Bobbie Byrne MD, MBA is VP/CIO of Edward Hospital, Naperville, IL.
Tell me about yourself and the hospital.
Edward is a really the quintessential community hospital. We have 400 beds over two hospitals, one of which is behavioral health, and we have an acute care hospital. It’s the backbone of Naperville, which is a suburb outside of Chicago. We are making efforts to move into tertiary care and trying to bring tertiary care into the community so that we don’t have to have our residents going to the downtown hospitals.
We’re really so typical. We’re in the middle of America, in the middle of the suburbs. What we’re doing, I think, is reflective of what a lot of other people are doing.
I’m a pediatrician. My husband says I got hit in the head with a computer and I’ve never been the same. I was practicing and made the connection between quality of care and automation of care, and that if we were going to stay on paper, then we would never have any data to figure out what we were doing well and what we were doing poorly. Maybe 10 years ago, I ended up moving into IT on a part-time basis at the beginning, and then with increasing depth. It’s always been about, “Get it in the system so that we can measure it and track it and improve it.”
You just chose Epic. What is it about their story that’s making them dominate all the new sales?
A completely integrated record – inpatient, emergency, and ambulatory, clinical, and revenue cycle. They are the only company that offers this. It is exactly what our envisioning session showed us that Edward wanted.
I shouldn’t say that they’re the only company that offers it. They’re the only company that offers it with strength in all of those product areas. Very often when you’re making a decision, there’s some department that thinks that they’re getting screwed, and they usually are. There usually is some really significant weakness in one section of the product from any of the other vendors. In Epic, there just isn’t. Everybody feels like they’re getting a best-of-breed product, but they’re getting the integrated product that the organization needs. The only compromise was on the price. [laughs] That was the only negative.
Are you expecting a hard-dollar return on investment, or is it just a leap of faith that there will some quality and strategic alignment benefits that will make it net out in the long run?
My sarcastic response is that when electricity came into the hospital, were people expecting a hard-dollar return on electricity? I don’t know if they were. I don’t think they were. To me, the electronic medical record is becoming a utility. It’s the, “What is the implication if we do not put this in?” as opposed to, “What’s our return on investment for installing it?” I think in the Chicago area, it could be seen as a competitive disadvantage to not have Epic.
I assume that Epic was a lot more expensive than … well, I shouldn’t assume that, but in a lot of cases they’re a lot more expensive than the systems you didn’t choose.
The actual check that we send to Epic is a very small percentage of our budget. The difference in price between Epic and the other vendors on the software cost is, I think, pretty small.
Cache’ is expensive. That’s a cost that the other vendors mostly do not have. But the difference is in the people and in the requirements for implementation and the recommendations around pulling people off of the floors, sending them to training, having them come full time to the project. That’s really where the big dollars are.
It makes me wonder that if you use the Epic staffing and methodology, would the other vendors be giving you the same kind of outcomes that Epic is getting? I mean, is it really the product? I do think it’s a superior product, but is it really the product or is it the entire implementation methodology that makes the difference and the incredible success of Epic customers?
You’re in an unusual position in that you saw Epic as a competitor when you were with Eclipsys and now you’re on the provider side and have chosen them as a vendor. From your two perspectives, are they invincible, and if you were a vendor again, what would you do to mount a challenge to Epic?
At that time I was at Eclipsys, Epic and Eclipsys were formidable competitors. There were certainly deals that Eclipsys won and deals that Epic won. At the beginning of my time at Eclipsys, Eclipsys won more. At the end of my time, Eclipsys won a lot less, so there was a progression there.
I would say that at this point the only way to beat Epic is to find prospects where they’re not looking for a comprehensive system. One patient, one record, one bill is what we were looking for. If you have somebody who’s got that enterprise vision, single source of truth, I don’t know how you could beat Epic.
There would be huge time lag in building a new system. Where does that leave the pie of business that Epic might want vs. how much they’re going to get? People keep saying, “Well, the pendulum will swing back, it always does.” But what would it swing back to?
When I first got to Edward, we had this combined system where we had MEDITECH on the inpatient side and Allscripts on the employed physician group. People would say, “Well, shouldn’t we buy Epic?“ just because all the hospitals around had bought Epic.
