respectively), but it sounds pretty good.

HealthHiway, an India-based HIE platform vendor that offers connectivity to doctors in India for as little as $200 per year, gets $4 million in funding from Greylock Partners.

I’ve been getting hammered lately by vendors and organizations wanting me to provide free advertising. For Webinars and conferences, you can add them to my events calendar yourself at no charge. I won’t link to your survey, run your press release if it doesn’t interest me, or give you space for your promotional article, sorry. Everybody would stop reading if I cluttered it up with all that stuff like lots of industry sites do.

Craneware announces FY09 results, with sales up 68%, revenue up 23%, and profit up 29%. I just now remembered that I was on the hospital IT steering committee that approved what must have been one of their first US sales going back at least eight years ago. They had a pretty good story even then.

Inga is turning into Weird News Inga, having sent me this: a 65-year-old man gives the finger at a healthcare rally — literally. Healthcare reform advocates and protesters in California get into the stereotypical heated discussion (likely armed with lots of emotion and minimal facts) when a pro-reformer allegedly confronts an anti-reformer. The anti-reformer, saying he “felt threatened”, punches the pro-reformer in the nose. They get into a full-on fight and the pro-reformer bites off the anti-reformer’s pinky. It’s nice to know that such an important issue is being debated with civility by well-informed citizenry. I’m beginning to think that 90% of Americans don’t have the intelligence or knowledge to debate laws, vote, or serve on a jury, being intellectually suited only to vote contestants off reality shows.

The US Patent Office grants TeraMedica a patent for its Evercore solution and its concept of Clinical Information Lifecycle Management. 

Regenstrief EMR pioneer, HL7 co-founder, LOINC developer, and IOM member Clem McDonald receives the President’s Medal for Excellence from Indiana University. He’s now director of The Lister Hill National Center for Biomedical Communications, a research organization that’s part of the National Library of Medicine.

A great PR gimmick: the MyMedicalRecords PHR people offer to reimburse subscribers up to $5,000 if they get H1N1. The relationship between the offer and the product is tenuous at best, but it’s kind of fresh.

Up to 11% of doctors aren’t offering immunizations because insurance pays less than the cost of the vaccine itself. Studies show doctors send patients to public health clinics instead, but parents don’t often follow up and kids aren’t being immunized. CDC is very interested, having observed that half of kids with measles were seeing doctors, but didn’t get the shot.

Which of these doesn’t belong with the others: Eclipsys, athenahealth, HIStalk Practice, and Sage. The answer: none — all of those organizations (and others) are sponsoring the AAP Pediatric Office of the Future exhibit at the American Academy of Pediatrics conference in Washington, DC October 17-20. This isn’t one of those lame “media sponsor” deals where all you do is run free ads. HIStalk Practice is a real, “I’m writing a check” sponsor in support of our regular contributor, Dr. Gregg Alexander. Now I doubt you’ll start making travel plans just because HIStalk Practice is involved, but if you’re going to the conference anyway, check it out and maybe find Gregg to say hi. There’s no booth or anything, just a PC running a presentation that I haven’t figured out yet.

Norwalk Hospital (CT) CIO Jamie Mooney is named as a mentor for Columbia’s technology management program.

Former Eclipsys SVP Keith Figlioli is named SVP of the healthcare informatics division of Premier. He has no informatics background that I can discern.

From Weird News Andy: in Australia, Queensland Health has the answer to patient harm caused by overworked medical residents whose on-call shifts run up to 80 hours: drink six cups of coffee a day and eat more sugar. Maybe they should have added regular trips outside for a smoke or maybe a snort of cocaine.

Doctors from St. Vincent’s Hospital in Manhattan develop an AIDS exposure treatment widget that will be available throughout New York State. They treat exposure “as a gunshot wound in terms of urgency”, saying that infection risk is reduced by 80% if treatment is started immediately.

The Social Security Administration gives a former IBM futurist his first job as CIO, putting him charge of a $1.3 billion IT budget. He’s a good blogger, so maybe that sealed the deal.

