HIStalk Interviews Chuck Podesta, SVP/CIO, Fletcher Allen Health Care

You’ve been on the job for a year now. What were some of the high and low points?

The high points actually started with the interview process. I was very impressed with the organization. I was very excited about the EHR the project with Epic. A lot of the heavy lifting had already been done around project organization, budget, and resources. I was excited from that standpoint. I was starting at a time when the project was kicking off, which is an exciting time as opposed to all that pre-planning stuff that you have to do.

Any low points?

No, I really can’t see any. Burlington, Vermont is a beautiful city. It was the first career move I’ve ever made that had a boost, not only from a job perspective, but from a quality of life as well. 

You’ve just gone live with some early parts of PRISM and Epic. What’s next?

We’re into Phase II right now. We’ve gone live with the ED, the electronic health record, which included CPOE, bedside medication, and of course all the nursing functions and charting. We’ve also got the monitors linked in to the flowsheets as well. We completed that on June 6. It’s going very well.

We have CPOE, with 92% of all orders being entered by physicians after just a few weeks of going live. That’s extremely successful for us.

Phase II is our first ambulatory site. We have a large faculty practice, so we’re rolling it out in the outpatient area. That goes live in November. In the rest of 2010, we’ll be implementing our ambulatory sites. Along with that, we are also implementing Beacon Oncology for Phase II — that’s December of 2009 — along with MyChart, the patient portal. 

December 2010 will be our last ambulatory practice and the Cadence scheduling system. That finishes up the three phases of the project.

In conjunction to that, too, we have the opportunity to offer the Epic licensing to other community hospitals in the state and in the ambulatory sites as well. Our project is called PRISM — Patient Record Information System Management — and the extension of our PRISM project is called PRISM Regional. That’s a hosted group purchase solution. We’re working closely with Epic on that.

How will you be using MyChart?

Actually we just fired that up. We’ve got a team in place and we’re working closely with marketing to put together a plan to market that to the community. Two options that we’re looking at right now since we have the inpatient up — we can roll it out from that, but we’re thinking that the biggest bang for the buck is on the ambulatory site. So there’s the decision that we have to make: do we roll it out in December for the inpatients in our first practice and then just continue on with the practices, or, do we wait until we have all the ambulatory sites up and roll it out after that?

My guess is we’ll probably implement the inpatient side of it and then we’ll add on each ambulatory practice as it comes up. So the practice will have to work with their patient population to get them signed up to use it. But we’re still in the early stages of that right now.

Have you changed the project scope or timeline due to economic conditions?

No, we really did not. We were not part of a bond or anything like that. The money was basically money in the bank, so it wasn’t an issue that we were running into bond covenants or anything like that, or we would have to stop and conserve cash or anything along those lines. We were lucky that we got all that done before the market started to tank. So the investments were there. We met all of our deadlines.

What is the expectation for return on investment?

We’ve got a benefit utilization group. We came up with some of the different benefits. We’re also convening the group now that we’re live, actually going in and start to measure those. But a lot of the standard ones that you would see: measuring medication errors, some types of quality patient safety.

But what we see as the biggest bang for the buck is utilizing the system to help us drive towards a best practice. For example, if we have an initiative to reduce nosocomial infection rates, how can we use the system to prompt the clinicians to protocols that drive that number down? That’s what we’re really focused on right now. With Epic, with the Clarity database, which we have as well, which is the clinical decision support database of the Epic system — we’re going to utilize that heavily to start looking at where we can impact the care process.

Any specific timeline for being able to show those metrics?

I think once we deal with the initiatives we have right now, like medication errors, by the end of summer we’ll have some good data on those. We did calculate the "before" picture prior to going live. We were collecting data probably for a year before we went live on certain measures. Once we get over the learning curve, we’re going to go back and see how we’ve impacted those. By the end of the summer, beginning in the fall, we should be able to do that.

How are you engaging physicians?

To me that’s been a real success here. We’ve got an orthopedic surgeon who’s about half-time on the project. He has been instrumental. He knows the system inside out and has been instrumental in working with physicians.

We also have a physician advisory committee that’s very strong, providing physician leadership. The chairs have gone along on with them, so that’s working well. Our CEO is a physician, so that definitely helps with pushing the adoption. The physician leadership actually voted in the bylaw that, to be credentialed to practice at Fletcher Allen Healthcare, you have to use the system, including CPOE. That’s part of our success in driving that percentage up as well.

That was key and also our education process. It’s one thing to have a policy, but another thing is to implement a procedure that works. We did a lot of work with pilot groups. We took a pilot group of 10 physicians and ran them through the standard eight hours of training. With their feedback, we were able to design a training program that worked for physicians which was a combination of the e-learning modules and didactic classroom training. 

We let the physicians decide which learning environment they wanted to do, e-learning or didactic training. But in all cases, when it came to the certification process, that was in the classroom. So we let them learn the way they wanted to learn, but we made sure we certified them and there was a standard way to do that. That worked out very well and was very well received because you could do the e-learning modules offsite on the weekends and such.

The other thing that was unique with Fletcher Allen is that this whole project — the PRISM project — reported up through operations, not to IS. The two executive sponsors were the senior vice president for patient care services and the president of faculty practice. As the CIO, I had operational responsibility but not executive responsibility, which showed the organization that this is not a technology project but a process redesign. It was a change to the way that we deliver healthcare. I think that was a good way to go.