I said, you know, if we’re really going to do that, maybe we should really wait for some transformational technology. Maybe we should wait for a pure Web-based solution. We should be looking for that really disruptive technology. Maybe an EMR that’s so intuitive it requires no training or something like that. That’s really what I was thinking that the hospital enterprise system really needed.
Athenahealth in the physician office is a disruptive technology. They have a completely different business model and they do things very differently. They’re not a standard electronic medical record. If we could have something like that on the enterprise scale — not specifically their business model, but something that is just as disruptive. That was the thing I was thinking would be able to beat Epic. And it would be good for our industry, right, to have some fresh technology.
With healthcare reform and with the need to understand the patient across the continuum of care, it wouldn’t be prudent for us at Edward to sit here and wait for some theoretical disruptive technology to come forward. We have to run our business. We have to do what’s right based on what we have today.
I suppose it’s possible that Epic might be able to be the disruptive technology. Typically it would come from something outside of healthcare or from a new company emerging on the scene, but maybe Epic will be the one to be able to provide us with this next wave. I certainly think they probably would have a greater chance of doing that then anybody. Well, I shouldn’t say that …
You’ve going to have a lot money invested in staff training, salaries, and travel. You’ve written in the past about IT turnover. How will you create a culture that makes those expensive employees want to stay?
We actually have very low turnover, which is why when I have any, it’s a challenge. We are not always able to compete on salary, of course. I don’t think there’s any not-for-profit hospitals who can compete on salary all the time.
We have a really strong culture that has a very nice work-life balance. We tend to promote from within whenever possible so that individuals have a career path. We are increasing the number of career paths, so that people feel like when they complete the projects, that they would have the next step and they can see that somebody has gone ahead of them and advanced at Edward. We try and be really accommodating when people say, “I like to work on these types of projects versus these types of projects,” we try and adjust based on that.
It’s just a really nice place to work. People are very nice. Individuals really like their co-workers.
Those are the kinds of things that we do. We of course have work from home and provide the tools through all of your standard electronic communication so that people can work from home or work from anywhere.
I don’t fear the turnover as much as some people do. We will have some, I know we will. But we’re also then going to have an opportunity to get other terrific people into the organization. In the proximity that we are, we also live in a really nice community, so people like to live here and they like to work here.
Epic, both as an employer and as a vendor, tends to like to bring people in who don’t have much IT background. They almost seem to have an anti-IT bias, working around IT instead of with them. Do you see that as a challenge?
I don’t know that we’re going to have as much of a challenge. I believe that our IT department is really integrated into the hospital. We don’t have a big “us–them” kind of issue with our operational owners. I’m sure there’s a little bit of that everywhere, but I think the idea that we’ve always had to have a physician – and it was important to Edward to have a physician in the CIO position, because they really wanted to make that this wasn’t — that we were very connected to the business and very connected to the clinical workflows. We have former accountants who have moved over and have come into IT and vice versa, so we’ve had some people who’ve been in IT and then moved back into the business piece of it.
This was a decision that was not an IT decision. I mean, everybody says that about Epic. This really was a complete grassroots, bottom-up user decision to choose Epic, so right now, people are feeling really collaborative and feeling really close together.
The majority of our project is not being staffed by consultants or IT people. We’re pulling people off the floor, sending them to training, and then they will be full time on the project. We will end up during the project having fewer IT people working on it than we will users;. There’ll be more users working on the project than IT people and they’ll just be working side by side.
You are a CCHIT commissioner. Do you think certification has done what it was supposed to do in reducing provider risk and do you think that role is still important?
Well, that may be the most controversial question.
If you think about certification, I’ll divide into two phases. One is the formation of CCHIT, which was to help increase adoption of health information technology by removing some of the risk on the buying side, and that CCHIT certification really meant something and that when if you were buying a CCHIT-certified product, it wasn’t going to be perfect, but you could be assured it was going to have some baseline interoperability security and functionality.
I do think that that changed very much the way that people purchased systems. For example, the days of the scripted demos to make sure that you could do long lists of specific feature-function .. those days are gone, and mostly because if it’s a CCHIT-certified product, you can already pull out the long list of feature-function, security, interoperability items that you know the product can do. I really believe very strongly in CCHIT moving the market forward.
My concern is that certification for ARRA is a significantly lower bar than CCHIT certification was. There is absolutely zero requirement for anything related to workflow in the ARRA certification. An implementation doesn’t fail based on any particular nit of functionality. It succeeds or fails based on whether it fits the workflow of the user — the doctor, the nurse, the scheduler, the accountant, whoever is doing that.