Just as I suspected: using Facebook is a good mental workout that keeps your mind sharp, while texting, reading Tweets, and watching YouTube make you stupid. Evidence abounds.

The Army’s MC4 battlefield EMR wins two government technology awards. 

Fidel Castro editorializes on healthcare in Cuba, railing against Philips for offering discounts on medical equipment for Cuba and Venezuela, but backing off when the British government started investigating the patented software and parts it was sending there. They’re buying instead from Siemens, which is hardly shocking.

Former 3M executive Alan Wittmer joins Mediware as SVP of corporate development.

Ambulance chasers increased their TV advertising by 1,400% in the past four years.

E-mail me.

HERtalk by Inga

The nation’s unemployment rate increases to 9.7% in August. Also up: the number of jobs in healthcare, with the industry adding 28,000 more last month. Since the recession began in December 2007, the sector has added 544,000 new jobs. The biggest growth areas are in ambulatory care, nursing, and residential care.

Given the current employment situation, it’s not too surprising that more college students are showing interest in healthcare informatics and information management. Colleges offer 270 accredited programs (53 at the bachelor’s level) and another 30 are expected to be certified by the end of the year.

Healthcare data analytics company Verisk Health acquires TierMed Systems. The acquisition will allow Verisk to offer TierMed’s HEDIS reporting solution.

 
Here is a new iPhone app that sounds kinda cool, but I wonder if it will take off? For $2.99, you can buy ICEbeacon, which allows you to add family/physician contacts, allergies, medical conditions, and current meds. You also get a sticker to put on your phone, which alerts emergency personnel how to access the information. Personally, I don’t want to put a sticker on my phone. And do EMTs spend much time looking for patients’ phones?

The Department of Defense Military Health System extends its 16-year relationship with EDS, signing an $8.1 million, 12-month add-on contract. EDS will make technical enhancement to to DHIMS systems.

Christ Hospital (OH) implements EpicCare Ambulatory EMR at its 35-physician medical group and regional therapy centers. The hospital is also giving community physicians the opportunity to purchase the EMR and connect to the hospital’s system. When I went to the hospital’s Web site, I noticed they have end-user training roadmaps that can accessed (not sure if that is by design or mistake). The level of detail is pretty impressive.

The local newspaper discusses the recent Epic live at Carilion Franklin Memorial Hospital (VA) and its sounds as if all went smoothly. The hospital’s IT director is quoted as saying, “No one has cried, and that’s a good thing.” Yup.

I see the AMA has set up a Facebook page to communicate updates to physicians and patients. I guess I am not social media-savvy enough to appreciate using Facebook to get news from groups like AMA or HIMSS. I’d rather use Facebook to learn what my friends are up to (stuff like, “I washed the dog today,” and “My daughter had her first soccer game”). I also got yet another request in my Inga inbox to set up an account. I guess I could and then post things like, “Boy, was that CIO I interviewed today boring!” or take some inane quizzes like, “Which shoe are you?” Or not.

E-mail Inga.

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Janice Newell is CIO at Swedish Medical Center, Seattle, WA.

Do you think the government’s strategy of subsidizing EMR purchases is the best way to improve patient outcomes with technology?

I certainly share their belief. I think the only thing that’s going to push adoption is money. Whether or not their approach is the best way to do that, I haven’t given a lot of thought to. But I don’t think anything’s going to move these docs but money.

Will subsidizing the purchase of EMRs themselves incent usage or will there need to be more steps that follow?

This is the easiest question?

[laughs] The second part got harder.

Well, yes. Certainly, incenting them to adopt it is a necessary first step. Then at the other end of it, there’s this little, minuscule penalty they’ll take if they don’t adopt it. That’s certainly more significant as time goes on, the penalty.

But I think the other thing that’s going to be key is really getting some significant measures of outcomes in performance, and how is this really changing the outcomes and cost, because if it’s not doing all that, why bother? 

Is your strategy any different at the health system based on what the government does or doesn’t do, or are you pretty much down the path that you plan to stay with?

