Rob Culbert is founder and CEO of Culbert Healthcare Solutions of Woburn, MA.
Tell me about yourself and the company.
I started my career in the mid-1980s with a company called IDX. I had the pleasure of watching IDX grow by leaps and bounds over a nine-year career. I’ve been in the consulting world for over 20 years, starting Culbert Healthcare Solutions in 2006. We are just entering our 13th year, having a blast, and trying hard to help customers through all these crazy times of healthcare.
How is consolidation in health systems, software vendors, and consulting firms affecting your company and the industry as a whole?
We’ve seen it as well. It’s hard to avoid it. In some ways, it’s positive because it’s an opportunity to gain efficiencies through economies of scale.
The areas where we have seen it the most have been around organizations coming together and either consolidating billing operations or creating centralized billing functions. Also with IT opportunities. In many cases, organizations are able to make better IT decisions when they can spread the cost over a larger population to pick the technology that makes the most sense for the newer organization. It’s a win for the patient, obviously, the more centralized an electronic health record. From a billing and efficiency standpoint, organizations have great opportunities to do their job easier.
What is the impact of Epic and Cerner offering systems appropriate to smaller hospitals?
It helps the vendors get a customer that they might not otherwise get. The need and the interest in being able to outsource IT for organizations that don’t have the bandwidth to hire the technical talent in-house — it makes it a tougher decision if they have to own that responsibility. If they can leverage a larger organization that can provide security and disaster planning, then it’s the difference between selecting a system vendor and not selecting a system vendor.
People have always said that it’s hard to sell small hospitals pre-packaged software that was designed to meet the more complex needs of larger hospitals. Do you get calls now from some of those small hospitals that are implementing Epic and Cerner who need help with implementation, maintenance, and optimization?
We do. You’re right, it is amazing that smaller hospitals that you wouldn’t have thought of as being a traditional Epic or Cerner customer can now take advantage of that technology like the big boys. We see it quite a bit, whether it’s through an affiliation with a larger organization or becoming part of a larger organization. It really does help them to be able to get access to a system.
The content that has been provided by the vendors, in addition to the software, helps organizations make the right install decisions. There’s a whole lot more tools to help them through that process than there used to be. The timetable of how it takes to implement a hospital on these systems has narrowed quite a bit to make it a win-win.
Are hospitals with less-certain margins questioning the ongoing cost of maintaining these systems?
I would say it’s the number one worry that they have. Trying to balance the user’s need for functionality and technology to do the job and the costs associated with providing that technology and supporting that technology. There’s always a balance.
The challenge in looking at it compared to earlier times is that systems are more integrated now. Typically when we were involved in a practice management implementation or a hospital billing system implementation, you didn’t get involved with people outside of those departments. That can’t be the case now because so much of what clinicians do, in terms of entering medical data for electronic health systems, is going to ultimately feed the billing side of the house. There has to be a whole lot more coordination.
If you look at total cost of ownership and take out the non-pure IT costs that can be eliminated if you set up the systems correctly, the cost of expensive systems comes significantly down.
Are hospitals looking back at the cost and effort of implementation to decide if they got their money’s worth?
A number of customers that have asked us to help them take a look at what they’ve already spent. Many times it’s because they have board members or C- level folks who are reading the newspaper and find a horror story that talks about costs of implementing a system, the challenges that came out of the early days of that system going live, and the disruption it caused to the physicians and to the organization.
What we have found is that typically when you let the dust settle — because everybody starts out all thumbs on a brand new system regardless of the system — and you get to the point where they’re using it the intended way, the costs settle down. In many cases, we’ve been able to show customers that their investment turned out to be a very good one. That helped justify their willingness to move forward to a Phase 2 or Phase 3.
We typically don’t see a ton of big-bang implementations of every application across the board. We’ve seen an awful lot of cases where it’s been staged. There’s been nervousness around, did we spend too much? Did we get the value? Is the system doing what we want it to do? We’ve found that often that investment has proven to be invaluable and helped make the decision to move forward to completing the enterprise-wide system. It’s made it a “go” decision more often than not.
A lot of what passes for interoperability involves entities within a given health system connecting their respective systems. How much interest do unaffiliated health systems or practices have in exchanging information with those potential competitors?
The reason we typically see the challenges of trying to share all of the patient data within the multiple systems that one organization might have has more to do with the business need to grow faster, add more physicians, or help hospitals into the fold so that they can do their job better of managing costs and helping patients across a wider spectrum. The business decisions around needing to implement those acquisitions quickly happen far faster than the IT systems can keep up with changing them over. That business need is what has driven some of the system integration pieces to lag behind, where everybody would prefer to start right off the bat with a clean system that is fully integrated across the various entities that have come together over time.
After that, in terms of sharing with others outside of the particular organization, the interest is there and the need is there, but we see a mixed bag of success in that happening. It is dependent on what each of those organizations use for technology as to whether or not they have the mutual interest and the ability to afford the resources to put into sharing that data.
What factors should health systems check before hiring a firm to do major implementation work?
What is the goal at the start and the end of an implementation? In some cases, if an organization has a system software license that’s going to expire in 12 months and they have no interest or ability to extend that license, then they might be under the gun to do an implementation in that time frame, regardless of whether the organization is ready and able to handle all the change management that goes into making that implementation successful and do the change management and the re-engineering of work flow to best change advantage of what the software can help you with.
That’s where we see the missed opportunities — if there are pressures above and beyond just doing the ideal implementation. Some of those organizations, whether they like it or not, are making the strategic decision that they have to move forward, get the system up and running, and then do a wave of optimization after the fact in order to make sure that they round out all of the bells and whistles and the features that could go in place.
Any time you do a big bang implementation of this size, you are hitting people over the head in terms of the amount of change that they are going to have to absorb in a short period of time. You typically try to push out your training until the very end for almost any of your users, because whatever gap in time between the training and the go-live point is going to hurt their ability to remember what they learned in training and take advantage of all the tips and tricks that they’ve been taught.
Once users get used to the system, in some cases finding themselves to be using their thumbs more than they want to, optimization waves provide a great opportunity to reinforce best practices that may have been taught in the beginning but that were forgotten. In other cases, the organization has the ability to turn on features that didn’t go on in the beginning, or maybe they turn them on because they see challenges, opportunities for improvement, or the chance to make users’ lives easier. That never changes. Constant, ongoing training to help users take full advantage of the technology. It doesn’t happen overnight. Sometimes system implementations get blamed for being a bad implementation or a poor implementation when it’s really just the start of the journey.
What is the single biggest trend you saw in health IT in 2017?
The number of organizations that were looking for a partner or an affiliate to leverage their need for IT. Their need for knowledge of the IT in order to get the biggest bang for the buck for their IT dollars and spend. Why reinvent the wheel if someone has already done it very well and you can take advantage of their best practices to get you to the end game faster?
Do you have any final thoughts?
I’ve been in this business for over 30 years. I’ve watched providers come together, go apart, and come back together for lots of reasons. The most exciting part is that there’s an opportunity to use data to make the provider world so much better, allowing them to do their job for patients in new ways. We are only seeing a fraction of the benefit of EHR installs today because we’ve been so busy getting people to take advantage of structured notes and following a structure that can now turn into data that we can use to do great things.
It’s scary and it’s frustrating because it’s a much bigger pie than we’re used to when focusing on clinicals, financials, hospitals, or ambulatory business, but all of that now has the ability to come together. We’ve never had access to that information. We will have better ways to help the patient and run an organization more efficiently than we’ve ever seen.