HIStalk Interviews Rick Stockell

Rick Stockell is president of Stockell Healthcare Systems of Chesterfield, MO.

Tell me what Stockell Healthcare Systems does.

We write software for patient access and revenue cycle management. By patient access, that’s the registration and scheduling components. The revenue cycle is all of the regular registration, ADT, charge capture, medical records interfaces such as a 3M encoder, a collections module, and the 837 and 835 back. Eligibility checking, medical necessity checking, and those types of things.

Our roots are all the way back to McDonnell Douglas Healthcare that was here in St. Louis. We’ve been in the healthcare market for quite a while. We were a contract programming group from McDonnell Douglas. We did a lot of development for McDonnell Douglas and their mainframe and minicomputer lines.

We go back to the original UB-82. We were writing that, so we’ve been in the patient accounting and billing space for years and really understand how it’s changed and how it’s evolved. We’ve got a tremendous amount of experience in the patient accounting area and we’re going to use that to our advantage as we pull this product together. We’ve been in the business a long time, so we’re not an upstart.

Maybe everybody’s more familiar with the company than I am, but I mostly remember back in the days where 3M used your order entry system for Care Innovation, if I recall.

That’s correct.

Who would be most familiar with the company today?

We typically partner with electronic medical record companies. We’ve partnered with, like you say in the past, 3M. Until GE bought IDX, they used us for the same thing — order communication and order management. We also partner with Medsphere, with OpenVista. DSS is another one. They tend to be in the government space more than others.

They don’t have revenue cycle solutions. When they compete against the other healthcare vendors in the marketplace and to have complete solutions, they need an answer for patient access and revenue cycle. We’ve partnered with them. We’ve done that multiple times with them.

Also, some new ones that are international. Alert is one out of Portugal. We are also partnering with Eclipsys internationally. We closed a deal in Kuala Lampur, Malaysia — Pantai Health System.

I saw that. How did that come to be? You don’t think of revenue cycle when you think international, yet you’ve got this string of hospitals in Malaysia.

It has to do more with the footprint of the product. It’s all on a Microsoft technology, so it doesn’t require mainframes or any of that type of thing.

A lot of the older patient accounting and billing systems — ones that have been in the market for years, really, 25, 30, maybe even 40 years in the case of the Invision product line — most of them came from batch-oriented systems. They require a lot of hardware, a lot of software, layered products, and bolt-ons for them to be useful. It’s just not conducive to the international market because there’s such a large amount of the architecture dedicated to third-party reimbursement here in the States and the regulatory environment here, so it’s a lot different there.

It’s a real-time system as opposed to batch. The footprint’s smaller and it’s easier to use. It’s very user-friendly. It makes sense really quick. It’s got a complete relational database designed underneath it. To configure it for different needs is relatively easy to do. We’re in a lot of different market settings — behavioral health, long-term psychiatric, government, all kinds of different reimbursement models.

At Indian Health, we have three sites. We’ve gone independent from the Indian Health Services and we’re opening our own facilities and they’re like a commercial private/public consortium. We’re very, very flexible in our abilities to implement different revenue cycle designs, Because of that flexibility, it lends itself to the international market.

You mentioned the Alert product and a couple of variations of the VistA product. How easy is it to coexist with those applications?

It’s actually very easy. I think we’ve integrated now with interfaces to about eight different clinical information systems; including Cerner and Eclipsys. We did it with GE as well, their original Centricity line. I think they re-labeled all that. Now it’s really the IDX product, but we haven’t integrated with the IDX system. But the precursor, the original versions of Centricity, we’ve integrated with. So, yes, we’ve done quite a few. In the behavioral health area, Sigmund, MindLink, and Sequest. 

We’re really, really good with HL7. You recalled we did order communication for 3M — their Care Innovation suite. We also built the order communication component for the original Centricity product for GE. Since we’ve had so much experience with HL7 integration with these electronic medical records and departmental systems, it’s really pretty straightforward for us to do integration to a clinical suite.

It sounds like you could either be the revenue cycle component for a vendor that has only the clinical and departmentals; or you could be the clinical component for someone who has the revenue cycle.

No, normally we’re really the revenue cycle. We’ll do some order communication if they don’t like order management. If they’re not really good HL7, bi-directional — you know, orders in and out and ADT and all that — if they’re really not good with HL7 or have limited capabilities with HL7, we can stand in as the order management system for them until such time as they can get that on board. Principally, we’re patient access and revenue cycle.

It seems like a lot of companies are either offering revenue cycle services or software, or both. What trends are you seeing out there since you’re the independent among that group?

The traditional revenue cycle sector is a lot of bolt-on technologies. They’ll work well or co-exist with Epic, Siemens, or McKesson and do a lot with the output of the bills. UBs and 1500s are produced off the primary patient accounting system. They do contract management, for example, a standalone; and then the 837 and 835, some of the electronic claims, and that type of thing. Maybe eligibility checking on the front end, that they just offer services that are really kind of bolt-on. They’re really integration-oriented, just in different pieces of an existing patient accounting system like the older ones.

Our approach is that we’ve built everything into the products, so contract management is part of the product. The eligibility checking and medical necessity checking is part of the product. We don’t need a bolt-on to do that. The 837 processing, 835 processing is embedded in the product so there’s less of a dependence on bolt-on technologies.

We find some of the bolt-on players are trying to get into where they can start to integrate more directly with the electronic medical record to increase their value. We can already do that, and have done that for about a decade now, plus, the order communication piece.

What would be the attraction for customers to look at your solution?

If they are in the market for a new electronic medical record system and they don’t have a good solution or it doesn’t integrate well. Their traditional system, their registration and patient accounting and billing systems — if they don’t integrate that well with the new EMR or if the vendor doesn’t have a good solution for that, then what we are is a replacement opportunity to replace that older patient accounting system with something that works more seamlessly with the electronic medical record. That’s so we can capture charges at the point of care if the electronic medical vendor that they choose doesn’t do charging very well. It handles the clinical components for orders and those end results, but it doesn’t do charging very well.

We can interface at the order level and convert those to charges — charge on order, charge on result — and map those orderable items to the appropriate charges. Then, of course we have a charge master and we can have the HCPCS codes and modifiers imbedded in the charges and make that a little bit more seamless, which reduces the batch charge entry requirement and less manual entry of charges.

I can see, with one of the VistA products or with Alert, they would probably bring you in as an option, but it must be tough if you’re trying to get replacement business. You’re competing against the vendor who’s already in-house. Is that difficult?

It can be because they’ve been in place for long periods of time, maybe 10 years or longer, that they’ve been working on the patient accounting system. But some of the problems with that is that they can’t get the reports they need. It’s difficult to get the information out of the system. They don’t have as good a control over the revenue cycle. Either their AR days are longer or there’s more leakage of cash or reimbursement because of all the integrations they have to do to the bolt-on products.

We can build a pretty good business case that it’s more seamless, it works better with the clinical information system, reduces the amount of staff that’s required versus a lot more automation in our solution. Where a lot of the other systems require a lot of manual touching — they’re more like inspection-based instead of exception-based — so there’s an opportunity for operational efficiency with using our system over some of the older mainframe or batch-oriented systems that have been in the market for years.

How do you think the Meaningful Use and the whole healthcare reform change is going to effect the revenue cycle side of everybody’s business?

It seems that regulatory compliance is one of the big change agents that are always in healthcare. With Meaningful Use and ICD-10 and some of those things, I think it’s going to have an impact on the back-end systems as well. I’m not sure that the clinical information systems just on the front end are going to be adequate to address all that successfully.

I know that in the case of ICD-10, specifically, you’re talking about a larger field length because it’s a larger coding method than the ICD-9; like six or seven digits versus like four or five. So then that’s a change of storage location. That’s got a lot of different places to go and fix that because they’re on traditional file systems where the applications were originally written. We’re already ready for ICD-10 because ICD-10 is what’s being used right now in Malaysia, so we have an advantage there.

I think that all these regulations, as they come along, are going to put a lot of pressure on the older systems. It may be the cost of making changes to those systems may be more than the vendors that own those products are willing to put into them.

I think with all the excitement about clinical systems, maybe people have forgotten about things like ICD-10. What are your thoughts on how that change is going to affect everybody?

There’s the coding. I think, in the medical records area particularly, where they’re coding; that there’s so many codes that coding method’s going to cause a lot of change for all of the medical records departments. With the Correct Coding Initiative, that’s a lot to learn. Everybody’s been on ICD-9 for quite a while and ICD-10 is a lot different.

Then, all those codes will have to filter through for the claims and the edits that come along with those. New codes are going to be a little bit more complex. I’m not sure what impact they would have, specifically, on the bills themselves, but that would open it up for a lot more rules. There may be a lot of gaps in the older systems that might take quite a while to fill when they move to ICD-10 and I think we’re ready for that.

What do you think about ERP systems?

That’s a very mature market. In the US, it’s Lawson, which seems to be the one that has most of the market share.

We are integrating with Oracle in Malaysia. That is an opportunity. Oracle had a couple of tries at trying to get into the healthcare vertical and hasn’t really had much success with that, especially in the US. I think that an opportunity to get into the healthcare market, probably internationally, is what we’re going to see more with Oracle.

We don’t run into PeopleSoft or SAP very often. Those seem to really high-end and geared more towards the manufacturing environment than healthcare, but I think they’re going to continue to do all right.

I think that most people have made decisions for the ERP system, but again, traditionally, accounts receivable would be part of that solution. But when you’re having to do everything down at the encounter level and case mix and all those types of things in healthcare, it really strains the architecture of those ERP systems, which seem to be much better suited for direct customer-vendor relationships as opposed to this third-party and multiple payers and coordination of benefits.

One of the other things that everybody’s paying some attention to, at least, is data warehouse, data retrieval, and business intelligence. What are you seeing in the marketplace for that?

That’s another bolt-on opportunity, it seems, in healthcare. That’s another thing that’s embedded in our products.

Since we’re on a Microsoft environment, you have the whole Analysis Services that’s part of SQL Server 2005. And now, 2008 is even stronger — we’ve got scorecards and analytics. The warehousing is built right into the product, so the detail source that’s coming from our applications feeds the warehouse directly. We’ve got some pretty good score-carding and reports right out of the application set that makes BI a lot easier.

For us, it’s not a bolt-on. The product automatically can see it’s a warehouse that has a lot of those key performance indicators and scorecards and analytics built right into them. For example, we have one for denial management because we get the 835 detail back. We post the details from the 835 so you can drill all the way down to the level of detail of a line item that would be on a bill. If that detail was passed from the 835 from the payer, we can capture all those details and report on that.

Elimination of denials is something that’s much easier for us to do. It’s integrated right into our collections module. If you get a denial, if it’s something that’s workable, we will map that denial right into the accounts receivable system. The user knows that there has to be some action item to clean that up or address that denial. We’re using the business intelligence and warehouse for operational efficiency and management insight.

Does that complement or compete with Amalga?

I don’t know if it competes with Amalga. I guess it could complement Amalga, but Amalga seems to be really more of a framework around the whole care delivery delivery model. Ours is operational efficiency — all of the revenue cycles like AR, days calculation ratio, collector productivity. Those types of things are what we’re using for the warehouse, as opposed to trying to capture various points of care. I think Amalga’s got a much broader approach to healthcare than we do. We’re more specific to our area.

You’ve been in the industry for a long time. Looking outside of your company and your products, what’s going to be happening over the next 5-7 years?

I think that moving from paper to electronic, there’s going to be a lot of workflow issues from that. I think the traditional batch system that we’ve had for quite some time –  they’re going to have to have replacements for that. I know that all of them — Siemens, McKesson, Eclipsys, etc. — have large revenue cycle systems that they’re trying to bring to market to replace those older systems. They’re usually larger. I think they’re really aimed up-market more than they are mid-market or even down-market.

I think there’s an opportunity at the community hospital level, for certain, because they do have money and they’re the ones that haven’t been able to automate like the larger institutions. They have more wherewithal to spend on electronic medical records. A lot of them already made decisions on what they’re doing. Then they’ve got those vendor relationships that probably are going to go with their revenue cycle solutions.

But you get into the community hospital space — the pressure to have an electronic medical record in place for Meaningful Use and all these other things — I don’t know that the revenue cycle systems are going to be able to keep up with the older revenue cycle systems that some of the smaller vendors have. They’ve got to be able to keep up with all that.

One that comes to mind is QuadraMed. QuadraMed’s had a difficult time trying to handle both the clinical R&D and the revenue cycle side, which is a tremendous amount of R&D. They’re kind of caught. They can’t go up-market very well; that’s pretty much saturated by the larger vendors. I think the community hospital space is underserved and I think it’s a great opportunity for us. In that real small footprint, we’re more affordable, easier to use, and have less moving parts when you start looking at all the bolt-ons that have been traditionally required. I think that’s an advantage for us.

Any concluding thoughts?

I think that we’re going to continue to see what we can do in the international space, continue to partner with clinical information system vendors that don’t have a revenue cycle component. There are people looking to get into the electronic medical record, but outside vendors that are taking a look at the US market and say, specifically for the community hospitals that the vendors served — and there’s a lot of competition out there and there’s a lot of clinical information systems that are already written and up and operational around the world — they’re looking at the US market, maybe, for an ability to expand for them. They won’t have a revenue cycle solution with the US regulatory and third-party. A company like ours that’s independent would be a good partnership opportunity for them.

We could help bring some competition into the US market, maybe, from overseas that hasn’t been here before.

HIStalk Interviews Daniel Barchi

Daniel Barchi is SVP/CIO of Carilion Clinic of Roanoke, VA.

You just finished your massive Epic project, with eight hospitals and 100 practices brought live over a couple of years. Tell me about that project.

When we decided that we wanted to integrate from 11 different medical records — 10 electronic and one paper — down to one integrated system, it was 2006. At the time, we were also merging from being a confederated health system into a single Carilion Clinic, so the two projects converged nicely.

We knew if we wanted to operate like an integrated system and have a continuum of care for our patients, we needed one tool to do so. It was an easy choice to select the one integrated EMR.

We ended up choosing Epic because they had a reputation at that time, and I think still do, for implementing well. We knew we had the focus of the entire organization, so we took advantage of it and used it as a tool to integrate all of our hospitals and our practices onto one platform as rapidly as we could, while still protecting the use of clinical data and the health and safety of our patients.

Carilion was a high-profile Siemens client and an early Soarian adopter. What led to the change from Soarian?

Soarian had a great reputation and was doing a lot of innovative things. But when we traveled to Malvern in the summer of 2006 and saw where they were in the development cycle, they were making progress, but they weren’t going to be ready to do everything that we wanted to do as rapidly as wanted to do it.

We knew that we wanted to implement our integrated EMR in every clinical area and work financials in at the same time — front office, back office, hospitals, physician practices — and so it really forced us to find another vendor, which we did relatively quickly.

Soarian has been on the drawing board in some phase of rollout for forever and it still seems like it’s always going to be a year or two more. Do you think it will be a tough job for John Glaser to make Siemens a little more competitive with the window of opportunity that’s out there?

You know, that’s the reputation Siemens has had, and yet it’s a great company. We’re still a big Siemens customer for its many imaging products. If there’s anybody who can make this happen, well, it’s John Glaser. I was alternately surprised and thrilled that he was the one going to take the helm, so I’m happy for him.

I do think, with the right leadership, they’ve got all the right tools and financial backing. There’s certainly a need for more integrated systems. Two or three big companies should not have a monopoly on everything that is out there. The more systems that meet all of the needs of our health systems, the better.

When you looked at systems, what were your overall thoughts?

At the time, in late 2006 to early 2007, we were looking for one that flowed seamlessly. At the same time, I didn’t want our technology team to make the decision. We were adamant that it had to be our clinicians and our financial teams that chose a product that was going to work well, both face-to-face with the patient and in the back office as well.

When we did the selection, we got literally 300-400 doctors, nurses, therapists, and financial folks in the room with some of our IT folks as well and scored them. We went from eight, through a quick cut down to four. We had four vendors on site in front of 200-300 people in a large auditorium. We narrowed that down through the choices of my colleagues in Carilion Health System down to two.

That’s when we had 300-400 people in a room looking at day-long shows from the final two, which were Cerner and Epic. We put a team of about 10 doctors, nurses, therapists, financial folks, and IT folks on the road to do a couple of site visits to see Cerner and Epic in action. Like I mentioned, we chose Epic in the end because they had seemed like a great partner and we were eager to select a vendor that was going to work with us for a rapid implementation.

When you look back at what you chose and where you are today, was Epic something that you were truly excited about compared to your experience with Soarian or was just the best of what your choices were?

We were truly excited. This was not that many years ago — three, three and a half years ago — and certainly, they’ve made a lot of progress even since then, but it was state-of-the-art at that time. In fact, we are still operating all eight systems and about 110 physician practices on the original version that we installed, the Epic 2007 version.

We have plans to upgrade for Meaningful Use purposes next year, but we are very, very happy with the way that the system is operating in all aspects of our health system. At the time, we were very excited about consolidating our many different systems onto one platform. It has certainly met our needs.

Tell me about the structure. You did it all internally — who led the teams? How did you actually set about doing this to get it done on time?

The first thing I’ll say is that you’ve got to have cooperation from all facets of the health system to make it successful. We had great executive leadership and good cooperation with physicians and nurses. While our IT team staffed and managed the project, I made sure that our governing structure was led by our chief medical officer and chief nursing officer.

We were led at an executive steering level by a small team — a CMO, CNO, chief financial officer, the head of our physician practice group, and me. That small executive team ended up making the hard decisions.

Below that, we had our IT team, led by a vice president of clinical information systems who was essentially our vice president of the Epic project team. Her name is Kay Hix. She did a fantastic job organizing the structure and allowing us to use our existing infrastructure to get it done.

Instead of going out and hiring a third party to do it, we decided that we would make our IT team work in tandem with a new Epic team that we set up, and largely within the confines of our existing organization, built a team to develop, train, and build and implement the system.

Underneath Kay, she had two directors, one primarily focused on ambulatory physician practices and one primarily focused on the hospitals. Beneath them was a large team of talented people, including about 35 trainers. We ran training from about 7 a.m. to 11 p.m., six days a week, to train more than 7,500 users.

People say, “Well, Epic just sends out a lot of inexperienced kids who follow the cookbook.” How would you describe how they got involved and contributed to your project?

