HIStalk Interviews Joe DeLuca, Knowledge Architect, Fulcrum Methods

Joe DeLuca is knowledge architect with Fulcrum Methods of Oakland, CA.

Give me some brief background about yourself and about the company.

I have been in the healthcare informatics and information technology industry for about 30 years. I started back in Wisconsin, primarily doing research work on effectiveness, the use of information technology to achieve what we would call the early ‘80s critical effectiveness, and better efficiency and efficacy. That started my career in wanting to help improve the healthcare through both consulting and the development of measurement tools. That culminated in the development of Fulcrum Methods.

At Fulcrum Methods, we provide methodologies, templates, and standard tools that help organizations go through the information technology planning, vendor selection, design, implementation, PMO processes – all focused on outcomes. The theme in my career has been aligning the specifics of a clinical improvement process or business improvement process with the use of technology. I feel very fortunate and privileged to have been part of this evolution over the last 30 years as it continues on.

You co-wrote the book, The CEO’s Guide to Healthcare Information Systems. What mistakes do you see hospital CEOs making with regard to IT strategy and their relationship with their CIO?

I think I would break that into a couple of components, if you’ll allow me to.

I think there’s been a tremendous shift in the awareness of the role of information technology and responsibilities of the CIO over the decades that I’ve been doing this. I think today the CEO-CIO relationship, whether it’s a direct report or not, is much more respectful than it was in the past. Progressive, if you will.

The mistakes that are made today have to do with incomplete involvement of the CIO in the strategic visioning process for the organization, and in the assessment of how information systems can progress, accelerate, and differentiate the organization. I think it’s better than it used to be, but it still requires some improvement.

For example, we have many technologies … I’ll pick on one because it was just recently noted in part of HIStalk … NCR’s healthcare kiosk was sold to QuadraMed. There was a time when the whole kiosk self-serve technology was foreign to the healthcare industry, and many regards it still is, depending on the adoption rates.  But there were some leading CIOs who came forward and said, “You know, we really need to look at this. This improves our patient convenience. It improves our satisfaction scores. It gives us better access to information, increases productivity, and so forth.”

That kind of thinking — bringing that forward — is something CIOs need to do more. That’s just a small example of that versus waiting for the CEO or the executive team to dictate more of what should be done based off of someone else’s doing it.

Because of Meaningful Use, people are making huge investments in clinical systems. Some of those decisions are being made fairly quickly and without a lot of publicly obvious analysis. Do you think those decisions are adequately involving the CIO?

I’m going to say yes to that. I think they are, because I think that the investment dollars and the potential for the stimulus dollars in inventive payments and then eventually, the Medicare disincentive payments and penalties are ironically forcing the CIO, because of that financial perspective, into a larger role with more credibility and more involvement on these decisions.

I think the patient safety initiatives that started to launch 5-7 years ago had a similar effect, though I think that bubbled off a little bit with the implementation of the systems and the increasing roles of the CMOs and CMIOs in the organization. So I would say there is adequate involvement, or an increased perspective.

I’d also say that today, with the emphasis on what’s going on at Meaningful Use, the CEOs have a better conviction, are more aware of and are focusing on the quality of the implementations that are occurring. At least in my consulting work, I see CEOs and CFOs actively sit back and go, “This is not just about getting the money. This is about doing it correctly. This is about doing it so that we permanently change our processes. In order to do that, we have to have a team of medical management, CMIOs, CIO, and other elements of the organization to achieve that.”

I’m sure some places consider the HITECH money they’re going to get as the initial return on investment. The CIO gets a pat on the back for achieving that. What pushes the next set of steps?

For the first point, in some organizations, I’ve seen the CIO and the team involved share some incentive bonuses relative to achieving Meaningful Use. Not large ones, but it’s certainly happening.