We’re pretty much down the path. We had really made a huge commitment. We’re a relatively small health system, about $1.3 billion. We had already made the commitment that we were going all in with the Epic system, and so committed about, let’s say, $120 million to it over the past four years. We were going there anyway.

When you look back at that investment, would you say it has paid off as you expected four years ago?

I certainly wouldn’t say that it paid off yet, because in fact, we still have pieces that we’re implementing. But yeah, are we starting to achieve the things that we had outlines we were going to achieve? Absolutely.

What kinds of things were you looking for as measurable benefits?

Certainly we were looking for providers in general to have the information that they need as they’re actually caring for patients wherever they are. We’ve certainly achieved that, in that we have it available everywhere.

Also, in terms of improving our quality metrics, I’ll give you just one small example. Pain reassessment is always an area of interest as both a customer satisfier as well as a JCAHO requirement. Our pain reassessment measures were not that good. We made some changes to Epic in terms of what kind of notices the nurses get about pain reassessments being due. It has moved the pain reassessment measures from the low 60s to the mid-90 percent. The nurses are doing the pain reassessment in the timeframes that are required just by changing how the system was supporting them.

So certainly on the quality metrics, we’re starting to get some traction. Also, in the financial arena, we’re getting some traction. It’s a pretty broad swath there. Certainly it has improved the revenue cycle in terms of how long it takes us to get the bill out the door. It’s improved the level of billing we do, more accurate with better documentation.

Also, still in the financial arena, it’s also helping us standardize processes across the organization. One area that’s a biggie for us is the operating room. Before Epic, we had so much variation that it was incredible. The surgeons have taken it upon themselves with Epic to really start the standardization process of what supplies they use, what supplies come into the room, what ones shouldn’t be there at all. So all kinds of good fiscal outcomes.

But a lot of that must have been other than just technology. You must have had a lot of change initiatives to go along with it. How did you package up your implementation and your change management to make this all work?

It terms of actually sitting down and changing wholesale processes in our operations, we actually started out doing that. We quickly abandoned that approach because what we found out is, sure, we can sit down and talk workflow with our folks in operations. They would describe to us what they thought happened and how they thought things worked. But in fact, we found out that it was pretty consistently not happening that way.

We ended up adopting the approach of, let’s use a good model system, get it in, and make the improvements after that. So in fact, many of the process changes are coming afterwards.

It seems that anybody your size and bigger, along with some smaller, are buying Epic. What’s their secret sauce?

A couple of things. One is that they are an integrated system. I don’t even know how many modules they have any more, but they have one system that supports care in the clinics, care in the hospital, in the operating rooms, all of the billing and revenue cycle, pharmacy, lab, home care, you name it. They have modules to support all of the different functions.

Instead of us going on in a best-of-breed world, where we add two dozen different systems, each individual system, we now just have Epic. It is much more effective from both a user experience and an IT experience to have the same data, the same application be available wherever you are. If you think about healthcare as just a continuum of care, it just happens in different places, either the clinic or the hospital or the ED, it really supports that kind of a model if the organization itself thinks it’s a system. So that’s one reason.

The other big reason is that the Epic implementations are successful. They’ve done this enough. I think they provide very good support for organizations to actually have a successful implementation. I’m not sure I can say of all their competitors that their implementations go relatively smoothly.

How does that work when basically they are young people trained usually from scratch with no industry experience? What are other vendors doing wrong that they can’t do what Epic does?

Certainly the young people without the industry experience has some downside to it. Frequently they’re great technicians without the industry expertise. And if something goes wrong, that could cause some problems. But in terms of the process for actually going about with kind of a project, they have been doing it long enough in documenting what the process is.

Just insisting that their customers go through this process, sure, we all have some variation in how we do it. But Epic is pretty clear in the way they want you to do things. And so we all do things in a somewhat similar manner in implementing Epic.

They are there the whole time. No matter what, you’re going to have an Epic team with you through the implementation.