I’d say the team that we worked with from Epic was top notch in every way. They are very focused on the area that they know well, and almost skill-typed. If you ask an expert in one area about another area, they are quick to get their colleague involved and won’t go out on a limb to guess at what they might not know.

In that way, it seems like Epic does a very nice job of training its people to be subject matter experts. They can have people very deep in knowledge without having to worry about being too wide.

It also works out well with the health system team because we’ve certainly had subject matter experts, whether it’s our OR team or our ED team, who was going from a legacy application that they knew well. They had been trained on Epic, but wanted to interact with an Epic person who was a subject matter expert in that area.

In that way, it seems like Epic has been able to replicate — and continues to replicate — its success with a slightly changing but relatively stable workforce.

Everybody wants to be Epic these days. Can other vendors copy what they’ve done?

I hope so. People ask me, “What’s Epic’s secret sauce?” I often say, if you look at the two biggest players — Cerner and Epic — Epic is Apple and Cerner is Microsoft. Both very talented companies, but each has a unique feel and flavor about them. Even when we were making our selection, Epic felt more university campus-like, while Cerner felt more business-like.

I think that other health information systems can do as good a job as Epic without trying to replicate all of its collegiality. But at the end of the day, I hope that other health systems continue to grow in the way that they are and that we have more systems out there that meet the needs of hospitals and physician practices.

Do you see that happening?

One of the challenges — and I’m amazed every time I go to HIMSS and walk the halls — is all of the small start-ups who think that there is an opportunity to break in at this point. I think if you’re a relatively established big player — one of the big ones already, an Allscripts, a GE, McKesson, Cerner, Epic — there is opportunity to grow and gain market share. I’m happy with John Glaser and his role with Siemens because I think he will make it happen there as well.

Growing from a smaller, unknown vendor at this point into one of the larger players? No, I don’t think so. I think this is a game of musical chairs. Within five years, every large and medium hospital and health system will be seated in the place where they’re going to be for the next 20 or 25 years  without much opportunity for anybody smaller to work their way in.

You’re talking about for the major, core systems – correct?

Exactly.

CIOs could be fairly accurately characterized as risk-averse and finance people obviously are. How would you approach the market? People say they want innovation, but nobody seems to want to be the first to buy it in hospitals.

The funny thing is the tools that we have out there at our fingertips have been adopted in such a limited way. I think I saw the fact recently that fewer than 14% of US health systems or hospitals have achieved 10% or greater CPOE to this point. It’s almost funny to be out there demanding more innovative products when we’re not even using the products that are out there well.

I think there is a lot of runway for hospitals and health systems to use the systems that they have, tweak them, and make them more meaningful for their physicians and patients before we go out and try and demand something else. I think that the products that the big players have put out in front of us today should more than satisfy our needs for the next five or 10 years, even without a whole lot of smaller innovation.

What’s held everybody back? Why aren’t they using what they paid for?

It is very difficult. I’m surprised at even the way that some large health systems have achieved what they have. You know, and all of our colleagues do, that these are tough and challenging projects made challenging not only by the fact that they’re very complex, but they involve human lives, so there’s a premium on risk. They involve physicians who are well trained and want to be very efficient and good in what they do and see these tools occasionally as a threat to the way that they operate, and a threat to the way that they care for their patients.

Balancing all those factors is very difficult. Even a well-run project, which on paper has good governance and structure, if it doesn’t balance those needs, and especially if it doesn’t meet the needs of the physicians and the nurses using the system, it’s a recipe for failure.

What are some things that you learned that most people would not pick up on or that you wouldn’t have expected that really made a difference in how your project was completed?

I’d say the factor that made our project a success more than anything else was a buy-in to the schedule. We knew that this was something we needed to accomplish across all of our hospitals and practices. We knew that if we went very slowly it could take many, many years, and that if we were going to achieve the benefits for our doctors, nurses, and patients in a reasonable timeframe, that meant we had to implement in a reasonable timeframe.

That meant we had to make our hard decisions upfront and then stick to them and operate in a system fashion. When we focused on our order sets, for instance, we went from more than 3,500 order sets down to 500 common order sets. It was not 120 order sets for Hospital A and 50 different order sets for Hospital B. It was 500 order sets which you could use, and were the same at every one of the Carilion Clinic hospitals. We did all of the hard work upfront, set a schedule that we said that unless we were going to put patient safety at risk, we were not going to deviate from.

Then, once we had that focus that we knew what we needed to achieve and when we needed to achieve it, we looked for any outliers that would get in the way. As long as everybody was on board — our executive leadership, our clinical leadership, and our project team — we didn’t deviate from the schedule. It was more like riding a train than it was stopping and approaching every new hospital and physician practice and making decisions about it.

For a lot of hospitals, their problem is that their milestones are all wrong. They have to pay more money when they get the code loaded and then pay more money again when they get implemented and go live. It’s almost like an anti-sense of urgency.

That’s a great point. One thing we did was we bought an enterprise license upfront so that we had laid out the capital dollars initially. It was just a question of when we were going to use it, not if we were going to pay more when we got around to using it.

We also front-loaded the project. We did our largest hospital first. We have our largest, 880-bed hospital going to down a smaller 120-bed and even smaller hospitals than that. We decided to start with the 880-bed medical center first because we knew that we would run into the biggest, hardest issues there. Once we solved them there, we would just replicate the same process at our other hospitals.

By getting all of the right people on board, knowing that they had to make the right decisions upfront, and that there was not room for error at a smaller hospital that we could go back and fix later on, we really did have focus and cooperation in a way that I think we would have not had had we started at the other end and worked our way up.

You mentioned Meaningful Use. Are you comfortable with what you think Meaningful Use will be and where you are?

We are comfortable. I’m very interested to see what rules come out. It’s been a fascinating process to watch it all along. I do hope that the standards are held relatively high, but I agree with many of my colleagues who worry that they’re high, almost to the point of a lot of people not being able to participate. It almost seems like it begs for a common ground — that that bar is set high enough that it causes us to achieve more, but not enough that it decapitates anyone.

At this point, I expect that it’s going to be challenging for many hospitals across the United States to achieve it. We’re comfortable with almost all of the elements as they’re laid out today. There are four or five that don’t come easily that we have planned reporting for. We’re prepared, but we’re counting on achieving both certification and Meaningful Use in fiscal 2011.

You mentioned Carilion’s move to the practice-type model, the Mayo model, in 2006. What kind of IT changes did you have to implement to support that?

It was all about integration. We had 11 different systems, more than 512 different interfaces, and we had the challenges of trying to get down to a common way of operating because we really wanted the physician in Roanoke to be able to refer to his or her colleague in Blacksburg, and for both of them to see the same information on a discharged patient from our medical center. We thought we were only going to be able to do that, not by brushing up on our 500-plus interfaces, but by having it all operate on the same system.

One thing that we had done was that we had a whole lot of experience with the GE Centricity product. In the previous eight years, we had rolled out GE Centricity to every one of our 140 physician practices. When we implemented Epic, we knew that we had a responsibility — not only to our patients, but to the doctors that had put all the work of entering and maintaining that information — of having it available at their fingertips the first time they logged in to Epic.

One of the biggest early challenges we had in this project was converting literally eight years’ and about 800,000 patients’ worth of data from GE into Epic. We had a small team led by two of our physicians and about five of our IT people who did nothing for about four months than plan the migration of the data and test it over and over again.

Then, when we actually did push the button and convert the data, our data center literally chugged for about 11 days converting all of that information from the GE system into the Epic system, so when our first practice went live, it was all there. That was a commitment we needed to make so that our physicians had, in their new tool, all of the data that they had in their old tool.

There’s a new Virginia Tech Carilion School of Medicine. How are you involved with that?

We do have a new school of medicine that we’re very proud of. It’s been a challenge. In the past four years, we have implemented Epic. We’ve build 200,000-square-foot new medical center. We’ve acquired two major practices. We’ve acquired one hospital. We’ve built a research institute. We just started the Virginia Tech Carilion School of Medicine. All of which made for a very busy past four or five years.

My team and I are responsible for the technology for the school of medicine. It’s been a fascinating experience helping them stand up their practices, implement IT for them, and put the systems at their fingertips so that they’re ready to go when their first students show up 23 days from now.

One of the most fascinating things was participating in the selection of medical students. The Virginia Tech Carilion School of Medicine used an innovative interview approach where they had many people, lay people and clinicians alike, participate in the student interview process. Getting to do that was a highlight in addition to being the CIO for that school of medicine itself.

In terms of the curriculum for the medical students, are you involved in any IT or informatics training components?

Yes. In fact, we’ve made use of the medical record one of the components of the school of medicine. It’s not something that the students will have Year One, but by the time they get to their clinical rounds, we will have them trained on the Epic electronic medical record and built templates for them to use on their own, in ways that they can step slowly from viewing patient data initially to full CPOE over a period of about six weeks.

The other hat you wear is that you’re involved with the Virginia Information Technologies Agency. What kind of work is being done at the state level?

I’m proud of the way that throughout the Commonwealth of Virginia, we’re cooperating to make sure that the data that we have in each one of our health systems is available to others. Part of the HITECH Act was $2 billion set aside for HIEs. Five of the CIOs of the other large health systems in the state of Virginia and I serve on a Governor’s Commission to help define the standards for the HIE.

We’re also on the advisory board for implementing it. We’ve been meeting in our state capitol  at Richmond  for the past 12 months focused on how we’re developing HIE, who we will have implement it for us, and how we will begin to exchange data and interchange with the NHIN as well.

What are your IT priorities for the next several years?

One of the things that has been nice about getting to the point where we’re close to wrapping up this implementation is that we know that for the next five years, we’re going to be all about optimization. We don’t want to go into the next big project. We don’t want to go buy the next new piece of cool technology. We want to take what we’ve built and implement it and make it work as well as we can for our physicians.

We have an optimization team, which is getting larger all the time, and that we hope through our upgrade to the 2010 version of Epic next spring that we will bring even more useful technology to our clinicians. Our priority, instead of being very forward-thinking and cutting edge, is all about using this tool that we’ve built to its maximum advantage.

Any concluding thoughts?

It is a heady time to be part of healthcare IT. For the first time in my career, my mother understands what I’m doing because it’s front page in The New York Times. I’ve really enjoyed being part of it. Doing it in a large health system and trying to make it integrated is very rewarding.

An HIT Moment with … Dennis L’Heureux

An HIT Moment with ... is a quick interview with someone we find interesting. Dennis L’Heureux is SVP/CIO of Rockford Health System of Rockford, IL.

What are your most important IT projects at Rockford Health System? Which ones represent a change in strategy from just 2-3 years ago?

The most significant IT undertaking at RHS is the introduction of an integrated electronic medical record. This said, it seems that we can tag almost every project we do as “important”.  Among other important projects are C-PACS, Bed Management / Patient Flow, Utilization Management, and Patient Dietary Service.

Many of these projects were defined as needed during the past three years but are just getting underway. Strategically, however, we are now exploring the feasibility of a more tightly integrated approach.

You’ve said that the hospital’s transcription program is cost-competitive with offshoring because of speech recognition. What benefits have you seen, and how does dictation and transcription fit into your electronic medical records strategy?

Before leveraging speech recognition technology, we could not seem to compete with offshore transcription options. As we analyzed costs, we found that typical employee benefit costs measured in cost per line seemed to be the component that made us uncompetitive.

However, speech recognition — we use Enterprise Turbo Speech from Nuance — has provided us the ability to drive transcription productivity high enough to offset this disadvantage. Additionally, it is important to note that in-sourcing our transcription workload also increased the qualitative satisfaction that our physicians demanded.

As we transition to an EMR, we believe that we will use voice recognition to allow physicians to add narrative to their patient’s records. We are in the process of taking a look at the benefits of Dragon Medical, which would allows our physicians to dictate directly into our EMR for real-time documentation.

What changes do you anticipate from healthcare reform, specifically with regard to reimbursement?

I believe that healthcare reform will increase volume and reduce reimbursement. Overall, providers will not fare well if they do not align their cost per unit of volume to the corresponding reimbursement per unit of volume. As bundled payments are offered, this will create a need for more cost accounting detail.

Are you considering any innovative technologies or vendors that the average hospital CIO would not have heard of?

There are many innovative technologies being introduced. For example, natural language processing and script digitization. However, many CIOs are not well positioned to take risks since budgets are razor sharp and it is difficult to prove ROI beyond a paper exercise.

That is why I believe it will be difficult for new products to find any kind of market penetration unless they are built into existing, well-known products. 

What are some ways that the IT department interacts with the clinical front lines to improve patient care?

Technology is hard, but process change is harder. IT is learning that much of what it does relates to facilitating change, and this cannot be done without direct involvement with care givers at the point of care.

Integrated implementation teams are the norm these days, whereby IT analysts must work in tandem with those that are to optimize the utilization of the expensive information systems we invest in.

HIStalk Interviews Howard Messing

Howard Messing is president and CEO of Meditech.

How’s business?

I think we’re doing very well. The stimulus bill has certainly stimulated.

I noticed on the financials that operating income dropped last year for the first time. Was that just an accounting irregularity, or what happened there?

Operating income dropped last year… Well, we had a drop in sales last year because of the first half of last year. Nobody was buying anything because everybody was figuring out what was going on. That’s probably why you see a small drop in there.

I take it that’s totally reversed and then some.

Right, the problem being that between the time we make a sale and the time the income shows up is the better part of a year. Even though we were making a lot of sales, the second half of last year wasn’t reflected until this year.

Tell me about the challenges and the successes with 6.0. That’s a pretty big step for the company.

6.0 is, yes, a very big step for us. We’ve rewritten a bunch of our software from scratch, which we tend to do every certain number of years, certainly every 7-10 years, as we get new ideas and better ideas. It’s gone pretty well. It’s gotten a great reaction from people.

The biggest challenge for us is that we have so many customers running our older version of software that we have to not only maintain the older version, but actually continue to development in it. We’ll have to continue that for some number of years to come until the vast bulk of our customers upgrade to our newer software.

In addition, we still have the rest of our apps. We’ve only done a core set of applications so far. We’re going to have to do the rest of those over the next 2-3 years.

I take it those would co-exist? If someone wanted 6.0, they could still run everything, it’s just they would be 6.0 on some things?

Right. That’s the way we do it.

I would assume there’s quite a number out there running Magic?

Yes, there’s quite a lot.

Do you have a feel for how many that is?

Something over 1,000-1,200 sites, I believe, are still running Magic.

And your total count — I don’t know what it is now. It used to be around 2,100.

2,100 or 2,200.

So half are still on Magic. Is that the next logical step, that they would go all the way from Magic to 6.0?

Yes, we do have a plan where people go straight from Magic to 6.0. There’s no reason to go to the intermediate.

There were some good things said by the folks at the HIMSS conference — by Dave Garets, if I remember right — about the CPOE adoption with 6.0, which seems to be dramatically improved. Was that part of the reason for rewriting it in a way that was more Windows familiar?

Yes. I think the big difference there is functionally. The old stuff and the new stuff currently is pretty much the same, but the look and feel is certainly different.

People, particularly doctors and nurses, are much more desirous of a modern look and feel and they’re willing to accept things a lot easier if it’s a modern look and feel. I think, yes, that’s why you’re seeing a much greater acceptance. I don’t know about much greater, but a greater acceptance, certainly, with 6.0.

At the same time, the new interface also has allowed us, I think, to reduce things like number of clicks and all those good things. That’s also helped.

Some of the attention that’s out there now is going to companies like Eclipsys and Cerner for opening up their system to third-party customization or hooks into the application. Meditech’s always been pretty close to the vest on not letting clients screw around with the underlying stuff. Is that something that’s in the works or do you even believe in that concept?

I’m not really even sure what the competitors are doing in that area. We’ve always had some ability for our customers to define some things on their own, but overall I would say no, we don’t believe in customization as a desirous thing. It certainly is a necessary thing, on occasion, to do.

I think, moving forward with certification and the patient safety and all that, it’s probably going to be a less attractive feature for people to use than it is in the present time. We don’t have any great plans on that.

What do you think about the whole certification argument? Do you like the way it’s changing? What are your thoughts, as a vendor, on what certification means to you?

What certification means to me? I guess in many ways, I would have been the last one to say that certification was a good thing, but I have surprised myself by coming around quite a bit in thinking that it, perhaps, is a good thing for our industry. Certainly, we’ll quibble over the details of how it’s done, and quibble about the particular way of the government’s getting involved.

I’d like to say I’m a short-term pessimist and a long-term optimist, but in the long run since I worry a lot about patient safety, I think certification may very well be in everybody’s best interest. I would rather that it was cast in terms of results rather than specific ways to get there, but over time, I assume that we will get modification into the way it’s written and be able to do it in a meaningful way — not to use the word too much. We’ll see …we’ll see.

In the short-term, yes, it’s a pain in the ass because you’ve got to get it certified. We don’t know all the rules and we may have to get it certified multiple times, but so long as it’s a level playing field for everyone, and so long as the eventual outcome is to have better systems and interoperable systems, I don’t think it’s necessarily a bad thing.

How do you think the whole CCHIT will change now that Meaningful Use is off on a different direction? What do you think certification’s going to look like in a year or two?

I really don’t know. We’re certainly will have some people who continue to look at it and put their ideas in and we’ll see how it goes.

Do you think, under the CCHIT requirements, that you had to invest R&D to do stuff that customers probably didn’t really care about that was still on the checklist?

A very small amount of that, but most of what’s on there is stuff that people do care about. I’d actually have to think long and hard about something that nobody cared about.

Meditech’s one of the few systems out there that’s really appropriate for those many small hospitals that maybe aren’t very far along on their IT journey. Are you doing anything new to go after that business?

Not really. First of all, we think we’re suitable for all hospitals regardless of size, but I will agree that the small hospitals find our cost of ownership to be particularly good for them, and tend to work with us. No, we’re not doing anything specific to do that, other than we continue to watch our pricing to make sure that we remain appropriate for various sizes of hospitals.

What competitors do you face across the table most often?

I think McKesson is certainly in the medium-sized hospitals as the competitor, and I think we face them most often. In the small hospitals, probably CPSI. In the large hospitals, it’s mostly Cerner. Occasionally in the largest hospitals, Epic.

I’m assuming you displace some in-house vendors occasionally. Who are the ones that usually get displaced in favor of Meditech?