For example, in the office-based setting, tasking between physicians and nurses is a huge workflow component. That’s part of CCHIT certification, not part of ARRA certification. But you know if the physician or nurse in the office can’t affectively communicate and task patient follow-up back and forth, the implementation is going to fail.
I am afraid that we are going to hear a wave of stories of failed implementations of ARRA-certified products. I fear that we will have physicians and offices saying, “I bought a certified product. Why can’t it run my office? Why doesn’t it do these basic things in the office?” It may do it, but the certification doesn’t guarantee that you’re going to have a product that’s actually going to work for the environment that you’re buying it.
There’s that argument to be made that CCHIT-type certification is for the product and maybe ARRA is the certification of the implementation, which are really unrelated because you can do some pretty amazing things with some pretty crappy products and you can take a really good product in the wrong hands and turn it into a disaster. Do you see any influence of the Regional Extension Centers in trying to close that gap between what the product can do versus what the users try to make it do?
I think that it’s exactly the right idea, you know, put experienced people feet on the street in the areas that people are trying to implement. I have not seen a lot of real impact of the Regional Extension Centers. I think there’s a lot of regional variation. I know that some here are doing really great things and really helping, and then I think that some others are not.
I’m not saying it’s easy to get into these small doc practices and make it work. I think it’s really hard. I’m not so sure that the Regional Extension Centers have really checked the box or been successful yet as a whole.
Everybody who’s trying to predict the next hot trend thinks it’s going to be data warehousing and business intelligence based on electronic data that these electronic medical record systems will create. What are you looking forward to or planning for at Edward Hospital as far as what kind of data you’ll have and what you’ll do with it?
We’ve had a data warehouse for quite a while. I think it’s because we were running a different system in the inpatient as in ambulatory as in operating room. We really needed to have a data warehouse in order to get any kind of basic information to run the business.
I do think that that’s going to deepen, but I find it very interesting. The biggest thing we’re working on other than Epic is a clinical integration project. What I mean by clinical integration is clinical integration in the FTC definition, where groups of hospitals and groups of physicians who are independent come together to work on cost and quality metrics and then therefore can come together to contract with commercial payers. I think a lot of people will consider it a steppingstone to an ACO, perhaps not with Medicare, but with the commercial payers and with not quite as much risk as there would be in a full ACO. It’s a way to learn something about aligning physicians.
While we have this really nice robust data warehouse, the data that we’re looking to rely on from our independent physicians is billing data. I can’t believe we’re still doing this, but if we’re trying to say, “What can our independent physicians give us that will allow us to track our cost and quality metrics so that we can present to commercial third-party insurance companies that we really deliver better service,” the kind of data that they can give us is the claims feed. We’re looking ICD-9s and CPT II codes.
And you know what? I don’t feel great about it, but it’s better than having no data. I can’t expect these small physician practices to be … you know, they don’t have data warehouse, a business intelligence person. They can only give us what they can give us and that’s that.
I think we can be really hospital-focused and think about all of our big IT resource staff, but when it comes down to it, the majority of care is being delivered in the ambulatory setting by physicians. Even though physicians are becoming employed at a very rapid rate, there still are a whole lot more independent physicians out there delivering care. They have the data. Ten years after being in IT, I never thought I’d be back to a claims feed.
When you look at the important trends and challenges with the ones you see at your hospital and in the industry overall, which ones do you think are most significant?
If you have like five number ones, they can’t be number one? I think the pressure on declining reimbursement just impacts everything, because it’s across the board and impacts everything you do — new program expansion, investment in technology, investment in training, all of those things. It creates an enormous amount of pressure.
The increased patient-consumer empowerment. The idea that well, physicians refer a lot of patients to Edward and physicians are a very important customer of mine. There are times when the patients pick the hospital first and then they pick their physician, so they’re coming to Edward first and then they’re looking for an Edward physician. I think that that’s just going to continue to increase.
Any final thoughts?
I have to tell you I’m super-excited about what we are doing here. I feel like the entire time that I was at Eclipsys and the entire time I was at CCHIT, I was working towards this really comprehensive, patient-focused electronic system. I’m now getting to implement it. I’m pretty excited about it.