Meditech and Epic seem to have a similar approach that, right or wrong, they genuinely believe they know better than the customer and protect them from doing things that don’t make sense. Do you think other vendors are too catering to their customers instead of saying, we know the product, just do it our way and it will work?

I think so. Yeah. And the other ones are run by a bunch of marketing people. Meditech and Epic are the only ones that are run by software people. The other ones have a huge marketing influence, sales and marketing.

You have to deal with the idiosyncrasies of Epic, but at the end of the day, if it works, it’s OK.

You’ve said that federal stimulus money must be carefully managed or it will go down a rat hole. Did you have something specific in mind or was that just a general comment?

[laughs] Yes, actually, I did have something very specific in mind. What I had in mind is that there is so much variety in the systems that people have now, and these are just the organizations who could afford to be moderately early adopters.

I mean, if you think about the hundreds of systems that are already in the marketplace, and then you think about multiplying that by some factor as every Tom, Dick, and Harry sees an opportunity in the marketplace and comes up with the $99 EMR, I think it’s scary.

And then you have these little offices who really don’t know that much about technology or how to really use it in their practice, or what can go wrong with that technology in your practice — you know, 99 bucks and I’m going to be able to get $44,000 from the government, how could I go wrong?

So while we already have the data exchange issue in healthcare, some of it because not many of us have much electronic data in front of it because there’s so much variety, but if you multiply that by whatever factor is appropriate with people going out and doing every Tom, Dick, and Harry system, it just seems that there’s a lot of opportunity for that to turn bad.

I think what the government is trying to achieve wouldn’t be achieved if we just end up with, instead of three million islands of information, now we have 23 million islands of information.

Do you think that the certification process as well as the “meaningful use” criteria are going to make that less likely to occur?

No. Say we double the number of EMRs in the marketplace so that people have on their plate trying to exchange data. They’ll not all pass certification, but it’s still going to be a data exchange challenge.

I read your local newspaper’s article that said, hey, what an irony, we’ve got three of the best hospitals in Washington that are basically almost in the same neighborhood, and they can’t exchange information. How do we address this issue of everybody’s being their own silo?

At the end, at making it Epic-specific — with our Epic system, we are actually in the middle of a project to bring our largest affiliated group, about 150 docs, on to our Epic system. So they will be using Epic in their clinics, their own service area. All they have to do is share clinical data with Swedish, and they’re using our Epic system.

Instead of just having a system that supports follow-up functions within Swedish, we now have a system that supports all of the patients in our largest affiliated group, too, that we cross over thousands of patients every year. Our intent is to do that with a lot more of our affiliated groups where they can create their own little space within Epic. They can have their own service area.

It’ll be like they have their own system, except that it will be our Epic system and we will all share clinical data. We won’t share financial data, but we’ll share clinical data.

Another piece, once again at the risk of being Epic-specific, Epic actually has a capability where there are a number of us now around Puget Sound that have Epic. We have it, MultiCare has it — that’s another billion-plus organization — Everett Clinic up north. Epic actually has a feature where in fairly short order, we can have the Epic systems exchange data with each other.

Was that something that led you to choose Epic initially?

At the time, no. It was more the integrated feature that let us choose Epic initially.

How about MyChart? Is that an important part of your strategy to get closer to patients?

Absolutely. It has the ability for them to get at their information without us being the guards at the gate. Sure.

If you look at where you are and where you need to be, what do you say are your most important priorities and your biggest challenges right now?

We still have a few big pieces that we haven’t implemented yet. Two of them happen to be billing. So we need to do those other two big pieces for the professional billing and hospital billing. We’ve actually started that.

The tail end of the spectrum that we haven’t done yet is home care. So we still need to do that. Also included in that is getting it out to our affiliates. So that’s one bundle of work, which is implementing it in more places, more functions.

The other priority is a combination of improving the systems that’s been installed and actually continuing to work out how we’re going to get value out of it. So using the system to be a facilitator for our standardization efforts or workflow improvement efforts. Those are big items for us.

Improving the system itself, making the system simpler, I should say, and using it to improve our work processes.

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