It’s a mixture of all of them.

Yes?

Yes. I’m not going to single out any particular vendor.

Have the demographics of your customer base shifted as far as size, location, or type of hospital?

Yes, I think the size is slightly larger than it used to be. If you would have asked me five years ago, I would have said our sweet spot was 200-225 beds. I would say it’s closer to 275-300 beds today.

If you took that as a percentile, that’s probably a fairly huge chunk of the hospitals that are out there. I’m sure you probably know that number by heart, but that’s, I would guess, most of them by far.

Well, we think we’re in about 25-28% of the hospitals in the country, if that’s what you’re asking me.

I was just saying, if somebody drew a line and said, “Well, your sweet spot’s 300 beds,” or whatever it is, you would still not be ruling out very many potential prospects.

That’s true, that’s right. We don’t want to rule anybody out.

What about hosting? What’s the latest buzz on people wanting hosted solutions or turnkey solutions?

Actually, that’s kind of interesting because I used to not be at all a fan of hosting. I didn’t think that made economic sense for Meditech customers again because I thought our cost of ownership was pretty low.

Having said that, I’ve seen more interest over the last year or two than I expected, and not necessarily from the places that are most cost-pressed, which is what you would expect. I think a lot of people are taking the attitude that even if they don’t save money, it reduces management time and frees them up to deal with more long-term issues.

We’re seeing more of it. We ourselves have no intentions of providing that service directly, but there are various people out there who are interested in providing that service with Meditech software and we continue to say that’s fine with us.

When I talked to you years ago, it was the ‘stick to the knitting’ philosophy; that you didn’t want to be in something that was distracting. Is that the reason that you don’t want …

Absolutely. We sell software and the services around that software. We don’t do anything else.

The proposed acquisition of Eclipsys by Allscripts moved the idea of integration between hospitals and physician practices to the forefront. What do you think about the acquisition and that trend of people suddenly short-listing only those vendors who have strong integration with outpatient?

I don’t pay too much attention to what the competitors are doing, so I don’t know that I have any particular impression on Eclipsys and Allscripts. But in general, I agree with the philosophy and something we’ve promoted –  that there has to be tighter integration with all avenues of care, both ambulatory and acute care and eventually, nursing homes and independent care and whatever.

Obviously the biggest connection is between ambulatory and acute care, and one way or another, there needs to be a seamless integration with that, both in terms of getting the doctors to appreciate better what’s going on and in terms of taking better care of the patient. So I think you’ll see, whether it’s by acquisition or strong partnerships between companies, a tighter and tighter integration between all horizontal attributes of care. We’ve done that for a long time ourselves with our partner LSS, but even with us, I think you’ll see a tightening of that integration.

At the same time, still recognizing that for a long time to come, there are going to be doctors out there who have their own systems that are not necessarily the one that the inpatient or the acute care facility might choose for them.

Are you finding that that question comes up more often when you have prospects; and are they comfortable with the answer that you can give them on your strategy for either one system for doctors, or foreign systems that you can integrate?

It does come up more often. I’m very happy with that answer. It seems to be something that most people respond well to.

What do you think about the trend of smaller hospitals that are struggling with everything from technology to financing being acquired? How do you think that will change your business?

I don’t think it will change the business that much. There may be less customers, but they will be bigger customers overall if that trend continues.

I think we’re actually a few years away from the real cost pressures hitting our hospitals. Many of my hospitals would disagree with me on that. They’d say they’re under that pressure today, but as the baby boomers age in the next four or five years, there’ll be a lot of cost pressure and there’ll probably be a lot of consolidation in the hospital industry at that time.

When we have customers of ours that are acquired by another hospital, often our system is the one that stays in place. Often they do a search to decide what they want to do and it’s just another competitive situation. I don’t think it changes the business that much.

It might hurt a vendor that specializes only in the smallest hospitals if they tend to disappear, but I actually don’t think the smallest hospitals will all disappear. There’s a need for those small hospitals out in rural areas, and many of them are fiercely independent.

It seems like nobody even blinks an eye these days when you see a deal signed for $30 or $50 or even $100 million. Does your phone ring more often when hospitals that can’t afford that suddenly think the Meditech picture looks attractive?

Well, I blink at somebody spending $100 million. I don’t really understand some of the economics behind these decisions that are being made at a time when the hospitals are claiming they’re under so much cost pressure. Then you see them making these gigantic deals for huge amounts of money for a system that I consider to be basically equivalent to what I offer for 20% of the cost. It’s very, very strange, and I think that will catch up with people in the long run.

So, I’m not sure how to answer your question, but we continue to say that we’re good value. We’re not looking to take advantage of anyone by raising our prices tremendously. We think that, in the long run and with the cost pressures now, people will more and more realize that we were a good alternative.

Assuming that it would be difficult to look at the marginal benefit compared to the marginal cost of $10 million versus $100 million, why do you think people are making those decisions?

I think there’s some element of people thinking if you’re spending that much, you must be getting a better system. I think there’s some element of … how do I want to put it? There’s some element of people wanting to … I have to be careful how I say this.

Many hospital managements are afraid of losing their doctors, and so they turn the decision over to their doctors. The doctors are not necessarily concerned with the overall finances of the acute care institution, so the cost does not become a factor in the choice. I think we see a lot of that happening. I don’t think there’s any way it can be cost justified.

As I understand it, the HITECH reimbursement isn’t based on what you spend, it’s based on volume. Bottom line, it would stand to reason that the less you spend, the more you get to keep of the difference. Are people asking you to run those numbers?

They do ask us to run those numbers. That’s the way I understand it. Like I said, I think it will come back to haunt some people who are spending gobs and gobs of money on some of these systems.

And it’s not, of course, just the capital upfront. The maintenance is going to be just excruciating on some of that.

Right, right. Total cost of ownership is huge on some of these systems.

Are you pricing 6.0 differently, or is that basically just a replacement at the same price?

It’s a replacement. We don’t charge different amounts for different systems. It’s too complicated.

Your maintenance fees are, I assume, still low?

Our maintenance fees are basically the same as they’ve always been. We charge basically, 1% a month of what people buy for maintenance and we intend to keep that. Not that there aren’t modest raises over time, but we try to keep it low. We don’t think that our systems are difficult to maintain.

With other vendors, not only do the price goes up, but so do the maintenance percentage. It seems like it shames the other vendors who get 18 or 20% on five times the cost.

They don’t seem to be shamed by it. If they were truly shamed by it, they would do something about it.

Or the customers would stop buying.

Right, right.

How do you educate someone who somehow sees that as an equivalent alternative? Are they just not price sensitive?

To be honest, we don’t actually lose many sales to the real expensive systems that are out there. Many of our customers do toy with it. Many of them do understand it’s too expensive and then back off on it.

We just do what we’ve always done, which is we want people to want our system. We don’t want them to buy from us because they don’t want somebody else’s system, so we continue to demonstrate what we do.

If they bring up specific features that they think they’re getting with somebody else’s system that we don’t have, we try to point out to them that it’s actually there in our software. Hopefully, we make our case and it’s a strong one, that it’s better to go with Meditech.

Three or four years from now is when I believe the real crisis will happen in healthcare. Again, I know people say it’s happening now, but I really believe it’ll be three or four years from now. As the baby boomers enter Medicare, hospitals are not going to be able to spend as much on healthcare information systems as they do today. I think Meditech is very well positioned for when that happens, and the companies that are charging a lot will have built cost structures that they won’t be able to maintain.

Do you think there’s a certain snob value that a hospital says, “Oh, I can’t run Meditech. I’ve got to have Epic or Cerner because that’s what all the cool hospitals like mine are running.” Do you think that there are people who never even pick up the phone to call you?

Yes, I believe that exists. I think it’s less than it used to be. I think we’ve made a lot of progress, particularly in the multi-hospital chains. Particularly among the Catholic hospitals we’ve done very well, so I think it’s less than it used to be, but yes, there is certainly the snob appeal or whatever you want to call it — the CIO of the large teaching institution who can’t do Meditech because we’re also in community hospitals.

I would assume your win percentage is a lot higher when the CFO is involved more actively.

I’ve never really looked at that, to tell you the truth. I’d imagine it’s true, but I’ve never actually thought about it.

What’s your overall thought on the proposed Meaningful Use criteria and the whole healthcare reform issue and how it’s going to affect your business?

I wish the Meaningful Use was caged in terms of results than it was caged in terms of features of software. Then, I would think you would have a much better impact on patients than it, perhaps, will caging it the way that they’ve done it. It’s certainly is driving a huge amount of sales for us today in time, as people decide they have to make a decision now.

If they are going to change systems, they won’t be able to afford to change their system 18 months from now when they’re in the thick of trying to get that money from the government. So, it’s driven a huge amount of business today, which I expect to be a blip.

I expect that 18 months to two years from now, there’ll actually be a lull in people buying systems; much as it was after Y2K, wherein 1999 was a huge year and then 2000-2001, business really fell off. I see the same thing here.

I do wish the government had spread this out over a longer timeframe. I think that our customers would be able to be better focused on the real results they can get from it if we had done that rather than chasing after the money and doing the minimum they can to get the money because it’s under such a tight time frame. But again, as I said before, I’m a long-term optimist. I think in the long run this will all be good.

How do you plan for your business knowing that that hump is going to go away after the people have locked in with whoever their partner is?

The main thing we’ve done is limit the implementations that we’re doing currently, which has been a struggle. We have done that in term of we are growing, but we’re not growing so fast that we’ll have people who won’t have what to do 18 months or two years from now.

We’ve really spaced out the implementation. As people coming to us for the first time today are getting dates for delivery that are well over a year, to sometimes, depending on what they’re buying, as much as 18 months from now, which many of them don’t like. But that’s the way we control the business and make sure that our long record of no layoffs and controlled growth remains intact.

How do you think your job will change as CEO?

I don’t think it’ll change very much at all. Neil Pappalardo, who has been our CEO for 40 years or so, has just decided that it’s time for him to give up that title, but in effect, I’ve been running the day-to-day business for quite a while now. He’s still around; he just has been gradually spending more and more time on other pursuits, and so thought it was time to pass the baton. So, I don’t really think it’s going to change much on a day-to-day basis.

Is there a movement to prepare to transfer to the next generation of leadership?

I think we’ve always done that. It’s the case that we have appointed new officers several times over the past three years. I think you’re going to see us doing that again before too long.

We have a great set of people who are what we call directors, the round of people who report to our officers. It’s a lot of good people who have been here a long time who see this as their life’s work, and they will gradually take over. Our succession planning is thought out very carefully. We try very hard to get people promoted before the person who they are going to be, so to say, replacing, is ready to retire.

For example, we had a VP of development, a fellow named Bob Gale, who about 2-3 years ago we promoted him to senior VP and brought in a woman by the name of Michelle O’Connor, and she has been gradually taking over responsibility from him. You’ll see that in all of our areas.

This is one of those boom cycles where suddenly everybody and their brother want to be in healthcare IT. Is the company going to stick to its guns about not selling, not going public, not changing?

As long as I’m around it will. Yes — the answer to that is yes. We have too much fun the way it is. Again, we think the prospects for the future are very, very good. We see no reason to change the structure of the company. It’s worked well for us and we don’t see any benefit.

If you looked out 5-10 years, what are the strengths, weaknesses, opportunities and threats for Meditech?

I think the biggest threat is if the healthcare system changes in such a way that we can’t adapt correctly, and nobody really knows where the healthcare system is going. There are certainly many competing thoughts. That’s one of the reasons that I have been pursuing international business is to give us some stability that doesn’t depend on, let’s say, one healthcare system in the world. I think that’s the biggest, biggest risk we have.

I also think in some ways that that’s our biggest strength, in that we’ve shown flexibility. We reinvented ourselves many times and shown that we can have multiple generations of software running that address the different needs of the healthcare system. Hopefully, whatever does happen, we’ll be able to deal with.

Anything else you wanted to talk about or any concluding thoughts?

You know, there’s one thing you didn’t ask me about that I think is going to become more and more important as IT systems become more and more central to the clinical care process, which is patient safety. That’s something that’s a very big personal concern to me. We’re making every effort we can to produce a safe as possible software as we can. To some extent, I wish that the ARRA requirements actually included some patient safety issues as well in them.

I’m sure that the FDA, if they ever get funding, will start to regulate our software. In Canada, our kind of software becomes a medical device in about a year. We’re going to have to be regulated if we were a medical device which has patient safety implications. I think that’s the biggest issue for the industry that we should all be cognizant of and we should all care a lot about.

The only thing that keeps me up at night is the fear that we’re doing something that’s going to hurt someone. I hope that all the other CEOs have the same kind of feeling, because if one hurts somebody, it casts a light on the entire industry.

Generally when that happens, either it wasn’t designed to be very usable or the QA wasn’t very good. What steps do you take to build that safety into the product?

We certainly have a fairly thorough QA process that we do to make sure that the software is as absolutely safe as it can possibly be. Then we also have a fairly detailed process when a customer reports a possible patient safety issue. That problem is immediately elevated in status. We make a quick determination whether it’s even possible that there’s a patient safety issue so that we can notify all customers of the possible issue. Then we throw a lot of development resources and QA resources on it to figure out what the problem is and fix it.

I agree with you that sometimes patient safety issues are bugs, but sometimes they’re just a misunderstanding of how the software needs to be used; or a question of terminology. Those are actually a lot tougher to find, so you have to be that much more careful in your design, and that much more careful in your quality review of things.

An HIT Moment with … Sharona Hoffman

An HIT Moment with ... is a quick interview with someone we find interesting. Sharona Hoffman is professor of law and bioethics and co-director of the Law-Medicine Center at Case Western Reserve University School of Law in Cleveland, OH. She recently published an article, E-Health Hazards: Provider Liability and Electronic Health Record Systems in Berkeley Technology Law Journal with co-author Andy Podgurski, a CWRU professor of computer science who also contributed to the information below.

The article suggests that a hospital may expose itself to liability for physician acts, from which it is currently protected, by forcing doctors to follow its EHR-enforced practice guidelines. Should this be a significant concern?

This is a complicated legal question and I don’t think it should be of primary concern for hospitals. Whether a hospital is vicariously liable for the acts of physicians will depend upon the degree of control it has over them. Often, a hospital can prove that the physician is an independent contractor. In some circumstances, however, doctors are found to be employees and not independent contractors. The issuance of an EHR practice guideline alone, however, probably will not undercut the independent contractor defense.

Provider errors due to software usability issues have made headlines recently. The article suggests an option of requiring all EHRs to use a standard user interface. Given the competitive and proprietary nature of the EHR industry, is that likely or even advisable? Is there a precedent in other industries?

Major software platforms like Microsoft Windows and the Mac have user interface standards or guidelines that application vendors follow. An EHR interface standard should define an essential level of consistency between the UIs of different system. It shouldn’t require them to be identical.

How much liability do software vendors and hospitals have for programming errors and setup mistakes, respectively? Do you think those cases are coming up but being settled out of court such that the problem is understated?

Vendors would have primary responsibility in such cases. Vendors both design the software and help hospitals implement the systems and train employees. Hospitals would have liability if they tried to customize the system inappropriately on their own or did not engage experts to provide responsible training. They could also be held liable for mistakes that employees, rather than independent contractors, made with the system that caused patient harm.

The vast majority of cases that are filed in court do not produce a reported decision and many of these are settled, so you are right that it is difficult to know how many EHR cases have arisen.

In fact, regardless of litigation, a major problem is that there is no adverse event reporting requirement. If an EHR system has a problem, the vendor or user doesn’t have to report it to any regulatory agency. Nobody is keeping track of what kinds of problems are arising and how frequently. Therefore, EHR system purchasers can’t obtain information they need to make educated decisions.

The article concludes that the federal government should oversee and monitor EHRs in some way that goes beyond simple certification. Explain why that’s the case and who in the industry should advocate for government involvement.

EHR systems are much more than just record-keeping systems. They manage patient care in a lot of ways, and therefore, they are safety-critical. They provide doctors with prompts and alerts concerning patient allergies, other drugs patients are taking, and the patient’s medical history. They provide a mechanism by which doctors order diagnostic tests, medications, and other treatments. They will create the patient record and could be the way by which a physician communicates with other departments or with the patient herself. 

If anything goes wrong with any of these functions because of software bugs, computer shutdowns, or user errors due to poor system design, this could be catastrophic for medical outcomes.

The FDA regulates drugs and devices. A responsible doctor would never think of implanting a pacemaker that is not FDA-approved, because a flawed device could kill the patient. We believe that EHR systems will be just as critical for patient welfare and therefore, they require an equal degree of government oversight.

Anyone who really cares about patients and medical outcomes should be advocating for government involvement.

As you looked at the EHR industry and EHR adoption by providers, what aspects concern you the most, both as an attorney and a patient? 

EHR systems have the potential to improve patient care significantly. They can increase efficiency, provide doctors with essential information about the patient, and help doctors make optimal medical decisions. Most other industries are computerized, so it is certainly time for the medical profession to catch up. However, in implementing EHR systems, we must proceed cautiously and responsibly.

It is extremely important that the government establish appropriate approval and monitoring processes for EHR systems. These must include an adverse event reporting requirement.

We have heard from a lot of health care providers that the systems they have are difficult to navigate, reduce efficiency because they require too much time and data, and disrupt the relationship with the patient. Some doctors feel that they are overwhelmed by irrelevant or trivial electronic alerts and that they don’t have time to listen to and examine patients because they are too busy attending to the demands of the computer.

Therefore, we need regulatory standards and criteria that ensure that vendors minimize these problems. Once a practice purchases a system for millions of dollars and trains its staff, it will not be able switch to a different system that is better. It is only with appropriate oversight and quality-control that we can maximize the potential of this technology.

HIStalk Interviews Terry Edwards

Terry Edwards is president and CEO of PerfectServe. 

Tell me what PerfectServe does.

At a high level, it’s all about making it easy for clinicians in a hospital environment — nurses and doctors — to connect with the right doctor at the right time and in the right way. It’s about enabling communication processes that are accurate and simple.

Then from the perspective of the doctor, it’s about enabling processes that gives physicians the ability to really selectively filter and control the communications that they receive throughout their work day. When I use those terms, ‘the ability to selectively filter and control,’ it’s really about enabling them to mold the flow of communication that a hospital directs at them around their own personal unique workflows.

