Tell me about Kern Medical Center.
KMC is a 222-bed academic medical center. We have eight residency programs with the UCLA School of Medicine. We’re the only trauma center between Los Angeles and Fresno. It’s a county-owned facility.
You’re going to be going live soon on Medsphere OpenVista. You’re still on for November, right?
No, we’ve delayed it. We had a rather serious virus.
I heard about that.
It took our IT staff off of everything but getting the virus fixed for about three weeks. As we looked at moving back, we started getting into the holidays and so on, and really felt we needed five weeks of uninterrupted training. We decided to go live February 8th.
What would you say are the good and the bad things about the project?
I’ve been very happy with both sides. Plus, our employees have really stepped up and have done a great job with the builds and have not taken the shortcuts. For just what they were offered, the staff’s just put a tremendous amount of good work into it.
The Medsphere staff has been great to worth with. We started this off with the idea of it being a partnership, and I think it really has been.
How large is your IT staff and what capabilities do you have in-house?
The reason I’m hesitating is we’re moving to a model of the county IT staff taking care of the infrastructure that would move all of our servers downtown. Then we have a small staff left out here to deal with applications. I think out here we have about eight FTEs, but then we’re also supported by people who work at the downtown location. I think probably another six or so are totally devoted to us, as well as some other county IT staff that helps out on specialty things.
It’s difficult for a small- to medium-sized hospital to be looking at a $40 million expenditure for an EMR system. Do you feel that you had to give up something to go with OpenVista or do you have any regrets?
Not yet. We started integrated testing this morning. As of midday, it’s going very well. It looks like it’s a system that will work for us.
I was familiar with VistA from the VA. I wasn’t at the VA, but a lot of our physicians in San Diego worked at both our place and the VA. Physicians generally like the system. I think some of the things we’re giving up on bells and whistles are things that are distractions anyway. So far I really haven’t had any regrets.
The VA model’s a little different since they have somewhat of a captive audience of physicians and nurses who don’t really get to choose whether to use it. How do you plan to get, specifically, physicians to interact with the system?
Our physicians are employed.
All of your physicians are employed?
Yes. We won’t really run into a lot of the issues of Meaningful Use that community hospitals will. Basically, the physicians have really embraced it. They’ve done a lot of the work on the builds. I think they’re excited to see it come.
Are you replacing anything with OpenVista or is this all new?
The CPOE and the electronic medical record are all new.
Up until you go live, you’re purely paper?
You mentioned Meaningful Use. When you look at what dollars are on the table and your timelines, how are you feeling about the Meaningful Use possibilities?
Even with the delay it looks good. As you probably know, you really have to be up to speed on July 1 to get 90 days in before October 1. We’ll be live in early February, so that will give us several months of experience to see if we’re falling down in any areas before we do that last 90 days. I think that should go very well.
Would you have done it without the possibility of HITECH payment or was that the deciding factor?
I think that really pushed it a lot. It turns out, in looking at cost savings by having an electronic medical record, that will pay for itself even without the stimulus funds. But the stimulus funds really, I think, are what moved it to the front burner and it’s kept us on a tight timeframe.
You mentioned the cost savings. What kind of outcomes do you hope to achieve when you are fully electronic?
We’ll save about a million dollars a year in forms and paper and the storage of the forms and paper. Probably another million a year when it’s fully implemented on costs to the medical records department. That’s really just a little low-hanging fruit. We’re expecting a lot of operational savings, but they’re just a whole lot more hard to quantify.
On your team that’s implementing, I assume you have representation from physicians and nurses that are involved?
Oh yes, and everybody who will touch it is represented in the steering committee.
Did you do a lot of work with standardizing order sets or evidence-based medicine when you were building the system?
That’s really a lot of the work that’s going on. Our clinical people got much more involved in that than we originally thought we would, and they’ve done a lot of good work.
Are these physicians that are practicing physicians? Do you have a physician in charge of the project or is it just a collaboration?
There’s a physician in charge of the project. She’s one of our thoracic surgeons who’s also practicing. All of the physicians who are involved in the project are all practicing.
Do you have any that are naysayers? Are you hearing from those yet or are they just taking a wait and see attitude?
Really no one is naysaying the project. There’s little things here, little things there that they don’t like and there’s some compromises we need to make with some of the other systems that will have to interface to it that we’ll probably eventually replace. But no serious “let’s just pull the plug and forget about it” type of naysayers.
How do mobile devices fit into your strategy?
Actually, the whole input device is one of the things I was most concerned about because we don’t have experience with it and everybody has different ideas of what they should use.
The mobile devices just seem their screens are just too small. We had a device fair here and had all the various vendors bring in various devices from hand-helds to iPad-like devices, to regular PC screens and laptops and so on. I think most of the users pretty quickly realized they needed a much larger screen than an iPhone or something would accommodate. We ended up selecting laptops in some areas and PCs on carts for other areas.
Will you have remote access?
Yes, it will be Internet available.
When you look around the community, what’s the status of EMR adoption among the physician practices? Will this change anything?
I don’t see a lot of physician practice adoption yet. There are a couple of large groups or specialty groups that have electronic medical records, but the community has a lot of still-solo practitioners and small groups of two and three physicians that don’t seem to have done a whole lot yet.