When the program was put in place and the set of Stage 1-2-3 distinctions were put onto the timeline, it was really quite an intelligent process out of Washington, DC. The emphasis on Stage 2 … some of it is just increasing the numerators on number of medication orders that are processed through the system electronically, but many of them, especially the physician requirements, the eligible professional requirements, really do focus on increasing the patient involvement, the patient interaction with care, transferring some data along the continuum of care in a consistent way that can be used and interpreted by the providers along the continuum. That clearly is the movement towards whether we want to call it accountable care or value-based compensation or pay for performance or population management – good things to do for healthcare, things that have been needed for a long time.

I think the impetus to continue will be the business value that’s now achieved from certified electronic health records as it moves towards managing a population, both for quality and for economic gain. At the end of the day, the health systems and eligible professionals are still going to look at what’s the financial benefit associated with Stage 2 and clearly Stage 3, with an emphasis on population health improvement, are the incentives to continue to move along to the end road further.

If a CIO realizes that most of their responsibilities and the expectations placed on them involve keeping systems up and running, having the help desk be responsive, and keeping cost under control, what are some strategies they can use with this opportunity that HITECH and the potential of Accountable Care Organizations have put in front of them to earn a more strategic role?

I think the first realization that CIOs have to come to grips with is that they can no longer think information technology, infrastructure, and application systems. Many have progressed beyond that. The CIO today, in order to advance and survive two, three, or five years from now, has to be thinking informatics. I use that term very precisely.

They have to be thinking about how the information that is managed through the information technology assets are actually used to achieve that business benefit for the organization, that clinical benefit for the organization. It’s really quite beyond just efficiency. Efficiency is certainly one element of it. Could I move my transactions along faster? But it’s really the informatics component. How do all of these different aggregations of data get transformed to clinical information that then improves both our care position with our population and our financial position?

The key survival element is to get very deep into this learning curve, if they’re not already there. Get in front of the questions that are being asked.  If someone today says, “I’m going to build an Accountable Care Organization. I’m going to need to have some quality improvement metrics.” Great. That’s certainly a starting point. The CIO needs to be saying, “How are we going to actually improve care? What’s the next step in those quality metrics? How does that integrate in with a patient-centered medical home? How much do I understand that, so that instead of waiting to be informed by the physician community, by payer community about this, I can actually inform my executive team about those needs two or three years from now?”

What structure and expertise does a CIO in a medium to large hospital or hospital network need that they didn’t need two or three years ago? What do they need to operationalize that change in philosophy about what IT is all about?

There are many demands on the CIO, operational as well as strategic. They need to have a strategic thinking department that may not actually reside within the IT department per se. That could be aligned very, very tightly with the strategic planning group ,with the CMO of the organization, and also since most medium or larger organizations today will have some form of a medical foundation or medical group affiliation, really aligning closely and understanding their needs and their vision going forward.

They also need to have a very strong data modeling capability within the organization. That’s not necessarily to build a custom clinical data warehouse or clinical performance reporting system, but to really be able to understand as all of a sudden, “Gee we have to plug into a patient-centered medical home that’s using remote management technology for congestive heart failure patients.” The minute we say something like that, we have a superficial vision of the clinical flow of information that moves along in order to achieve that. You need someone in the organization who can sit back and model that at a meta level, and inform all of the other elements, both within the IT department of the data characteristics, the patient transactions that need to occur along the way. It’s not really from a technical perspective, but it’s understanding of what’s behind the data and understanding what’s needed to make that data harmonious across all the different ownership patterns of the data.

I will also say that with the explosion of mobile technologies, the CIO really needs to have a good handle on mobile technologies and what that means.

Are IT departments going to be funded to do that? Are CEOs aware of these multiple priorities, everything from customer service to Meaningful Use to analytics to integrating with physicians and other partners, and giving CIOs being given the budget and the responsibility to carry those things out?

I think it’s a split vote right now. One of the concerns I have about Meaningful Use is that it’s forcing this huge investment up front in electronic health records. There may be a hangover effect similar to what happened with Y2K, where all of a sudden, “OK, you had your share. Now we will only fund and continue this progression in very select areas or in a marginal way.”