Give me an example of two or three problems that this would solve.

Let’s say that we are three physicians, and maybe we’re cardiologists. Our workflow rules might be that we each take our own calls during the week beginning at 6:30 a.m. until 4:30 p.m. except for the days that we’re off.

John is off on Tuesdays, Bill is off on Wednesdays, and I’m off on Thursdays. On those days that we’re off, one of the other two covers for the person who’s off. Then we have our consults during that same weekday time period, handled by our PA. Our PA will route those to one of us based on the things that are unique to those consults. In the evening hours and on the weekend hours, everything is handled by one doctor on call and we change that schedule daily. One guy would cover the whole weekend, like Friday night through Monday morning.

In addition to that, maybe John likes to have everything just route to his cell phone in real time. He doesn’t mind being interrupted; he like being really accessible. Maybe Bill likes only the urgent things routed to his cell phone, and for everything else, he wants a text message to show up on his phone. Me, maybe I’m just a numeric pager kind of guy — I just want a call-back number and that’s it, but beginning at 9:00 p.m., I want you to call me at home.

Instead of all those instructions living in pieces of paper, Rolodexes, and call schedules in three-ring binders and things in and around the hospital that nurses and other doctors need to refer to and interpret every time they need to call one of us, we build all of those rules into the PerfectServe system. We give the hospital one number to dial.

This is where the ease comes in. If I’m trying to reach Bill, I just call on the system and I say, “Bill Smith.” The system will confirm that, it will interpret the rules, and then route the call either to Bill or maybe the PA or one of us according to the workflow rules, and then our individual instructions for that specific moment in time. It does it automatically.

That sounds something a little bit similar to what Vocera offers. Who would you consider to be your competitors?

Our competitor is the status quo, just in terms of all the manual processes that are in place in health systems today. Vocera is not really a competitor. They’re really a complementary technology in that Vocera is more like a device or a node on PerfectServe’s network or PerfectServe’s platform.

We can answer calls and messages that would originate on Vocera devices and we can send calls and messages to clinicians on Vocera devices. But Vocera, for the most part, is an ‘in the four walls of the hospital’ solution; whereas PerfectServe includes the communication to physicians regardless of whether they’re in the hospital or out in their practices, or mobile — wherever they are. We’re device agnostic.

Someone comes to you and they decide what end-user devices they need, whether it’s voice-over-IP or plain old telephones, or whatever. Then you’re what rides in the middle to decide, when those calls come in, how to route them?

Exactly. It’s about really intelligent workflow-based, rules-based routing according to the rules of the recipient. Physicians are the biggest users in terms of receivers of calls and messages, and then those who might be around them as part of their workflow — like a nurse practitioner, physician assistant, or some other sender.

Like in the example that I gave, the consults during the weekdays would route to a PA. If, for example, I was the nurse on the floor, I might not know that those are the rules, but when I called in and said, “Bill Smith,” I might hear prompt, “Are you calling about a consult?” Yes. Then, that would route that call to the PA, and maybe the outcome would be a voice message where I can leave all the detail, and the PA picks those up throughout the day and then determines where to forward it to.

So if I’m calling a doctor and their preferred method at that moment is to roll to a pager, do I then get prompted for their pager number or does it just say, “Your message will be delivered,” and then it logs you off and it just does what it does in the background?

Yes, it does what it does. When we configure the system in a hospital, we configure it so that we’re pulling all the appropriate Caller ID information. We map that back to departments so that we greatly reduce the need for nurses to key in numbers and make mistakes and things like that, as well as speed up the system.

Everything that happens on the platform is documented automatically. We’ve developed an analytical tool that then allows, say, a chief medical officer at a hospital to look and see how many calls and messages we are initiating to which doctors and from which departments, and drill down into that by specialty and contact method. When you have that data, then you can begin to use it as a tool to enhance process improvement for those clinical processes in which communication are really a fast, and/or efficient communication is central.

What about patients? Would physicians’ practices use this as the front-end for patient calls?

Yes. There is another module of the service that is designed to replace the conventional answering service. That provides a portal, or an access point for patient calls coming into the practice. The caller experience is different than the hospital portal, which is optimized for communication that originates from clinicians at a given hospital site.

What would be the compelling reason that they would do that? I know a lot of them are really tied to their answering services.

It’s the elimination of human error. In the current communication processes, whether they’re those that originate at the practice, or those that are being done manually in the hospital environment, the complexity of the physician workflows coupled to the manual processes — you’re basically dealing with a high volume of highly variable processes handled in manual ways, so you have a high degree of communication breakdown.

When you have a breakdown, you have situations where the wrong doctor, for example, is paged or called when he should be off. Or maybe a doctor, when he is on call in the middle of the night, his rule is that he wants his pager to go off and not his home phone to ring. The reason why is if the home phone rings, it wakes up everybody in the house. Whereas another person, when they’re on call and they’re at home, they might sleep in a different room from their spouse and they want their home phone to ring.

With doctors, those breakdowns really result in a high degree of frustration; and then the overall process inefficiencies cost them time. Time is the only thing that the doctors have, really. That’s their key asset.

Looking at it from the hospital perspective, tell me about what the advantages would be to hospitals and to patients for physicians being able to directly access physicians and nurses to make their communications with physicians.

Those benefits, at the highest level, really accrue up into the coordination of care, the reduction of risk, and tighter physician alignment. When I talk about tighter physician alignment, I mean really being able to integrate the care delivery processes of the hospital with the communication workflow of the physicians. These things are important because of the high volume of communication that takes place just in the coordination of care.

For example, a typical 300-bed hospital will probably initiate some 15,000 voice-related calls to doctors every single month, or 180,000 a year. These are interactions where it’s about: there’s been a change of status on this patient; or we’ve got these results and I need to act, but I need to know what order you’re going to write.

Those events are all related to patient care. When you improve the accuracy of those processes, then nurses aren’t wasting time making phone calls to the wrong people. You reduce the delays in communication and decisions can be made faster. That has an impact on not only reduction of risk and quality, but faster throughput; and it can make a contribution to reducing length of stay and everything related to improved efficiency.

You mentioned the measurement of length of stay. Have any users done any quality measures or satisfaction measures?

We had started a study with one of our small hospital accounts and we didn’t complete it because of some changes in their operation, but that was a study that suggested that we had been able to impact length of stay when physicians used the tool in the right way; but some of that data was inconclusive.

I was in a meeting actually yesterday with one of our clients at the St. John Health System where we were talking about value. It was a value analysis discussion with some of the executives. They had indicated that their length of stay had gone down with PerfectServe. There were many things that they had done to drive that, but they felt that PerfectServe was a major contributor.

Has anybody ever asked you to do anything with emergency communication to an entire group, where one call blasts information out in different ways to more than one person?

We have what we call a ‘team alert’ function, and it’s really designed for smaller clinical teams; although I think we have some applications of maybe 50-100 people. We’re not designed for mass emergency notification. There are other companies that do that.

Where our team alert applications work is when we have processes — such as a process around mobilizing an open-heart team or maybe a cath lab team where there are multiple people who might serve in one of the handful of roles — we need to know who’s covering which role at what time. Then we need to have fail-safe or measurable processes, where we can get a message out and know and receive confirmation that it has been retrieved or acknowledged within a certain time period, and if not, it escalates.

We have a lot of those applications that are out there and running in hospitals for not only what I mentioned in terms of cath teams and open-heart teams, but rapid response teams and other code teams as well.

I had read the case study on your site of Fairfield Medical Center and the cardiac cath lab, which I thought was pretty cool. Can you describe that and think about other ways hospitals might do something like they did?

In that particular application, they had … it was again, manual processes, and they literally had one person who would go down and manually call through a list. It just took time. They were able to basically replace multiple calls, and the time and the acknowledgements back and forth, with a single phone call.

There’s another case study on there around Henry Ford Macomb Hospital, and that’s an interesting story. They had an environment where there was a lot of dependence on paging. The call-backs and the repeat calls were creating satisfaction and quality problems between the ED physicians and a lot of the primary care doctors.

The ED physicians got together with the primary care doctors and they said, “Look, we’ve got in PerfectServe the ability to filter communications that go to you from the ED. Here’s the deal. If you guys will enable rules to route calls from the ED to your cell phones, we’ll make sure we’re on the other end of the line when we call you.”

They put that process in place and saw significant increase in real-time calls to physicians, which had a major impact on helping them improve flow, as well as physician satisfaction with both the ED and the primary care doctors.

What are the time and the requirements and the cost of implementing?

The costs depend on the size of the hospital and the medical staff, but the time requirements are … I mean, there are certain things that can change this a little bit, but typically, in about a three- to four-month time period from the project kickoff.

In fact, we just went live at Monroe Regional Medical Center just about two or three weeks ago. I guess it was about three weeks ago because it was in May. That project kicked off the end of February, and in addition to the planning, the big job of implementation is gathering the workflow rules of all the members of the medical staff and educating them on what the platform can do. That starts with some high-level awareness, workshops, one-on-one meetings with heavy admitters and other key doctors and practices; then gathering and collecting all this information and configuring it, and then we have the go-live.

In Monroe’s case, we went live on one day with the entire medical staff, 552 doctors, and they were immediately, out of the gate, processing at a rate that was equivalent to probably about 20,000 interactions a month. It will just go up from there.

On that particular thought, one of the things that has really amazed me about their organization, even to this day, is that it’s the kind of project that a hospital can do and actually succeed. I mean, it has a major impact on nursing and a major impact on physicians. They can actually drive a process change in a very short amount of time and realize and see those benefits just immediately.

HIStalk Interviews Loran Hauck

Loran Hauck, MD is senior vice president of clinical effectiveness and chief medical officer of Adventist Health System of Winter Park, FL.

Tell me about your Cerner electronic medical records system.

We have our Cerner electronic medical record installed in every single hospital campus that we own. I think that’s 36 campuses. We’re blessed that, as large as we are, we have one common EMR vendor across the entire system.We finished that process in about four years.

Now we’re in the process of rolling out computerized physician order entry. We have five sites live and quite a few to go between now and October 1 of next year.

In terms of your overall corporate strategy for measuring and improving quality of care at the individual hospitals that range from tiny to huge, what efforts are you undertaking to work on that from a corporate level?

Before we started the project, our CEO was real clear that he wanted us to collect data so that we could publish. We sat down with my department, the Office of Clinical Effectiveness, and our clinical IT team and figured out a group of metrics that we could collect prior to CPOE implementation and then collect post-CPOE implementation so that we would have firm data on whether or not we were improving a number of things.

For example, mortality rates, length of stay, cost per case, compliance with national hospital quality measures, hospital-acquired infections, and things like that. We also have the Cerner clinical data repository called PowerInsight across our whole company so that from that clinical data repository, we can do retrospective mining.

It’s our intent to measure the impact of computerized physician order entry on a whole variety of measures — financial, quality, safety — pre- and post-implementation. We only have five sites live and we’re just beginning to do some early looking at that data.

What benefits have you seen so far?

I started to say I haven’t seen any of the financial data, but the point is that I did see a little bit. The difference in overall length of stay and cost in the early, early stages of our first two sites was not particularly eye-popping, but we found some interesting things.

For example, lab turnaround times and radiology turnaround times were dramatically shortened. When I say that, I don’t mean from the time a doctor took a ballpoint pen and wrote an order for a CT scan until the results were available for viewing. I’m talking about the time when a ward clerk or a nurse entered that order for the CT scan into the system and it was completed, dictated, and resulted and appearing in the system versus when a doctor gives a direct, online order. There were fairly striking reductions in lab turnaround times and radiology study turnaround times. 

It was something I wouldn’t have predicted. I would have thought once the order was in the system, it wouldn’t make a whole lot of difference. I don’t know if that’s partially the Hawthorne Effect — you know, you’re live with CPOE, everybody knows you’re measuring metrics, so they’re hustling a little bit more.

We plan to look at all of the CMS and Joint Commission National Hospital Quality Measures and see how our scores are improving. We’re just a little too early for me to give you anything concrete there, but early impressions are that it’s going to make a significant difference.

Tell me about the collaboration with the other health systems in your order set work that you’re commercializing through Zynx. How did that come about?

That came about because of an idea from Dr. Jeffrey Rose, VP of informatics at Ascension Health. He’s a good friend of mine. He called me up one day about four years ago and he said, “Hey, Loran, I’ve got an idea. There are three of us that are very large Cerner clients. We’re also Zynx clients. We’re also faith-based health systems and we’re all in markets where we don’t compete with each other. What would you say we tried to form a collaborative and see if we could do several things: build some content in common and share our learnings with each other from what we’ve learned from our CPOE implementations so that we can shorten the learning curve for everybody?”

We got together in Nashville, Tennessee and met in one of the Ascension hospitals for a day and talked about it. At the end of that, we said, “This makes sense. Let’s do it.” 

The fourth partner of the transaction was Zynx. We really needed Zynx to help us with some of the projects we wanted to do and accelerate their order set module development. 

Did you actually develop the content together and weigh the evidence and make decisions, or did each of you do sections and then merge it together later?

Well, that will take some explaining, so let me just jump right in and explain that.

Believe it or not, it took a while for our respective corporate legal departments to get an agreement in place to create the Care Collaborative. It was an intellectual property agreement.

In the mean time, all three of us were really under a lot of pressure to get content started because we all had aggressive timelines to get CPOE implemented. To some extent, while this thing was in its formative stages, we all took off and started building content independently.

Once the collaborative was legally created, we asked Zynx to create a shared library on their Web site. If we were getting ready to build content for stroke or heart failure or pneumonia, we could go onto the Zynx Web site — we agreed amongst ourselves we would share our content freely between the three of us — and we could look at the Ascension Health order sets for stroke. We could move them over into our corporate library and then edit and modify them. So, one of the things we did was to share content that we had each independently created.

Zynx had very weak content at that point — that was four years ago — in the pediatric arena and it had no content whatsoever in neonatology. In conversation with Zynx, we decided this was something that we would do in a truly collaborative way. We got some neonatologists, neonatal pharmacists, and neonatal respiratory therapists — a variety of disciplines from each of our three health systems. We had about eight or ten neonatologists and the other specialties I mentioned. That group met every two weeks for two hours in an evening for two years. Adventist Health System took on the responsibility of leading out in that.

It was a virtually meeting on the Web. Everybody logged on to a Web conferencing site and you could see the Zynx authoring platform. The neonatologist that led the project from our health system and a neonatal nurse practitioner would create a lot of the draft work. Then the committee would meet and discuss it and they would literally edit it and update it and make changes live during these two-hour work sessions every other week. They created about somewhere in the area of 38-40 neonatal order sets that deal with all the common conditions in neonatology.

Zynx assigned a physician so that the Zynx team knew what our content development timeline was over the two-year period. They were ahead of us. They knew that next month, we’re going to work on neonatal jaundice or neonatal sepsis, so they would be out reviewing the medical literature trying to find the evidence ahead of us. They were finding the evidence and then clinicians from all three health systems were reviewing it and creating the order set content in this parallel process. It really was an amazing, amazing accomplishment.

The neonatologists really bonded. We had several meetings on site. It came together in Orlando, Florida for two days, from 8:00 a.m. until 5:00 p.m. — worked on site to accelerate the process. That was the best example of where we totally, totally collaborated to create brand new content that we, all three, implemented in our CPOE library.

Much of healthcare practice, rightly or wrongly, is localized. Were there areas where you didn’t reach consensus on what the best practices should be? Along those same lines, would other hospitals be able to use what you’ve developed and not find them in need of some changes because of localization or because it doesn’t fit their practice?

Very good question, and here’s the answer.

Not very many people do experiments on neonates, so there’s not a lot of hard … in the medical literature world, we call it ‘randomized double-blind, placebo-controlled trials’ of testing Drug A versus Drug B on a newborn, or Treatment A versus Treatment B. 

Some of the work was based on consensus. Consensus meaning in our hospital in our neonatal unit/NICU, we do it this way, we do it this way, and there was some negotiating and back and forth and eventually, the consensus — which is actually the way that many guidelines are developed. Evidence is used wherever it exists. That is pretty firm because if the evidence is solid and it is what it is and it doesn’t matter whether you’re in southern California or Maine — it is.

In the areas where there was an absence of evidence and some of the order set content was created based on consensus, then that would be somewhat left open to local adaptation. If client licensed the Care Collaborative libraries and said, “Wow, I really like this neonatal content, but in our NICU we do this one thing different,” some aspect of the care of a newborn/neonate, it’s very easy to customize the content for a local facility.

To answer that question in terms of a health system, we — Adventist Health System — made the decision right out of the chute that we were not going to create a set of CPOE content for Hospital A or modify it or add new content for Hospitals B and C. As big as we are, by the time we had 37 sites live, we would have thousands and thousands of order sets and no way to keep the content consistent to update it because there would just be so many varieties and so many different flavors of it.

The other two health systems in our Collaborative — Ascension and Catholic Health Care West — came to the same decision. We know one health system that after they had eight sites live, had 3,500 order sets and they had like 60 more sites to go. We just knew that wasn’t going to work. That was one of the beauties of the collaborative. 

We met every month and we would talk. We had a working group and an executive group. We would talk about what we were learning, what was working. The experiential knowledge of not only building the content process, but the implementation process we shared with each other — that’s an enormous benefit of the content library, the Collaborative content library, that now exists. It builds off of the experience and the knowledge of three large health systems that are rapidly deploying CPOE.

An order set is a guideline, but not a hard and fast rule. Are you measuring the compliance and adherence to those sets within individual facilities?

Yes. just was talking to our CIO about that two hours ago. We are using our Cerner clinical data repository and the PowerInsight tool. We’re able to measure what percentage of patients the doctor used one of our evidence-based order sets, at least one, in the care of that patient. For our last three sites, we’re averaging about 65%.

Now let me be real clear about what that means. Our goal out of the chute was to build content for 80% of the most common diagnoses and surgical procedures for which patients were coming to our hospitals. We did an analysis of our DRGs and did a cutline of 80% of our total admission volume and said, all right, this is our goal. We’ve got to develop CPOE order sets for this many diagnoses. We never expected to hit 100%. Eighty percent was our a priori, out-of-the-gate goal.