I understand you’re on the board of the VITL?

Yes, Vermont Information Technology Leaders. That’s the HIE.

How will you participate in the HIE and what’s going to be your involvement technically as you move forward?

We will actually link up with the exchange based in Vermont. We have an opt-in process, so the consumer — the patient — has to opt in for the records to be shared. By the end of the summer, we should have those links in place.

We’re starting with lab results and orders, but then we’ll move rapidly to bi-directional continuity of care documents with VITL. The power of that is going to be that if we have other hospitals run Epic in our a single database, they’ll be automatically connected to the VITL exchange. That will be very powerful.

Is it tough being an Epic shop in the epicenter of GE-IDX?

Yes. I came from Massachusetts, so I don’t have the Vermont history here, but I do understand it was probably more of a tense situation back in 2003, 2004, and 2005 when the selection process was going on. I got here after that was all complete.

We do still have the revenue cycle for IDX. We also have ImageCast, the radiology system. So, we still have a relationship with GE-IDX. If we had gone with everything Epic and not had any GE here at all, it probably would have been a different issue. 

We meet with them on a regular basis. We’re actually in the process of potentially doing an upgrade of the IDX system as well, so the relationship seems to be good. GE is also the vendor that’s doing the exchange for VITL, so there’s plenty to do for everybody.

I understand Fletcher Allen gave the ACLU an advisory committee seat. Is the way you’re addressing privacy a lot different than where you worked previously?

Yes. If you look it at the HIPAA rules, opt-in is not a federal law. It does not come into any of the HIPAA guidelines. I think Minnesota is the only state that has actual legislation and made opt-in a law. But in my mind, it is the gold standard, and probably with the new ARRA privacy regs will probably be standardized in most places. So we decided at VITL to adopt that ahead of time knowing that it was coming, and then as part of PRISM and PRISM Regional we’re following those guidelines as well. We had a subgroup which I was on that is part of VITL; we did a lot of work in that area, and not only the policies themselves, but the procedures to implement.

What lessons learned can you share with other CIOs about your PRISM project?

I’ve been through a few of these with different vendors. I’ve done MEDITECH and SMS before Siemens. I’ve been doing this for about 30 years now and each one’s a little bit different; I always learned something new on each one. 

For go-live support, we had about 185 people with yellow shirts on, including the vendor, consultants, the IS team, the PRISM team, super users — it was just a sea of yellow out on the units and in ED. It really gave people comfort, even if they didn’t have a question, to look up and see four or five people in yellow shirts on. We had a lot of positive feedback on that, knowing that if they did have a question there was somebody there to answer.

We put in a best practice service center and spent a lot of time doing 24/7 with our service center. We ended up answering 9,000 calls in about an eight-day period. It was only about a four percent abandon rate. We trained those in the service center. We actually put them through the same training that the nurses went through. On the front end they had a lot of knowledge on the Epic system.

Senior leadership visibility. As senior leaders, we all had the yellow shirts on as well. We were here 24/7 doing different shifts, just being visible more as cheerleaders and support. Our management team delivered food. These seem like little things that are huge. When you’ve got a nursing unit in there struggling from the standpoint of learning a new system in patient care and all of a sudden the manager wheels a cart up in there with all kinds of food on it, it just means a whole lot to them that we were all in this together.

So those were the keys, and I think what I mentioned earlier: if you want to drive your CPOE adoption rate up, you really have to focus on that with good physician leadership. Also, potentially changing the bylaws, and the training, and support.

Also, one tip that I’ll give. If you are an academic medical center, if you have access to medical students within an urban area, use them to support the physicians. It worked out great. We paid them a small stipend. Typically they’re broke, they’re happy to get a little bit of money, and they’re young, they’re doing the Twitter stuff already so they just take to this stuff. They were tremendous. I think we ended up with about 20 medical students that supported the physicians. They were a great help as well.

But to me, what I learned on this one was really that the go-live support, the command center, the service center, and the people we had there — to me, that was the key. A lot of organizations may short-change that a little based on cost, but I think it’s key to getting past the go-live hump and then moving into a support model.

Last question: in your opinion, what are the biggest threats and opportunities across healthcare IT today?

The biggest opportunity is with the ARRA money. I think the threat is also with the ARRA money, depending on how meaningful use and certified EHRs develop and are identified. The HHS is leaving some of that open for public comment.

I think the biggest threat is that some of these vendors might not be ready. For the ones that do have the product, the line to get that product could be out the door. So from a timing perspective, it’s going to be difficult.

I think there needs to be some new models that are created for implementation across the country, because if you look at HIMSS’ eight phases of adoption, you’ll see how many are not even near meaningful use. The vendors don’t have the capacity and there are not a lot of educated resources on implementing EHRs. Those individuals that are educated are going to be snapped up by the consulting companies, then, charged back at three hundred bucks an hour.

So I think workforce development and the implementation itself is a threat, based on ARRA. That’s why I’m seeing some of these community hospitals going to their local large-hospital academic medical center and saying, "Can you help us?"

I think the model that we’re creating here with PRISM Regional — I’m starting to see with other Epic sites across the country — Geisinger, Cleveland Clinic – -some of the others where they’re actually looking at putting the system in and helping these community hospitals get to that meaningful use. So that’s where I see the opportunities are, but the threats as well.