I don’t know if they’re waiting to see what their respective hospitals do, or waiting for the ARRA funding or exactly what’s happening. Since we have an employed group, I don’t really focus a whole lot on the community physicians.
What about interoperability? Are you looking at that at all?
In terms of being able to share information with…?
Yes, among other facilities or regionally.
There are two very large federally qualified health clinics in our area. One of them is actually holding off on their electronic record. They may go with OpenVista as well after they see how we do. But we plan to, as soon as possible, have two-way communication with those clinics. We do some psych patients with Kaiser.
Probably insurance companies will be the next large thing, and then as the other hospitals come up with their own electronic records, we’ll expect to have interoperability with them.
Are you considering anything related to patients or consumers as far as a patient portal or any kind of functionality that patients would use?
You know, we’ve had discussions about it and that’s more of a long-term goal we’d like to do, but that won’t be available at startup.
As a hospital CEO, what elements of your overall strategies involve information technology?
I think that two of the differentiating factors for successful hospitals: one is imaging, which is fairly heavily IT related; and the other is IT and the ability to store and use information.
This obviously is the most important initiative we’re taking on this year, and I think, will be the framework for a lot of the quality, patient safety, and even financial things we do into the future.
When you look beyond Meaningful Use and ARRA and HITECH, how important will information technology be for hospitals that are trying to succeed under healthcare reform?
I think it will be very important for healthcare reform. It will connect the patient-home and the outpatient setting with the inpatient setting and with the ED so that there’s one record that caregivers in each of those settings can access. It will avoid a lot of duplication of testing. I think it brings together more, the medical group — even if it’s a virtual medical group — by the sharing of that information.
It also will give us a lot of information we can mine on how we’re doing with utilization, with quality, with patient safety. I think those elements will be very important under reform.
Do you think the OpenVista product is going to give you the technologies that you need to be ready?
What are your biggest fears or biggest opportunities that you see coming from healthcare reform?
I think there’s just a lot of confusion left in exactly how the 3,000 or so pages of the bill are going to be translated into many thousand pages of regulation and what all that’s going to mean for us. As a county hospital, one of our issues is going to be will the indigent patients who we now see who suddenly have coverage. Will they continue to use us?
Is your fear that they will or that they won’t?
That they won’t.
Some are saying they’re never going to get their EDs cleared with all these folks who suddenly have an insurance card.
Well, they’re already using the emergency department, so it’ll just be that they’ll have a payer source all of a sudden.
The real big issue that concerns me though is having insurance coverage doesn’t necessarily give you access. Dumping another 20 million people with coverage onto the system that’s already pretty undermanned, I think, is going to create a lot of waiting issues and appointment issues. A lot of people who may not be able to find a primary care provider.
There’s a concern that just because you have insurance doesn’t mean you can get an appointment. Do you see there being new roles for extenders of primary care physicians, or will doctors move back into primary care?
We’re in a medically underserved area, so we already have a physician shortage. We are talking to our clinics about how can we use mid-levels — how can we be more efficient with the patients we see?
You don’t want to push patients through too quickly or have too much mid-level intervention because part of the spirit of it is that they have a Medical Home and a primary care physician who spends time with them and properly directs them, properly oversees disease entities, properly refers to specialists. If we get into a “let’s just hurry everybody through the system,” we’re going to go right back to high ED utilization, high inappropriate referrals to specialists, and patients with chronic conditions not getting their meds on time, and not getting seen on time and not having intervention done on time. It’s going to be a balancing act.
Do you think that healthcare reform is going to save money or improve quality or both?
I think there’s going to be several years of very turbulent years while it settles in. I do believe the country already spends more than enough money to cover everybody, but it’s going to be those transitional years where we go from reducing payment from people who are currently insured — since, in theory, those plans won’t have to cover uninsured — to a more even system where almost everybody has coverage. But I think it’s going to reduce the coverage for all of us and it’s going to increase the access problem for all of us.
Certainly there’s already some polarity of the haves and the have-nots when it comes to medical care. Not just insurance, but the quality and quantity of care available. Do you see that gap widening between the haves and the have-nots?
No. If anything I think it’ll probably shrink. You mean in terms of disparity among patients?
No, I think that will probably shrink, and that’s probably going to be the problem for people who are used to having a full indemnity insurance card. As those plans drift down to looking more like Medicaid and more and more of the uninsured are covered, I think it’s going to be a leveling of the system. People who have lived at the high end of the system probably aren’t going to like it a whole lot.
Do you think it will create another class of patient and provider that go off the grid and use cash?
That’s what happened in England. There’s a National Health Service, and then there’s the private. Actually, private insurance service is down as well as private hospitals and private physicians. There could be some of that.
When you look out five to ten years, what are the hospital’s biggest opportunities and threats?
Health reform is both our biggest threat and our biggest opportunity. It’s the best of times or worst of times. We just don’t know which it is.
I think that there’ll be the turbulent years while we try to get used to regulation and people taking on different roles and our revenue streams coming from different areas. But I think ultimately, if we have good strategies and execute them well, it will be a real opportunity for us.
With our academic connections, we offer some of the advanced care in the community as well as the broader care, so it should be an opportunity for us in the long term. But I think it will be some difficult years getting there.