In these last three sites where I’m telling you we’re hitting 65%, the first one of those three went live April 20, so it’s just very preliminary data. By that, I mean physician experience with the content is very early. We’re pretty pleased with the rate of adoption. The goal of the evidence-based order sets is to not just make the physician ordering process electronic, although that has some benefits — drug-drug interaction checking, drug dose checking, drug-allergy, and drug-food interaction checking — but to actually take evidence that not all physicians may be aware of and put it into the order sets, create the orders that would help physicians follow the most recent, best scientific evidence that’s available.

As we increase our percentage of usage of those order sets, our expectation is that all those things that we’ve built, we plan to measure and monitor the things I mentioned — cost of case, length of stay, mortality, quality metrics, safety metrics, financial metrics — that will be able to demonstrate that it does, in fact, make a difference.

It sounds like you subscribe to the model that usually works, which is make it easy for the doctors to do the right thing.

Right, exactly. It’s pre-built. You don’t have to go out and order the imaging studies, laboratory test, drugs, and other things. It’s one-off orders. They’re gathered in an order set and they’re put in a logical sequence.

When there’s important new information … for example, in 2009, the American College of Cardiology put out new guidelines for the treatment of myocardial infarction and there were some pretty substantial changes in those guidelines. We spent a lot of time editing and updating our content to reflect those changes.  A couple of the cardiologists that were on our committee said, “Wow, I didn’t know that was now recommended.”

That’s an illustration of busy, practicing clinicians. You just can’t stay abreast of the exploding knowledge base in medicine. This is a way of creating a systematized, regular process with that content. I love your phrase — to make it easy for the doctors to do the right thing. That’s exactly what we believe.

You mentioned your CPOE timeline, which I assume is driven by the HITECH incentives. Is there anything in what you’ve read about the proposed Meaningful Use criteria that is worrisome to you?

Yes. When we read the first draft, the section on quality measures where the draft legislation said that we had to: a) capture the data electronically; b) aggregate the data; and c) submit it electronically, directly to CMS. That list was huge. There were close to 100 quality measures. 

Everybody turned to me and my evidence-based medical team and said, “What do you guys think of this?” I said, “Every single one of these is a great measure. They’re all evidence-based. But to create the ability to capture it electronically, aggregate it, and submit it electronically in this incredibly short timeframe is way too fast and way too aggressive.”

Quite a number of national organizations that we belong to felt the same way. We submitted a lot of feedback to Congress through the mechanisms that were provided and said to the secretary of HHS, “We believe these are all great measures and they should all be adopted. This is a great roadmap. You just can’t expect us to go that far, that fast.” That’s an example of just a by-product of CPOE.

As far as HITECH, the ARRA stimulus plan, that we hope gets modified when the final records are released here in the next two to three weeks, because it’s going to be an extraordinary challenge to comply with that in that short of a timeframe.

In your areas of responsibility, what would you say are Adventist’s most important IT corporate projects?

Corporate clinical IT projects?

Anything that you’re interested in that you think is important enough that it gets a lot of corporate exposure.

Obviously the system-wide implementation of the EMR, which we did in breakneck speed. We have one of the largest footprints of Cerner applications of any client in the world. We’ve basically have every Cerner application there is. So to roll out that many and we did it — by the way, since you’re an IT guy or you write about this, you’ll probably appreciate this — we did a big-bang implementation. On a Sunday morning at 6:00 a.m., we turned on the system at a hospital, live house-wide. We did one every month for over three years to get it done. That was an unheard-of accomplishment.

Back to strategies. Deployment of the EMR and creation of the evidence-based content for CPOE — that went on in parallel while we were deploying the base EMR. By the time we had the base EMR live everywhere, we had the content created in the Zynx world and exported it to Cerner PowerPlan and we’re ready to go. Now we’re moving aggressively into that phase so that we can be done by October 1, 2011 for HITECH.

Another thing that we’re looking at is health information exchanges. We own over 1,000 physician practices in Adventist Health System. We’re in the process of installing the NextGen physician office EMR there. We want to connect our physician offices. We’re in the process of co-developing an electronic medical record for long-term care facilities and nursing homes. It is a co-development project with Cerner.

We’re also licensing Cerner’s home health product. If we have our nursing homes, our home health agencies, our doctor’s offices, and our hospitals linked to a health information exchange, then we’ll have a health record that can follow the patient across the continuum. We believe there is enormous opportunity there to streamline the care. The physician has to be in an Accountable Care Organization to avoid duplication and retesting and to improve communication between the hospital and the other venues of care.

Any closing thoughts?

I’d like to speak a little bit more to the collaborative issue. You had asked a question about customization and localization. If a hospital or health system were to license the content of the Care Collaborative, what it really gets then is speed to implementation. For us, given our objective of creating order sets for 80% of the diagnoses across all of our hospitals, including our large quaternary medical center here in Orlando, it took us three and a half years to do that, working feverishly with 12 separate committees working in parallel.

One of the things that someone buying the Care Collaborative content gets is the advantage of all the multidisciplinary input that went into taking the Zynx content and refining it and making it more usable. Number two, this content is live and in use every day in hospitals around the country.

The third thing is that we as a system and our two partners in the Collaborative have made the commitment that we will review our order sets on a regular, systematic, scheduled basis and update them. If someone licensed the Care Collaborative library and then paid the annual access fee, you would have the ability to take advantage of the work of three large health systems. If you’re a 200-300 bed, standalone, not-for-profit community hospital with limited resources, for a relatively modest price, you get access to the intellectual work of three of the largest health systems in the country. 

HIStalk Interviews Glen Tullman and Phil Pead

Glen Tullman is CEO of Allscripts. Phil Pead is president and CEO of Eclipsys. This interview was conducted Tuesday evening, June 15.

   

Do you think it’s going to be a distraction, in the heat of HITECH and the window of opportunity that’s there, to be trying to merge two organizations?

Glen:  We are already working together doing many of the things we would be doing as part of the merger. We have top clients of ours who have shared clients like Columbia, like Hartford, like North Shore – Long Island Jewish, who’ve been saying to Phil and to me, separately, “The two of your organizations need to work together to create an integrated end-to-end solution.” So we’ve been doing that in a very haphazard, unplanned way.

The beauty of this is that now we can be much more efficient. Our teams can work together, That actually saves rather than adding complication. That reduces it.

The other piece I’ll tell you is our joint sales forces now have a much broader offering, which is easier to sell, than they did prior to the merger.

The last point I’d make is that usually in a merger the technology is an issue, but the beauty here is that we’re both from an architectural standpoint. We have Microsoft .NET and other technologies that fit together very well.

So from my perspective, it’s not a distraction, it’s actually an accelerator.

Phil:  I’ll just add to that by telling you that we’ve actually had one RFP process reopen after the announcement of the merger because they loved what they saw.

On the poll I’m running, I was surprised that the leading response of who benefits from this is Eclipsys clients, which I didn’t really expect. Does that surprise you?

Phil:  I think maybe the poll views it that way, but I think it’s a great benefit for both sets of clients because as Glen mentioned, we share mutual clients today. New York Presbyterian, Columbia would be a good example of that. Obviously, North Shore, which is our largest client, has also gone with Allscripts.

I think there’s a big benefit, certainly for the Eclipsys clients who are looking to broaden the Sunrise platform out into the community, which was a big driver for us to do this deal. So many of our clients are looking to incorporate the ambulatory physicians into their environment and with the huge footprint that Allscripts has. That meant a lot to us and it obviously means a lot to our clients.

On the flip side, there are a lot of Allscripts clients who would love to create that seamless patient experience going from the ambulatory back into the inpatient. This gives Allscripts an opportunity really, now with Eclipsys, to offer an inpatient solution that ties it all together. Too many physicians used to say, “Look, I’m working in my office, I see a patient, and the next thing you know I work in the hospital and I’m using a different system and I don’t even get the data out of my existing system back in the office.” I think that probably from the poll that you’re seeing it looks that way, but frankly, I think it’s a mutual benefit for both of us.

Glen:  I would just add that this is a merger, and the reason it’s a merger is because both sides benefit. What this is really about is it’s capitalizing on what today is the hottest and most important trend in healthcare, and that is hospitals are aggressively moving to capture the communities that they operate within. Hospitals have said, “We want to connect to physicians. That’s our lifeblood.”

If you think about that, each physician is worth between $1 million and $2 million to a hospital, so they want to be connected. They can’t buy all those physicians, so they want to connect with them. It would be easier to do business with them and do that electronically.

Eclipsys is tops in terms of usability in hospitals. If you believe the US News and World Report list of best hospitals, of the top 21, 18 are Eclipsys. We’ve got the top hospitals that are now going to be connected into the largest base of physician practices out in the community. It’s more than 40,000 practices.

I use the analogy — if you were starting a new bank and you came into a community and said, “I’m starting a new bank and I want to have an ATM network,” and you had a choice: should I build one, or should I connect to the ATM network that already has 40,000 locations? The choice would be, of course, connect to the network that’s already established that has 40,000 locations.

What we’ve done by putting these two companies together, we’ve created a new company that essentially has the top hospitals connected to the largest network in America of not only physicians, but ambulatory care. Post-acute care facilities, I should say. So when you talk about closing the loop of care … because at the end of the day, this is about the patient having one record and that means you pull information from the hospital, from the ambulatory world, and from the post-acute world, and you present it in one patient record. That’s what we can do today. No one else really has those capabilities all bundled together.

Both companies clearly had a reason to both hate and fear Epic. How does that change with the merger?

Glen:  I don’t think it’s so much hating and fearing Epic. I think the fact of the matter is that Epic’s solution is based on 25-year-old software. They have an ambulatory system that doesn’t really work for smaller practices, and that’s half the physicians in America. It’s the equivalent of trying to put a mainframe into a two-doc office. Can we do it? You can do it. Should you do it from a cost, quality, and usability standpoint? You really shouldn’t. 

This is less about fearing Epic. I mean, frankly, Epic needs to worry about what we’ve just created because this is a real solution on modern software with a real connection between usable hospital software and 40,000-plus practices that are already using at least one piece of Allscripts software, 10,000 post-acute facilities that are using it. Now you’ve got a real network. Somebody last week, one of the analysts, called it the Verizon of healthcare, which is a real connected network. For the first time, there’s software that can actually be used. I think this is going to create a very distinct competitive advantage versus an Epic.

Phil:  I’d just add to that. If you just look at the healthcare marketplace, the merger will create a network of 180,000 physicians, about 1,500 hospitals, and as Glen said, 10,000 post-acute, but it actually goes beyond that, because one of the things that I think all the physicians really crave is, OK, so now I’m connected — so what?

Well, the ‘so what’ is … and let me just give you a really interesting example of a client that I talked to just the end of last week. One of their biggest problems is that they track all this data, or all these hospitals do this. They showed — and this is a typical big scenario — one patient that showed up seven times over a two-year span for the same problem in the hospital. When they analyzed why that happened, this patient shows up in the hospital the first time with this problem and they’ve got the best, brightest minds with all the CPOE, the integrated environment the hospital creates, and they see this patient and they go, “I know what’s wrong with this patient,” and they follow the protocols that are already built into order entry. They’ve got their order sets, they take care of this patient, and the patient leaves.

The patient then goes back into a primary care environment and then they start to deteriorate for whatever reason. They didn’t control whatever their chronic disease was. They go to the primary care and the primary care goes, “Yup, I’ve seen this before about 30 years ago, and this is how I treat that patient.” None of the protocols that treated that patient successfully in the hospital transfer to the ambulatory environment.

So, the ‘so what’ here for us is now that we’ve got these physicians connected, our goal is to use clinical analytics and clinical decision support to take the fundamental care that patients are receiving in a hospital. When they move to a post-acute or go back to their home, all these protocols will follow with them so they’re not returning to the hospital at a higher level of acuity because they go back into an environment that doesn’t understand how to treat them.

This is the massive inefficiency that exists in our healthcare system today. What’s interesting is Medicare is going to stop that. They’re already starting at a high level, I would call it, with the Never Events. But at some point when you can look at following a protocol of care and the pathways associated with an optimal outcome that a physician doesn’t follow in an ambulatory setting that results in that patient showing up in an acute care facility and at a higher cost, someone’s going to know that. I think that’s ultimately where we’re going to get to in this bundled payment for quality reimbursement that I think we’re going to move to over the next 3-5 years.

Glen:  One other thing I’d just mention. You mentioned Epic. We are both, Eclipsys and Allscripts, big believers in open systems. We’ll connect to anyone. We’re working with a variety of systems. That’s important because while our offerings will be richer and more vibrant, we are an open system and we believe that the information has to flow. That’s a very big difference from somebody like an Epic.

You mentioned in terms of the differences — again, modern software versus 25-year-old MUMPS; open versus closed; ambulatory — we have it, they don’t; and again, more of a PC versus a mainframe. When you put all that together, what’s really happened is, for the first time, the market has real choice. We think they’re going to choose this new, combined organization that we’ve created together.

Some would say the advantage of Epic is that they’re privately held and all the work that you have to do to integrate two quite different companies and two quite different sets of products has to be done under the careful scrutiny of Wall Street. Are you concerned about how long this will take and what kind of scrutiny you will get while this all takes place under the covers?

Phil:  We actually love the scrutiny. We really do. I think that’s a great point, and the reason that we love it is that you’re going to be able to see the progress every quarter. When you’re a private company, you have no clue what’s going on behind the curtain. You don’t know how profitable they are; how many people they’ve got working on all the problems.

You know, I got LASIK surgery about three years ago, maybe a little longer now. The reason that I chose the company I went with was because they were public. I could read every one of their filings and see who was suing them for not doing a good job. You have no clue what goes on in a private organization.

I like the scrutiny. I think Glen does, too. I’m responsible, with Chris Perkins, for the integration. We’re going to be able to demonstrate the progress that we make, but let me just say this, and I think that Glen started off by saying it. We already have mutual clients that have merged or integrated, where we can believe that there’s a level of integration between our software.

The reason I say, ‘believe it’ is because at their level. what the user sees, what a physician uses at Columbia and that’s integrated with Sunrise, is very real to them. That level of integration has already occurred. You could talk to them tomorrow and they’ll tell you absolutely, I get whatever I need and I’m done. But that level of integration is at that first phase. We’ve made it usable, data transfers, and as far as they’re concerned, they’re done. We’d like to do it at a much deeper level, but it’s transparent to the user. That’s the first thing.

The second thing is we’re both Microsoft .NET and SQL Server. That makes the level of integration far less complex as a result of the platforms being the same, and as Glen mentioned earlier, the open architecture that we have. Allscripts has an architecture called UAI and we have Helios. The similarities are quite amazing, and of course we didn’t realize this until we started doing our diligence, but both of us have abilities to actually integrate levels of applications at a speed that would be very difficult if they were Oracle, Linux, MUMPS. It’s just fortuitous in many ways that we’ve got the similarities in the platform.

As far as the operational integration goes; again, there’s incredible complementary resources between the two companies. I won’t get in and bore you with all the details, but I will tell you that operationally, Allscripts was taking advantage of some of the back office functionality at Misys. They can now take advantage of the back office functionality of Eclipsys. It almost transfers over pretty neatly when we move the operations into a combined company.

We have substantial resources in India for development, for product support, for back office finance functions. Allscripts can take advantage of those. We’ve already mapped out — and of course, we’re going to get down into it at a far deeper level of detail now — but we’ve already mapped out exactly how the integration would work on an operational level. We’ve already started our planning an integration team on the product side.

We’re already getting excited because we’ve already been able to do stuff in just a few days because we’re actually working together, as Glen said, in an organized fashion as opposed to two companies separately sharing clients out there. We can actually do things that we never thought about doing earlier and we can do it a lot more quickly.

Glen:  The timing is perfect. It’s interesting. We were just getting ready to spend millions of dollars on upgrading to a new financial system and, lo and behold, one of the choices is one that Eclipsys is already using and they have great expertise in. Now that makes that decision and saves millions of dollars. It makes the decision easy and they have the expertise to do what we would have probably struggled with. Again, when you look at some of the things we have to do, it fits together very well.

I’d also point out … you talked about being public. Being public means you have a certain discipline, and when you’re well-managed, you don’t mind that. But if you look at what we’ve created together, this is a company that’s going to be accretive in 2011. This merger is going to be accretive, number one.

Number two, we’re going to be producing $40 to 45 million per quarter free cash flow. Forty to $45 million per quarter free cash flow. And we’re talking about a synergy, cost synergies, that will ramp up to about $40 million per year. When you look at those numbers … and doing all that, our R&D spent between the two organizations will be one of the highest in the whole industry. With all of that, we can create great returns for our mutual shareholders and yet deliver world-class products.

Phil mentioned Sunrise 5.5. That’s brand new, it’s coming out. It’s been a year longer than anyone else — a year in QA and QC to make sure that this product, when it hits, is perfect, or as close to perfect as software can be. In the first installs, we’re seeing that … all that investment.

Similarly, on the Allscripts side, both our Enterprise and Professional products have been updated recently. We’ve worked through some of the kinks that we had in the Enterprise product. Professional, that came out — the full redo of that — without any issues, and it has the least number of defects, I think, of any product in the industry.

Quality products, strong financials, and a great base to draw from. We think that when you put these together… You know, the most important thing, I’d say is the genesis of this transaction. Sometimes you see companies merge and say, “Why’d they do that?”  Other times you see companies merge and the clients scratch their heads. This merger was driven, in large part, by a lot of our clients, some of the most prestigious organizations in the country, who said, “The two of you belong together. This would be better for the client if you were  and better for the industry.” A lot of people are frankly saying it’s wonderful to have an alternative to some of the old-time choices that they had before. We think that the clients’ reaction has been strong and we couldn’t be more excited.

There was a number given, I think, in the conference call of expected annual growth of 8-10%, which doesn’t seem all that impressive. Is that basically just under-promising and over-delivering?

Glen:  Well, there’s a little bit of that, but more important, a strength of both organizations is almost 60% of Allscripts revenues — and Phil, roughly the same amount for Eclipsys? — are recurring.

Phil:  That’s right.

Glen:  So you’ve got this enormous base of recurring revenue because we both have such great customer bases. The problem with that … that’s great news for an investor, but on the flip side, that base doesn’t grow the way new sales grow. When you look at that, that base is probably growing kind of CPI. The base is growing 2-3%. If someone’s paying you software maintenance on their software from year to year, you’re not going to be increasing that very much because that’s so big. If that’s only growing — that huge base of 60% of your business — is growing 1-2%, to get to 10%, that means the other parts of your base have to be growing 20, 25, 30%. That’s surely true in areas like electronic health records, where our separate growth in those areas is in the 20s and 30s. Again, you have to accept it.