I’m actually seeing in the consulting practice about half of the organizations constraining IT growth rather than expanding IT growth. That’s resulting in extending the Meaningful Use deployment schedule. We won’t try to get all the money up front that we could, or we won’t try to get any this fiscal year, but we’ll string the investment out or two or three years and slide in right under the wire relative to the reporting attestation guidelines. I’m also seeing pulling back dollars that might otherwise be used for – I’ll call them experimental programs, but that’s not the right term – but for exploratory efforts that might be going on, like piloting that kiosk.

I think it’s going to get worse. I think as the cost pressures come in, we will see further emphasis on containing IT costs to some industry standard metrics that may be underfunding the environment.

I think we’ll also see – talking out of the other side of my mouth on this – a greater emphasis on system impact. If we can prove that it will speed things up, make things better, quicker, faster, improve patient safety, or support some form of a new reimbursement model … those will get funded differentially.

New systems always cost more than the ones they replace, and once the Meaningful Use money has been spent and forgotten, hospitals will be locked into high-cost maintenance. The hospital has a low margin and no real potential for it to get higher, but the IT budget has to grow because all of the systems that were optimistically brought. How will hospitals reconcile their original appetite for IT versus the ongoing cost to keep it?

I agree with those trends. Just as a footnote. I recently completed a total cost and ownership budget for an EHR purchase, working on a graph with percentage hardware, software, and implementation costs, and maintenance and support over time. I went back to a similar study that I did 10-15 years ago just to see what’s actually somewhat happening. As you would expect, hardware cost has gone down pretty significantly as a proportion. Software dollars were about the same as the total proportion, a little bit higher. Implementation costs and ongoing software support were almost twice what they were as the percentage of budget.  

I see that as a problem. The reaction from any organization will be, “These are fixed costs. We know we have to have the software vendor invoices paid, so we will cut end user support. We will trim down our help desk functions. Instead of using an N minus 1 release program,  we’ll go to N minus 2 or N minus 3.” I think that it’s a very real issue. There will be a constant tension in that environment.

I think the other thing that happens is the competition for resources between things like information technology and clinical services, when you have a revenue cycle and top-line revenue is flat or margin is under further pressure. Those contentions, those issues between those buckets of money, become even greater.

Give me some predictions or some unconventional thinking about what you see as the future of healthcare IT.

I think we will see, unfortunately, a major security breach that will damage the view of what we can do in information technology that will potentially hurt the long-term evolution of sharing of data amongst providers. We’re all somewhat very concerned about this. We have information in our silos. We know how to exchange it selectively. We’re now opening this up further with health information exchanges and so forth. I think that’s all very good, but I think we will have a breach that will somewhat shock us.

I think the role of the medical home will rapidly change to not only its physician-supported view, but we will have a new class of care attendants in the home environment. This could be, for example, myself taking care of a chronic asthmatic child or an insulin-dependent parent, where the technology that we will use will be much broader than what we perceive now as the PHR — Personal Health Record, and some monitoring that might be attached to it – that will really be into assisted diagnoses, some replacement of what we would consider to be normally a physician- or clinician-supported process. I see that coming fairly quickly within three to five years, especially as the health insurance exchanges come into play and we move a huge population of uninsured people into the insured population without an adequate supply of provider resources under the current physician labor model.

Last but not least, I think that the aggregation of some of the clinical information into our data warehouses and into our clinical performance reporting systems will support and provide breakthrough benefits for new disease management models. Once we really get some of this information consistently applied, we’ll be able to  overlay pattern analysis and other considerations that we don’t use today, which will help us improve population care.

Any concluding thoughts?

I would make a couple of observations. First, I appreciate the opportunity to do this. 

I have one other concern in the industry. Where’s our next generation of informatics leadership coming from? I am concerned about the CIO for now, concerned about incentives for CMIOs and CIOs to come into the industry and stay in the industry and to fight through the challenges and barriers that are out there. 

One of my closing comments would be, keep this dialogue going, keep people reading things such as HIStalk. Hopefully, that will provide the community that will support the evolution of us in the industry very different than 30 years ago.