Phil:  Yes, the metric there is really on backlog growth. As Glen said, if you remember on the Eclipsys pricing model, we sell predominantly on a subscription basis and we spread that revenue over a 5-7 year period. Unlike a Cerner, for example, that takes revenue upfront, that’s why you’re going to get a different metric. But the metric to follow is really the number of deals that we’re signing and the backlog growth that we have.

Glen:  By the way, it’s better for — let’s be clear — it’s better for the clients if you balance the revenue with how they use the product, as opposed to taking a big hit upfront the day they sign it. That’s not a benefit to anybody. We actually have to do the work to get paid for it. We think that’s good for clients, and it’s good for us. It aligns us with our clients.

Probably the one consistent observation is, gosh, there are too many EMRs now under what will be the same banner. Surely some of them have to be retired. What are the thoughts about, are there too many and are there plans, preliminary or otherwise, to prune the family tree a little bit?

Phil:  I love this question. It’s a great question, and I’ll tell you why I love it. It’s because the marketplace demands different kinds of solutions depending on the workflows and specialties of the physician practices and the workflows and complexities of the acute care environment.

Let’s just take the ambulatory piece, and I’ll let Glen jump in here, but if you look at our combined ambulatory EMR solutions, you’ve got MyWay — great product for the single-physician practice, simple, easy to install, allows them to keep a workflow that allows them to see a patient every 15 minutes. Primary care, they’ve got 50 codes they need to bill, and they’re in and out and done.

PeakPractice on the Allscripts side is a great product that will take the market slightly bigger than that, where they’re looking at a more complex environment, and Peak is Software as a Service. Again, it’s a great technology. It’s brand new. As you know, Eclipsys purchased that from a company the end of 2008. We’ll be able to take advantage of some of the great content now that Allscripts has and pour that into the Peak product so we’ll be able to address that next tier up in the segmentation of the physicians.

Then you’ve got the mid-tier market, so we’re looking at the 10-20 physician range, and that’s where Professional fits. Again, it takes those physician practices with a higher level of complexity, different workflows, and Professional is a perfect product for that.

Then you go into the larger-scale practices; the faculty plans, all that good stuff. That’s where Enterprise plays, and that’s where Enterprise is being very successful. Now what you need to do there is you need to do something a little different. You’ll still be able to sell Enterprise on a standalone basis because you’ll still have the large physician practices out there who may want to have a standalone, but a connection back to the hospital. But more often than not, that’s going to be a full Enterprise solution where you’ve got the content and workflows of Enterprise being integrated onto the Sunrise platform.

Again, .NET, single database, single sign-on, auditing, context management will all be built into the Eclipsys platform. So now you get a seamless environment between the owned physicians — especially if they’re at a big group level, faculty plan, and so on — back into the hospital. We see zero overlap on the ambulatory side and we see that market segmentation naturally fits into our respective product lines.

Glen:  It’s interesting because if we wanted to optimize our bottom line, sure, we could only have one. I mean, Epic only has one. The problem is it doesn’t work in a one-doc or a five-doc practice. You’re trying to put a mainframe where a PC can do the job.

Phil:  Which is the majority of physicians.

Glen:  Yes. So they’re actually not optimized. I mean, again, look at the auto industry. You have a pickup truck, you have a minivan, you have a sports car. Imagine if somebody said to you, “Don’t you think you have too many? You have three different ones.” People would laugh. They’d say, they’re for three different uses, three different markets. Even within that, you have some variation for different specialties and the like.

There’s a reason that Eclipsys has been the leader in CPOE. There’s a reason that Allscripts has been the leader across each of the small-doc, midsize-doc, and large-doc practices in the market. That’s because we have products that fit the needs of our clients. The reality is if the clients stop buying them — you know, it’s great to speculate; for analysts and everybody else to speculate — but the fact of the matter is the clients are buying them and they’re buying them in record numbers.

If you look at our numbers from last quarter, last quarter we actually raised our guidance on bookings, on sales. Then, one quarter later, as you heard our CFO Bill Davis report when he announced this merger one quarter later, we’ve substantially exceeded the guidance we had given one quarter earlier for sales. Why did we do that? Because the clients are buying. They like the offerings that we have.

Ultimately, at the end of the day, people can speculate, but I like to use the metric of who’s buying the most. Where we see that, the clients are buying. We feel like the strategy works and that’s, I think, the best vote in the marketplace.

Phil:  One more point, not to bore you to death here, but Sunrise Ambulatory Care, for example, on the Eclipsys side, will benefit hugely from the richness of the content that Allscripts has built up over the years. Again, if you’ve followed Eclipsys, we have really great clients using Sunrise Ambulatory and we’ve made, I think, a huge market out of the oncology area. Now we’ll be able to really address a lot of the other ambulatory specialties which will benefit from that content and workflow out of the enterprise.

So when we talk about too many, we’ve actually got a perfect number, and we’re going to be looking to integrate back onto the Sunrise platform at the top end; and then work our way down through the segmentations. But every single one of those products will connect back to the hospital at whatever level of integration the hospital desires and the physician desires.

Glen, you mentioned some of the analysis commentary. When you look at what you’ve read after the announcement, both from the analyst perspective and from the industry perspective; are there aspects of what people have said that you think are either unfair, or that they’ve missed key points about why you’re doing this?

Glen:  I think that generally, the industry has understood, the analysts have understood, the investors have understood the strategic rationale. I think everyone buys into that. I think where people have had some confusion is the structure of the agreement. That is, why is Misys, who owns 55%, selling, and how is it structured?

The reality is there’s a technical rule on the London Stock Exchange where Misys PLC is traded. That says if you’re going to make an investment, you either have to control that investment, or it has to be de minimis. To translate that in rough terms, you either have to have more than 50% or less than 10%.

Because of that, when we came along and our Board looked at this and said, “It is a perfect fit here for Allscripts and Eclipsys to come together,” we looked at that and we said, “Boy, the way to do this is to use stock for this transaction, because that way, the Eclipsys shareholders and the existing Allscripts shareholders all benefit from this new, combined organization that we’re going to create.”  So that was the way to do it.

The problem is if you use stock to facilitate this merger, then all of a sudden the shared ownership of Misys PLC would drop down to 40%. That’s not allowed, because now they don’t control the asset and it’s not less than 10%. They were faced with a decision: should they invest hundreds of millions of dollars more in that company or should they use the opportunity to give their shareholders $1.3 billion back, keep 8% of the company, and allow us to move forward strategically in a way that best suits our own shareholders?

I think they made a very good decision. That decision is good for their shareholders. They have a billion dollars. That decision was good for Allscripts. The shareholders have a better position than ever. That decision benefits the Eclipsys shareholders because they’re going to, from this combined company, they’re going to have a larger, stronger platform to work with.

I think it was a smart decision, but I think there’s been some confusion because people don’t understand the intricacies of the London Stock Exchange and why Misys was essentially forced to either divest a large portion of their holdings or invest hundreds of millions of dollars more to keep their share above 50%.

I think that’s the most confusing part of what is otherwise a very strategic and understandable transaction. I mean, in today’s world, if you look at this, we’re combining two companies in what is one of the hottest, fastest-growing areas in the largest sector of our economy, and that’s healthcare. It is a $30-billion government stimulus being injected, and getting that money is all based on utilization. Just taking the two companies that are the leaders in utilization, Eclipsys in CPOE and Allscripts in the ambulatory area, and we’ve combined them to create a new powerhouse in this area of healthcare that is going to change the way healthcare is driven in America.

If I were going to grade the two of your performances, let’s say two years after the acquisition closes, what should my criteria be? 

Phil:  Let me start, and I’ll tell you from a shareholder perspective, I would like to see you grow the top line and prove your earnings per share leverage over that period. If I was a client, I would grade you by the integration between the product solutions to make this a great experience for their hospital and ambulatory environments so that the two came together. If you were looking at it from the employees, I would want to say that the next few years will be some of the most exciting with all the new opportunities they have to plan. Of course, the employee part you know you’ll get because employees love to share their rumors and stuff like that.

Then, finally, I’d tell you that the folks who I think are going to benefit the most from this will be the patients. Too often they’re the ones who get left out in any of these merger discussions, but ultimately, our goal — Glen’s goal, my goal — is to bring to healthcare what we’ve all wanted as individuals. That is, that wherever we receive care, by whatever specialists we see, whatever primary care physician we see, whatever hospital we go to, I won’t have to deal with the triplicate forms. I won’t have to deal with the duplicate tests. I won’t have to deal with an environment where physicians have no clue who I am.

Restaurants today, with OpenTable.com, have more information on me as somebody just sitting down to dinner than a physician has one me looking at me and my health, my life. If Glen and I can truly change that in the next two years by what we’re doing, then frankly, I think this has all been really worthwhile.

Glen:  There is nothing I can add to that, which is rare for me, but I think that summarizes it perfectly.

Is there anything I didn’t ask you that you want to talk about or any concluding thoughts?

Glen:  I’d just say that it’s really a privilege — and I think both Phil and I feel this way — to have this opportunity to provide a connected system of health that really gives an integrated, end-to-end solution, which is what everyone has been … that’s been the Holy Grail of healthcare, and it is within reach.

We’re in the perfect storm of all the reasons that people should change. The financials are there, the need is there, physicians are ready, the software is ready. This is the most exciting time in healthcare that we’ve ever had. We feel, like sitting on top of this new organization, we have a very unique opportunity and it’s a great opportunity, as Phil said, for all of the stakeholders in healthcare.

HIStalk Interviews John Holton

John Holton is president and CEO of SCI Solutions.

It’s been a year since we’ve talked. What’s new with you and the company?

We’re doing well, especially given the economic challenges that the country’s gone through. Our revenues were up about 15% last year and we added about 62 new customers, so we’re over 400 now.

We’re seeing hospital clients starting to do a second generation of buying. They understand that access management is more than just scheduling and pre-registration, that it really focuses on taking a look at customer service for the physicians and the patients and starting the revenue cycle as early as possible, ideally in the physician’s office or better yet, in the patient’s home.

They’ve really been receptive to our ideas. We’ve been focusing a lot on self-service ideas over the years, looking at other industries and how they use self-service tools, either over the Web or things like kiosks, to offer a much better customer experience to their clients. We’ve been trying to apply a lot of these to the healthcare or the hospital environment.

What about patient scheduling? That’s your forte.

Some of the first things we’ve done are self-scheduling.  By self-scheduling, I don’t mean requests, I mean actually like an airline reservation, typing in the information, your appointment preferences and automatically, within seconds, getting back appointment choices so you can decide when to have the service. We’ve got hospitals where the physician’s offices do self-scheduling, as well as the patients in their homes self-scheduling various procedures.

At one SCI client, more than 40% of their outpatient volume is self-scheduled. We’re starting to see some real progress made in those areas. A lot of the hospitals are in competitive situations and understand that it’s so important to tie physicians and patients through the service end; but the good part about it is it also starts a revenue cycle out in the physician’s office as well, or in the patient’s home. We’re starting to see those two ideas really catch on in the industry.

The new stuff that we’re really excited about is kiosks for the patient encounter and for check-in. We think, just like in the airline industry where they’ve been a huge success, or in the banking industry where they’ve been a huge success for the ATM machines, that there are a lot of possibilities and benefits that can be applied to hospitals in really improving their patient flow and the check-in and making a better patient experience.

The other thing that I’m really excited about is our ordering product now connects directly to the physician’s EMRs, and the EMR integration that seamlessly initiates the scheduling and revenue cycle activities right from the physician’s exam room. You know there’s a lot of effort underway with the stimulus money to get physicians and hospitals to use EMRs and then to integrate those and pass information. This is really a first step.

What are the advantages?

Our ordering product, Order Facilitator, automates the orders from the community physicians to the hospitals and then coordinates referrals among the primary MDs to specialists. The purpose of the programs is really to track every order and make sure that they’re not lost and that they’re legible. We provide that information and eliminate lost orders.

The doctor’s office doesn’t get interrupted, patients don’t have to wait around when they come in because the order’s been lost and they have to call the physician. The revenue cycle for medical necessity and for authorizations gets started in the physician’s office, while they’re still fresh in his or her mind.

I think one big benefit is that patient care is actually improved now because we can track every order the physician makes, and every appointment that’s made by the patient, and give the physician feedback as to which patients are following through on their orders.

I was pretty surprised at an article that appeared in The Journal of American Medical Association that said that up to 40% of orders written by physicians don’t get followed through by patients. That really doesn’t help much for their physical well-being. We’re excited that even a product that’s as administratively focused as getting orders into the hospital is able to also affect patient care positively.

Order Facilitator, the original version enabled, you to enter the orders — usually by the staff or the physician — through a portal or you could fax them over and they would be automatically entered into the system and then passed on to the correct departments and worked through a revenue cycle tool to make sure that they were preregistered successfully.

But now, with our new version, we are connecting directly to the physicians’ EMRs. Rather than receive a fax out of the EMR, we’re actually getting a structured record which eliminates the need for entering the order by the medical staff or trying to index a fax. We’re really excited about this. This may seem kind of ho-hum, that everyone has order entry systems, but in fact, when you look into it, it’s a very challenging problem.

As the Meaningful Use criteria get put into play, we’re going to have to, as an industry, deal with a lot of the challenges and quirks that we uncover and find solutions to them. It’s a Meaningful Use criterion to get the physicians to enter in the orders into the EMR. I think in Stage 2, sending it to the receiving provider will be required as well.

The challenge lies in the fact that the hospital systems that are in place today require an order message to have a medical record number, and often an account number. The physician’s EMR doesn’t know either one of these numbers and the hospital account number hasn’t been generated yet. If you have employed physicians and you’re all on a single system, you might be able to solve this challenge because you can generate an account number; but you probably don’t want to because you’d be generating a lot of accounts that may not get acted on.

With community physicians on all different types of EMR solutions, you have a real problem on your hands. SCI designed our orders product, now in the new release, to make sure that it’s architected in a way that it doesn’t require either a hospital medical record number or an account number. Through the process of ordering directly out of the EMR, it leads a scheduler and the registration folks through a process that gets the right medical record number on the patient as well as the physician’s EMR number. We’ve been able to cross-reference these electronically, and pretty easily. Then we pass those on to the various systems within the various hospitals.

Really, what we’re trying to do here is much like the way the integration engines standardized interfaces between proprietary systems back in the ‘90s, maybe even a little earlier. We are now integrating the orders between physicians’ EMRs and various hospital systems that need those orders without having to require the legacy vendors to go back and make a lot of programming changes to their system. These are not trivial changes.

You mentioned your business is up. Do you think having this inordinate focus on electronic medical records will take away from your business or will it help it?

No, I don’t think it will take away from our business. Our business is up because we solve real problems with real benefits to hospitals. We can make a huge difference to their bottom line very, very quickly; and we have a business model which is subscription-based. 

For a very small amount of money on a monthly basis, you can get our software and our systems with our technical model of the Software as a Service. It deploys very fast relative to other large enterprise systems. Your return on investment, which is just a monthly fee — say it takes you four or five months to get this in. You’ve got five months of a subscription fee versus millions of dollars you may have paid under the license model.

Hospitals reap more benefits. The ratio of benefits to cost is so extreme that it’s a no-brainer in terms of doing this. What we found over the last year and a half or so is that when hospitals had capital equipment fees is where license vendors and others were having difficult hard time. The hospitals wanted to continue doing something and wanted to continue making improvements. They looked to vendors with these models that were easy to get started with and didn’t cost a lot to get in, but you could still make real gain.

I think that’s why we’ve been successful. I think the only gotcha, maybe, is that IT staffs have only so much bandwidth, so they may be focused on EMRs rather than other aspects. We’ve tried to address that by requiring almost no involvement by the IT staff, given that we host everything and do the interfacing and the stuff to run efficiently.

Do you think the HITECH Act will encourage innovation or will it discourage it?

I don’t know if it will encourage innovation. I think it will encourage better practices by some of the larger vendors. I think there may be a move towards more certification. The vendors will be more responsible for putting out better software and getting that software installed. We’re continuing to see some very bad software being offered to the industry.

One vendor that I won’t name recently introduced a product in our area of expertise. Instead of putting the time and effort into developing a rules engine and being able to implement fairly complex rules, they did nothing more than stick Visio flowcharts in their product. You could click on it if you needed to know the rules and a Visio flowchart would pop up in front of the telephone staff who were answering the phone. They had to go through and figure the scheduling process themselves.

Last time we talked, you were pretty pessimistic about uninsured patients, credit markets, bad debt, and self-pay. In the meantime, we’ve had healthcare reform. How do you think that will change the situation?

Healthcare reform, despite all the naysayers, is going to be a benefit to hospitals. We have 18% more Americans of the total population who will have insurance, so there should be more money in the system. Obviously there’s going to be more scrutiny through Medicare and cost-shifting.

The thing that worries me the most was not the government-supplied insurance, but it was the new high-deductible plans that are sweeping the nation now; the high-deductible plans where a person may pay the first $1,500 or the first $5,000 for the family. What happens is because there’s little price transparency — and we’re trained from our old system not to even ask about these things — a patient will come in and get a procedure not knowing the cost. It could be something as simple as an MRI after they’ve twisted their knee playing softball over the weekend and its $2-3,000. That’s significant money to lots of folks. If the insurance company isn’t paying that, then you have a real problem on your hands.

The research that I’ve read says that if you don’t collect self-pay money before the procedure’s done, you have less than a 40% chance of collecting it afterwards. It doesn’t matter what socioeconomic class the person belongs to — people just pay their healthcare bills last. What I’m concerned about, and what I’m seeing more and more with our clients, is bad debt being incurred in the self-pay portion of these patients’ bills. I still think that it’s a big problem that’s sitting on the horizon that our hospitals are going to have to deal with.

I always like to finish with your predictions since you’ve been pretty well on the money there. Tell me what you foresee for healthcare IT for the next three to five years.

I think the next three to five years is going to be a heads-down focus on these clinical products; getting those in and getting them going. I think we’re going to see a bit of a shakeout in the industry. This is really going to tell, among the big vendors, who are going to be successful.

I think companies like ours, which are focused on niches — but really big niches if you could call the revenue cycle a niche — are going to be very successful. I think you’re going to see the emergence of companies that are not today thought of as major financial players in the industry. Financial system providers in the industry will come to the forefront and you’ll see some new companies.

If we’re talking in five years, I think you’re going to see some new companies that are leading those areas. I think there’ll be a much clearer delineation between companies that provide financial systems for the hospitals versus those that provide clinical systems.

The third thing is that I’ve always been a big believer that large, outsourced business offices are going to have to be the way of the future. There are huge economies of scale that are available starting from orders, scheduling, and pre-registration functions, all the way through to denial claims management and collection agencies. That whole process can be done on a very large scale much more effectively and save a lot of money for the hospitals.

I would liken most hospitals to mom-and-pop shops in terms of their expertise and ability to do these things. I think that what we’re going to see is even more. The for-profit chains have been at the forefront of developing these large regional business office systems, but I think you’re going to see private companies coming in offering those services and more and more hospitals taking those up.

HIStalk Interviews Jay Mason

Jay Mason is CEO and chairman of My Health Direct of Brookfield, WI.

Tell me about My Health Direct.

We’re a SaaS access management platform that broadly and seamlessly connects patients to healthcare appointments throughout either an entire community or an entire network. Think of it as OpenTable for healthcare.

It’s utilized by hospitals, the managed care plans, and state health initiatives to reduce unnecessary ER visits, to improve continuity of care with patients, and to correspondingly improve access to care for the patients. Those patients are primarily uninsured or covered by Medicaid or maybe one of their other public program counterparts.

Access management systems often do eligibility checking and other revenue cycle functions. Is that different than My Health Direct?

Yes. We take the term ‘access’ literally. We’re talking about access to health appointments and access to care versus access in a broader sense like revenue cycle management programs.

Talk about the ED overcrowding issue.

Two big articles just came out, one in USA Today and the other in The Washington Post. They coincidentally came out on the same day and speak to the same issue: there’s a tremendous amount of overcrowding in the ERs today.

People believe that’s principally due to uninsured patients. Studies show that’s not the case. Unfortunately, uninsured patients avoid care until it’s really bad. They get it when it’s absolutely necessary.

The drivers in overuse of emergency departments within the urban setting is patients who don’t have the knowledge and the skills and the resources to know what their options are to get care like you and I, who may be commercially insured. Not knowing what their options are, they’re going to the ER. The majority of times, it’s for for non-emergency conditions. They’re using it as a clinic.

We aggregate the appointment availability in the entire community with the community clinics and other participating physicians on a real-time basis. We make it available via a search engine through My Health Direct’s Web site for those people who are interacting with the patient. 

A discharge planner or a nurse or physician in the ER who’s interacting might say, “We put a cast on your arm, but we need to get that thing taken off in four weeks. Instead of you coming back to the ER to take it off, let me find you an appointment in your neighborhood and schedule that appointment now so we can get your cast off.”

It’s amazing how many appointments show up to do things just like that — to get a script filled or a cast taken off or sutures removed. We all know the right setting for that stuff is an ambulatory setting, hopefully a low-cost one or at least one with a lower cost than the hospital ER.

Practices never seem to be open during convenient hours, with nobody staying open past 5:00 or 6:00 p.m. Is there really enough capacity in the system to handle patients who don’t have the luxury of going during normal working hours?

You would be amazed how much capacity there is in a community. When we first started this thing four years ago, we really thought the problem is probably there are just not enough appointments.

What we found is there’s a ton of locations and they’re not very efficient as far as their model is concerned. We find a lot of unused and inefficient capacity in a community where we’re able to collect it, aggregate it, and drive volume to it and maximize the efficiency of what might be smaller community clinics or free clinics or independent docs.

The advantage to the clinic is that our system allows them to really operate. My Health Direct is a front-end revenue cycle management tool. A clinic might say, “Gee, I really need about 45% of my practice to be Medicaid. I’m willing to take 15% charity and the rest has to be cash.” They can load that into our system and we actually deliver that payer mix according to what their requirements are. It allows a doc to manage their portfolio of community-based care and know they’re not going to be inundated with something that they don’t want.

Specialists stopped taking ED call because they couldn’t get any paying patients. Do specialists and imaging centers really want to compete for ED referrals?

Their fear is that they’re going to get too much bad business. I don’t want to be inundated, as a PCP or a specialist, with too many charity patients. I’m willing to take my fair share, but don’t give me more than I think is reasonable.

That’s the problem is a lot of physicians, a lot of centers, elect not to participate because of either that experience or that fear. So, we said, “What a minute. If there’s a way to do a load-leveling or logistics management here and spread it widely and appropriately and allow the physician to have control.”

Who pays for your service?

We’re a community-based solution ultimately. Our clients are made up of hospitals, managed care plans, and then various public access programs or the initiatives. Those are all customers, currently, that pay for services with My Health Direct.

Who recruits the providers who will take the referrals?

We have provider relations folks who go out in concert with our clients. A hospital ER might say, “Look, there are six clinics within two miles of here.” They identify them and they work with us to get in front of those clinics and we can put them on a managed care plan. Then they say, “Yes, these are contracted facilities. We’d like to get these 37 clinic locations on.”

They identify, we work with them. We go together and we get them on the system. It’s a SaaS model, so this is a pretty easy implementation process for clinics.

Does your system go out in real time and poll the locations for open scheduling slots? How does that work?

We’ve got two methodologies to gather that information. Low-tech and high-tech, for lack of better terms.

The low-tech solution is there are, unfortunately, still a fair number of practices that are operating either on paper or an Excel database. We give those clinics our SaaS scheduling module that they can use to run their practice. It’s a nice improvement for them. It’s not a full PM system. It’s not intended to be, but for small practices who really are struggling to get to that next step, it’s a nice tool. We can maximize the throughput even though they may be a small clinic.

Or, for a higher-tech solution, we’ve built spiders into the major practice management systems. We can drop those in and, on a real-time basis, read the calendars of those major practice management systems.

How do you assure that they won’t be double-booked, once in your system and again on paper?

A lot of the low-tech practices actually do most of their business via walk-in. They don’t do a lot of appointment making, probably because they don’t have a practice management system to schedule it. A lot of the FQHCs — the Federally Qualified Health Centers — probably 80% of their business is walk-in, so we’re not running into scheduling conflicts on the low-tech solution because generally speaking, as I said, they’re working on a first-come, first-served basis.

Some people might not want to be seen by a doctor who’s so available that he or she will take automatically scheduled ED patients. Who makes the quality decision on the providers?

The hospitals, when they’re the client. They’re controlling what clinics are on the system and what clinics they want to interact with. Similarly, the managed care plans are doing that. We don’t have a quality assurance process to make the determination what clinics are in or not. It’s our partners, really, that are directing that.

Is there feedback? Let’s say it’s a hospital ED that makes the appointment. Do they know or care that the person actually kept the appointment?

Oh, yes, absolutely. It’s critically important. We really designed this thing on the floor of the ER with the help of a lot of overworked, underpaid nurses. Some of the feedback we got was that they want to increase the show rate. They want to make sure that people are showing for these appointments.

We’ve been able to document that we’ve increased the show rate tenfold from the old system — the old system being the nurse hands you a piece of paper with a couple of clinic names on it and says, “You need to go to one of these.” About 5-8% of the time, patients will actually follow up. The other, they’re not doing anything, and unfortunately, they show up back at the ER with complications to their conditions.

We confirm appointments with each clinic. At the end of every week, we ask the clinic, “Hey, here are the 42 patients we sent you. Please click this box and let us know if they showed, if they didn’t show, or if they rescheduled.” We aggregate all that data and feed it back to the hospitals and the health plans.

Why would they be more likely to show through your system? Because they’ve already got a confirmed appointment versus “Go make yourself an appointment?”

To a degree. Some of the criteria we use to find an appointment are obviously pair-typed. If this is a Medicaid patient, we need to find a physician who’s taking not only Medicaid in general, but who’s contracted with the plan that they’re in. That’s the first cut.

Then we look at the neighborhood they’re in. We want to get in close proximity to their home. We look at provider language. Many times that’s a barrier, so we add that. If public transportation is needed, we make sure that the provider offices that we’re selecting are on a bus or a light rail route. We have other criteria such as provider gender or religion, if that’s a preference for the patient.

You take all those things combined, much like OpenTable does. You find a provider that’s most culturally competent to what the patient’s needs are. That, and getting a confirmed appointment that’s printed off in the consumer’s language are the game-changers that allow us to find the right location. That’s why we’re getting the show rates that we are.

Unlike OpenTable, just so I’m clear, the patient themselves is not interacting with your system. Is that correct?

Not today. We are in Beta with a couple of clients and we’re opening up a direct-to-consumer tool as well. Not for Medicaid patients, but actually for commercially insured patients.

If you did that, would you follow the OpenTable model of allowing people to rate their satisfaction?

Yes. We’ve got a feedback loop built in.

With OpenTable, you see reviews and the price range and all the other factors that made their experience whatever it was. That would be interesting, where you didn’t have just anonymous reviewers, but those who actually confirmed their appointments just as someone made the OpenTable reservation.

That’s where we’re going. That’s kind of the future for the second half of this year is we want to be able to use it in an advocate model like we are today. Someone using it on behalf of a patient, be it an ER staff member or a managed care caseworker.

Ultimately, we want to get this into the consumer’s hands. It’s an easy to use tool that, for a hospital or health system, can help move market share. For the consumer, is a great differentiator in the market. I mean, everybody always complains, “Gee, it’s easier for me to order a book on Amazon or order tickets for a movie than it is for me to communicate in any way with my doctor. Why can’t I just get the appointment that I need?” That’s really where we’re heading with the next phase of our evolution.

You had a CMS contract with the State of Connecticut to reduce inappropriate ED visits. What was the result of that?

CMS provided some grants to states a couple of years ago. We were working with the State of Connecticut to write their grant and they were fortunate enough to get that.

We’re working with the state, the primary care association, the hospital association. We’ve picked about eight clinics and six hospitals throughout the state that were in desperate need of what we do, and it’s worked out great. We’ve been able to move those non-emergent patients — either if they’re triaged, or for follow-up care — to community clinics. We’ve got a tremendous show rate. It’s worked particularly well. It’s one of the more successful CMS-funded initiatives.

If you were going to use that, or other experience as a selling point, what are the numbers that would get someone’s attention to the strategic use of My Health Direct?

On a visceral basis, the ER staff knows what the problem is. They know they’re overcrowded. They know they have non-emergent patients. They know these people aren’t showing where they should show. Just intuitively, what we do makes sense. I think that’s one of the reasons why we’ve been as successful as we are is we’re a pretty simple tool that’s very effective.

But we have done studies with our clients and have found that there is a hard ROI, and that we’ve been able to, because of moving those patients, reduce subsequent ER visits. Additionally, we’ve been able to reduce inpatient confinements because we’ve got those people connected to what we’ll refer to as a Medical Home.

There’s got to be some quality impact as well. Obviously, if the no-show rate goes down when you make an appointment right in front of someone, that whole compliance issue then comes into play. Not just for what it costs or where they go; but whether they get treated at all.

Absolutely. There are clinical aspects along with operational efficiency aspects and financial aspects to what we’re able to do.

How do you think the whole ED visit and referral pattern will change with whatever healthcare reform changes?

Unfortunately, that is the elephant in the room. There have been a lot of studies. I mentioned the studies that were referenced by the two articles this week, but Medicaid patients are four times as likely to use the ER than a commercially insured patient. They’re using it for a majority of their visits for non-emergent care.

If they reduce Medicaid reimbursement, the result of that is fewer physicians are going to participate in those contracts. If you’re going to increase the rolls of Medicaid recipients by 30 million-plus, you are equally going to see a substantial increase in ER visits. You’re going to have a much bigger gap of supply and demand than we do today.

Today, it’s really significant. I think that’s the unintended consequence of reform is that we’re going to see our ER visits, which last year was 121 million ER visits in the country – it  could easily hit 150-160 million visits.

The other trend that’s occurring is that urban hospitals are closing at an alarming rate and so are their ERs. Not only have we seen a substantial increase in ER visits, but we’ve seen a corresponding decrease in the number of ERs. Compounding that with reform and what is going to happen with Medicaid usage, it’s a big issue, a very big issue.

More patients will have insurance, so I assume more providers will accept their referrals. However, it might be a golden opportunity to educate patients about how to properly use healthcare resources since they’re suddenly more desirable with insurance.

If they’re privately or commercially insured, the studies are indicating that those people are connecting with much higher frequency to their primary care physician. It’s the Medicaid population that we really need to think outside of the box and try to find ways to fully engage them in their care and trying to do that early and often.

I think that’s going to be our biggest challenge is the economy and the country. You have to try to engage those people so they’re not using the ER inappropriately and they are getting the care that they need.

HIStalk Interviews Bob Murphy

Robert Murphy, MD is chief medical informatics officer at Memorial Hermann Healthcare System of Houston, TX.

Tell me about your priorities at Memorial Hermann.

I’m the system CMIO at Memorial Hermann. The organizational priorities really continue to be the same. We’re trying to drive quality, creating the best experience for our patients and our physicians.

The Meaningful Use thing that just came out has helped stimulate or augment the priorities, but really, they were things we were doing already. It may be helping us accelerate in some areas faster than others, but we already had CPOE planned across the enterprise. We already had CDS [clinical decision support] in a pretty deep fashion.

We’ll probably add a little bit more in the documentation and maybe getting more effort on the ability to exchange information with our physician practices. We had all of these elements in place even before the stimulus plan was announced.

What’s your reporting structure?

I report directly to Dr. Mike Shabot, who is the chief medical officer, and dual-report to David Bradshaw, the system chief information officer.

How about underneath you?

I have the area of medical informatics — CPOE and clinical decision support. I have the groups that do the order sets and support the CDS. Also, some pharmacist informaticists and some outcomes folks who work on my team.

What are your thoughts about the value of CPOE in outcomes and patient safety based on recent studies? You’ve done this in more than one place.

You know the history of the literature. You know some of the things that have come out with potential unintended consequences, and I guess I’ve been a consumer of whatever research and practices and articles that come out to learn from whatever those experiences are. I think there are certain things that, as a physician, clearly you see the benefit of simple things like handwriting. Having practiced for over 10 years, I saw quickly that handwriting is a contributor in many ways.

In addition, you start to see the benefits of what clinical decision support can do. That’s probably the area that I feel is the most valuable in all of this.

On the flip side, seeing the potential for unintended consequences has made me very thoughtful and exhaustive in preparation to make sure that we do everything we can to prepare the medical staff, prepare the clinical operation staff, and to be very dynamic in responding to issues that come up.

It’s clear to me that well-implemented physician order entry with decision support can make improvements in quality of care. Internally, certainly we are seeing some demonstrable quality outcomes from that. We’ve gone a slower approach than many, so our implementation, our first two hospitals, went service line by service line over a month. It took us almost two years to get to 75%.

That was really by design and slow and purposeful, but now as we’re bringing in additional campuses and departments online, I think we’ll be able to accelerate. I think the initial focus on careful, slow attention has been beneficial.

Are you a Cerner shop there?

We are.

Everything that you have on the clinical side is Cerner?

Everything but our OB department. That’s the only major clinical area that’s still not Cerner.

How should hospitals approach the clinical decision support requirements of the proposed Meaningful Use criteria?

You really start to see several buckets of where clinical decision support is important. The first is there’s just simple check objectives — do you have drug-drug interactions, drug formulary, drug-allergy checking? I would say that’s often the most rudimentary type of decision support.

In fact, the more and more we evaluate it, the more we are refining that from the simple tool that the vendors supply. For instance, the major pharmacy databases — First DataBank and Multum — come packaged with these drug-drug interactions. The longer we’ve gone, the more we’ve customized and turned off the alerts that are not that helpful clinically. To sites that are just going live, I think it’s some thoughtful caution and what level you set any of those settings. That’s the first big bucket of those simple ones.

Then you get into the current proposed objective that says you must have five CDS rules and those must be related to the quality measures. I think that was in advance from the original draft, and I think it’s one of which most of us embrace and are happy to see.

That gets into the more complicated type of decision support of workflow and how you’re going to capture these patients. What’s the correct trigger? What’s the correct notification to what user at what time? Folks here knew those quality measures.

If folks are just getting started, they need to keep it as simple and straightforward as they can. Simple things like on an order set for an acute MI — make sure the aspirin is checked or contraindication is documented. The one thing for some advanced hospitals is, if I look at that one — aspirin in acute MI — most of our hospitals are 100%, and have been so for the last six months.

Is that helpful for us to put a rule in place for something we’re already 100% for? For us, probably not. But for hospitals that aren’t 100% and need something simple to get in, those are thing kind of things I think you’ll see them focus on.

The third element is what clinical decision support can maybe bring as you continue to advance the tools that you have. One that we’re investigating right now is how do you correctly populate a problem list? For a large organization, on the inpatient hospital side, managing a problem has become very, very difficult with so many users — physicians, consultants, nursing, and others.

What is the most valuable part of a problem list? From a CDS perspective, we may, in fact, try to focus on identification of certain conditions — diabetes, high blood pressure, heart failure — that we can identify with good specificity and maybe add those as part of our CDS portfolio. You start to see, again, from the rudimentary to the more advanced organizations, will have to progress. I think most places will have several years to get there, but it’s still going to be a big challenge for small hospitals, I think.

Most clinical decision support isn’t guidance, but rather non-personalized canned warning messages that are either turned on or turned off for everyone. What about being able to tailor specific types of warnings to specific practitioners or types of practitioners?

We have those features in place and I would say most large vendors’ sophisticated CDS engines will have those capabilities. The problem is the work that requires for that customization. It takes an analysis of workflow and even certain elements of credentialing — which user can or cannot respond and answer to a request to initiate an order? Can it be a nurse or pharmacist or a mid-level provider, or must it be a physician? At certain places, is it the resident or the attending?

It gets into such role-based specificity it really is a challenge, even with the tools that are available. They often allow that flexibility. It’s a real burden for organizations how to effectively analyze, plan, monitor, and continue to improve those sorts of tools.

But in general, it seems there’s a gap between what outsiders who are setting these things up think physicians should need to see or want to see, versus those that the real practicing doctors actually find useful. How do you address that gap?

That, again, shows you the scale from the rudimentary — the drug-drug interactions. For instance, we’re a large organization, so we’re doing the specific work. We will turn off the Multum pharmacy formulary drug-drug interaction. We will most likely build a custom alert that will be able to analyze several parameters of that drug-drug interaction, not just this patient falls into a generic category, but your patient is this age, this weight, on these other medications all at the same time; you may want to consider X, Y, and Z. That’s the complexity that it’s going to be there for.

I do worry a little bit about the industry just trying to put in drug-drug interactions from a generic platform across large organizations or large populations. I think you’re going to see more and more refinement, and hopefully, tools for which we can all share that information.

You’re starting to hear discussion on how are we going to build these repositories of CDS knowledge through perhaps the AHRQ or other groups who could help us catalog that information that could then be more easily implementable. Right now, that’s the most basic, core format — things like drug-drug interactions that have very low utility.

The average hospital subscribes to First DataBank or Multum or whoever and then just selectively turns things on and off because that’s all the time and resources they have. How much of the value of decision support are they really getting by just looking at those warnings versus real guidance that let doctors make the right decisions instead of telling them when it looks like they didn’t?

I can share our internal experience once we began looking at specific drug-drug-based pairs. When I started five years ago, we had a large population of drug-drug interactions that were overridden 100% of the time. We had pairs that were 98-99% of the time. You start to see the incredible burden that has. That may lead to alert fatigue.

I think we need to continue to study alert fatigue. There may be a critical CDS rule or intervention that is very specific and very sensitive and very important to be addressed. If, however, that’s firing in a constant bombardment of 10 or 20 interactions and interventions, the truth is, you will begin to ignore the most important interventions.

Our attention in the last several years has been to turn off the generic, non-specific items and build more and more custom. I think it really does create some challenges for smaller organizations to address that. I just have to hope to continue to see the industry and some of the specialty societies in informatics and AHRQ who can then help us come up with more specific proposals for effectiveness in the CDS space.

The announcement just came about of the three big hospital systems that licensed their order set content to Zynx. That didn’t work so well when Eclipsys paid a fortune for Brigham’s BICS rules back in the ‘90s. Do you think that the rules that one facility creates are useful to others?

There again, you get into some of the local details that need to be built, as opposed to the medical evidence that needs to be somewhat codified. That’s where I look.

I know the AHRQ has a project underway to look at screening recommendations. Those are pretty straightforward on the evidence, but once again, that information is very helpful for us to share. Even our experience on the effectiveness of a certain rule may be useful. But as far as sharing the actual codified rule, even among Cerner clients, that’s often just a template to get started, but it often takes the customized work from the local environment.

I can give a couple of examples. What is the correct value of a potassium warning? Is it 5.0, 5.5, 6.0? You can look at it a lot of different ways, but often the sensitivity and specificity is inversely related as those levels go up. Somebody at some point must make an objective decision what it’s going to be. Is it going to be 5.5, 5, or 6? Most often, you’re going to need a local decision on governance to see what your final flag might be set at.

Isn’t that kind of a conundrum, though? All these rules that are very black-and-white specific, yet every hospital says, “I don’t like the way those come.” Is medicine really scientific enough that a rule ever fits?

You can continue to imagine, with a large amount of data points, to make them more and more specific. Like I mentioned earlier, the more specificity you can have on a patient’s age and weight and previous medications and previous problems, they give you more data elements to make the rules and interventions more specific. But once again, you’re looking at large computing power. You’re looking at ways to not negatively impact response time, for instance.

It remains, I think, one of the big challenges in the field is to have things that have a very high positive predictive value — that when an alert fires, it changes behavior. I guess the ideal state would be that’s the only kind of intervention that would fire is when it changed a behavior. Most groups think well, if you can get above 50%, you’re probably doing a pretty good job, but approaching 100% will be very difficult. If you can get above 50%, most of your users are finding things more helpful than annoying. That’s probably a reasonable goal for most interventions.

You can measure that. Are you shutting off those that don’t change behaviors?

Absolutely, and that is another component of the work required to have effective CDS is that monitoring. As I mentioned, we do analyze response to alerts. We look at the clinical outcomes, not just the response to the alert.

Another interesting fact we’re discovering is there are times in which the alert is overridden, yet later, the correct behavior is changed. At first thought you say, “Well, they overrode the alert; therefore, it was useless.” But it turns out, in certain situations, you’ve at least prompted them to think about things. You notice as you analyze more data that they actually did make a positive response.

Certain elements such as warfarin dosing with an elevated INR — that’s been a classic example where we’re seeing that those alerts are helpful even when they override the initial alert. They can maybe dose it more correctly later in the stay and during the days of administrations. It’s a component of correct design and monitoring and continuous feedback to make them better and better for the users.

I think people miss the fact that CPOE itself is clinical decision support even without all the warnings and alerts because it presents only the most common orders and the preformatted doses. Would you agree?

I absolutely agree. I think that’s what you find in the folks that do this work longer and longer. You realize that clinical decision support is really a comprehensive approach that includes how you structure your data. How you present information is even a form of decision support.

Then, the computer-based logic is only one component, but how you build the order sets, the choices you give for selections, are often — we use the phrase, “You want to make the right thing the easy thing.” You want to make the right thing in the information you present them; the right thing in the orders and the sequence of the orders, the choices that are most available; and the right thing in a clinical decision support rule that may help catch things that were missed at first. All of those elements together help you have that comprehensive approach that’s necessary, I believe.

You’ve done some work with mobile devices.

That’s been an interesting journey as well. We were a very early adopter, six or seven years ago, at Memorial Hermann. At that point, I think there were some big technology barriers — large devices, heavy batteries, needing an internal wireless network connection — that were a struggle.

Now we’ve advanced into more the iPhone-enabled group. Once again, it’s the right device with the right information at the right moment. The big one we’ve seen a huge success on is the AirStrip OB product, which allows fetal monitoring to be seen by our obstetricians. They can talk directly to the nurse about what patterns they’re seeing. It’s had a large and growing usage with our obstetricians. It’s wonderful to hear from the nurses that they feel so much more connected to the physician in being able to review strips remotely together and then making a good decision. That particular product has been very well received.

We’ve not really gone into clinical systems on our mobile platforms. We have a trial coming up this summer of one we’ve internally developed for the iPhone, and it’ll just be a snapshot of patient data. The great thing about iPhones and web development is that those things can be pretty straightforward to produce, and so we’ll be trialing our own internal version of that later this summer. We’ll continue to see.

We’ve understood vendors are out there with CPOE Lite products, but at a certain point … I’m not sure. It might be a nice bridge to help physicians though it, but for a large enterprise, I’m not sure it’s going to be the kind of solution that they’re looking for.

You mentioned that you’re pretty comfortable, or had an early start at least, on Meaningful Use. Based on the proposed criteria, how prepared is Memorial Hermann and what to-dos do you think you need to accomplish to be ready?

I guess the biggest one is going to CPOE at what percentage at our hospital. We have 11 hospitals. Our first two hospitals came live with CPOE.

We clearly had the strategy. The hospital would come up and we’d get the hospital totally up to a 75% or higher physician ordering usage. Once we had that, we quickly realized at that point, that was the inpatient ordering, and we then realized that it was critical to have our ER on the same system. So, we actually took a pause and we have installed the Cerner FirstNet product while that was going forward. With that, all of our ERs are going CPOE, so that’s really the first unit in all of the other hospitals that will go live with CPOE.

Well, Meaningful Use came out and said there’s a 10% threshold. We thought, well that’s great, because the ER would cover that 10%. Then, to find out they’ve actually excluded the ER from that calculus at present.

Once again though, we’re not going to alter our strategy. We’re going to finish our first wave of rollouts. Then this fall, we’ll have additional hospitals coming up. But we still believe that we need to have a hospital-wide approach. We don’t want to get on a partial 10% of every hospital just to get the number. Some of our hospitals will be delayed. 

That’s probably the most challenging of the measures to hit. Most of the other measures we have good plans for and projects in place. I think we should be able to meet the other objectives pretty straightforwardly.

Any concluding thoughts?

As a physician, I got into this field of medical informatics, you know, you want to make a big difference for an organization and for patient care.

The longer I’m in this, you start see that people, process, technology triangle that defines medical informatics. I think it continues to be in that order — the people, the process, and then the technology. I’m finding that with the right amount of money and the right engineering and support staff, you can get the technology right.

The people and process of healthcare are challenging in the nature of healthcare. Often they’re just challenging from being the cottage industry that we are. That individual autonomy is such a strong current. But you hope and you start to see that by providing tools that provide consistency and standardization and provide value that you can help drive hospitals and populations to improve care.

I think that’s what I continue to focus on, really — the people, process, and technology. If we can keep focused on that, hopefully we’ll continue to do good work.

HIStalk Interviews Brigid O’Gorman

Brigid O’Gorman is a junior at Connecticut College in New London, CT, majoring in cellular and molecular biology as a pre-medical student. She is captain of the women’s hockey team, a registered emergency medical technician, and winner of a $10,000 Davis Projects for Peace grant for her project to implement electronic medical records in rural Uganda. Connecticut College is contributing $3,000 as well.

While traveling to the airport with a group of Connecticut College students leaving on a medical mission to an orphanage in Kaberamaido, Uganda in the spring of 2009, a drunk driver struck the van in which they were riding, injuring several of the students and killing the trip’s organizer, who would have graduated in 2010, and in whose memory the clinic in Uganda has been renamed to the Elizabeth Durante Medical Clinic.

 
Brigid O’Gorman
Photo: The College Voice

Tell me about yourself.

I’m from Eden, New York, just outside of Buffalo. I live on a farm. It’s really fun, I love it. My dad’s a physician, an internist. My mother has her own flower business.

I went to Nichols School in Buffalo for high school. It’s a private school. I was captain of the women’s hockey team there. I also played soccer and lacrosse there. Then I came to Connecticut College and I’ve been playing hockey here since freshman year. I’m now the captain of the team. I played lacrosse my freshman year, but decided not to do that any more because it was during spring break and I’d rather go to Uganda during my spring break. That was my option and that’s how I got into this whole Africa thing.

Going to Africa has been something I’ve wanted to do since I realized I wanted to be a doctor. I’d always wanted to travel. I’d been to China and Africa was the next place on my list to go. I absolutely love it.

I found out about this opportunity to go in the fall of 2008 through my school. There was a pre-health club meeting which I’m a member of. So I went to this meeting and a couple of girls were up there talking about how they wanted to take a group to Uganda on medical mission. That was like right down my alley. I went to this other meeting and signed up for it and that’s when I got to go last year.

What was it that intrigued you about Uganda?

Nothing in particular. I would have been satisfied to go anywhere in Africa, quite honestly. Uganda is where these two kids started that group to go and they had been there the year before with Asayo’s Wish Foundation. They’re out of Salt Lake City, Utah. They have an orphanage in Uganda.

I ended up going by myself, but what we did last year was go with Asayo’s Wish Foundation. I worked at a medical clinic in this town where the orphanage was. I wasn’t so much interested in children, although that was really a fun experience for me. I worked with a doctor, mainly, and I kind of played around with the kids.

 
Brigid O’Gorman, Uganda 2009
Photo: Connecticut College

What were your impressions from a medical or public health standpoint?

I got to take blood samples and got to look at the malaria parasite under a microscope. It wasn’t powered or anything, but it just had a mirror that caught the sun so it would shoot light up through so you could see it. Obviously technology is extremely lacking. They only had one of those in this medical clinic.

The doctor had one nurse that helped him out. The way it works over there in these clinics is that the doctor just kind of showed up whenever he felt like coming to work, really. He would just, like, show up and people would hear that, “Oh, the doctor’s in his office, so we can go now.” They don’t set up appointments or anything — people just show up and line up outside the office. They just kind of sit outside on the ground, first come, first served. You get there early and keep it and you get an appointment.

He and myself, we got to give them all sorts of medication. I brought over a lot of antibiotics with me that were donated by my father’s office here, so we got to hand out antibiotics. Most of the people had malaria, so we’d have to hand out malaria medication. There was a lot of STDs, so we had to hand out antibiotics for that.

From a healthcare standpoint, they really need medicine. There’s nothing. There’s practically nothing. I’d say the bulk of the supplies they had I brought over with me. That was kind of special just to donate all those things to the people.

Tell me about the grant you got to set up electronic medical records and how you got the idea.

I got the idea because while I was there last spring, whenever the doctor had a patient come in, he would write down their symptoms and ask them questions like, what are you here for? He’d write down their symptoms and what he thought they had and what he was going to prescribe them in this little blue book. It’s just like an exam book that I take my exams in here, so I was like, wow, that’s really weird that I’m seeing these thousands of miles away from my college. It was used to keep their health records in. I thought that was a little perplexing, to say the least.

After he’d fill it out, he’d give it right back to them and say, hold on to it. It would have their past visits to the doctor in it so he could go back and look and see what they last came in for and if it’s any pattern or relation or anything. A lot of the patients didn’t have these, because the doctor gives it back to them, so most of them lose them because they don’t realize how important these things are. They have no concept of staying healthy or this whole medical record system. They weren’t concerned about holding out to this blue book, so it was often that they didn’t have one, which was difficult to try and figure out if this person had a previous medical condition that you didn’t know about.

When we were there, I also worked in the orphanage with about 180 children who didn’t have any medical records either. I kind of built on that foundation of the blue book they were using. I bought blue books there and we started health records for all these children. We wrote down their name and age. A lot of them didn’t know their age because they were orphans, so we’d have estimate their age from their weight or their height. We started that last year and I’m really hoping that it’s continued and people are doing checkups on them and doctor’s visits and things like that.

This was what got me to thinking that they need a more reliable system, I would say. I mean, how are these orphans going to hold on to these little blue books when adults can’t? I thought, I’m a college student and I know about computers, which isn’t that hard to figure out. It’s not that hard to install them. I’ve done it before and it’s simple.

I was planning on using the electronic medical software, hopefully from MEDENT. I haven’t purchased it yet. I know one of the company’s branches is in based out of Buffalo, so I was hoping to talk to them and hopefully get some donations of this system for my computers. One of my dad’s doctor friends has this MEDENT software at his office and I’m going to go see it. I’ve looked at it online and it’s pretty much what I need. I actually need a simpler form of it because I don’t need X-ray scans, I don’t need all the pictures and MRIs they can set up on these systems. I just need patient assessment, patient information, history, just very general, simple things. I’m going to try to work with them and get that going.

I haven’t bought my computers yet, but I’m going to get four of them from Dell. I’ve already talked to them about it. I’m going to have them sent to my house soon and get the medical software installed at my house and set up this whole little system at my house so that when I get to Uganda, I won’t have to worry if something goes wrong with the computers. There isn’t really going to be anyone there to help me, so I’m just going to try to set it up prior to getting there.

I know they have gasoline over there and can power generators. The electricity they have isn’t a lot. They only had one light bulb that actually worked and they ran it on a gas generator, so I figured that would be easy to power the computers. I’d just get a bunch of generators and I could help them power more and have more electricity at this place. That was my original idea. Then I was talking with one of my advisors here from school and she mentioned why didn’t I think about solar panels? I decided to look into the solar panel idea. I learned a lot about them. It sounds a little complicated, but it’s really pretty interesting. It’s not that difficult.

I’ve located a business in Kampala, which is the capital city of Uganda, that sells solar panels and will install them for you. That’s where I’m going to be purchasing my solar panels and I’ll be doing that when I get there. It’s an eight-hour drive from where they are to where I’m going to be, where it’s extremely rural and there isn’t anything around. They’re going to drive them out there and install them for me, which will be great. I hired an electrician already to make sure that the electricity works. I’ve hired a computer technician. These are all native Ugandans, so we’ll see what I get. I’m pretty excited about that.

 
Brigid O’Gorman, Uganda 2009
Photo: Connecticut College

What will your system do?

I’ll have two facilities. One is at this medical center and another is at the local hospital, which is turning out to be a little difficult because this hospital is a government-run hospital and it’s actually from what I’ve heard and found out from people who are working there right now has ended up being corrupt and things are getting stolen, so I’m not sure how much I want to invest in that hospital, but I’m going to give it a try.

My primary facility for this will be this medical center that is on the orphanage property. My plan is to have two computers, one in the patient room when a patient comes in. That will be there for patient visits. The second one will be in another office in the building. That will be for collecting blue books and transferring information from these blue books into the computers. I’m going to have a system where the information is transferred from these blue books to computers, and at the same time, the doctor will be doing his normal patient care. Instead of writing things down in their blue book, he’ll be putting it into the computers, so we’ll probably be tackling two things at once.

I’m bringing printers because they don’t have any form of identification over there. That got me thinking because when I got my driver’s license, you finally have that little card that identifies you. It’s just a huge symbol of who you are to my mind. To make ID cards for these people over there, I really think would have a huge impact on them. I think they would absolutely love it.

We’re going to have webcams to take pictures of each patient, so their information will be in the computer along with their picture so that you can recognize them. The picture and their name will be printed on this card and we’ll laminate it and give it to them. It will all be on the computer, so if they lose it, we can print them out another one.

I was also thinking about making ID numbers for each name, just so that you can enter the number or name either way so the person’s medical files will pop right up. They hand you the card, you type in their number, and you have their medical file immediately sitting in front of you. You know their whole history and you know everything that’s been wrong with them up until now. That’s my goal for those cards — just to give them the thrill of having an identity and something physical to hold on to that says they’re here, they belong here. And also to expedite their gaining of their medical files that are in the computers.

They’re going to be powered by solar energy, so after the initial purchase, so it won’t cost very much, hopefully nothing at all except maybe for maintenance which shouldn’t be too bad because solar panels nowadays are pretty durable.

Part of my proposal, so that the system doesn’t degrade after I leave, is to start training some of the older children of the orphanage. There’s 18- and 20-year-olds living there, so my idea was to start training them on these computers and have a different type of vocational program where I would teach them how to input the information and teach them all about computers and what I’m doing so that they are that much further ahead.

In a country like this, especially in this rural area, having the knowledge to work on computers would be huge for children there. Maybe someday if they wanted to leave that area, they could go and work for the government in Kampala; they could work wherever they want. That’s another piece of my project that I’m really excited about, just to help boost kids up and give them something to do with their lives. 

Elizabeth Durante, 1988-2009, photo overlaid with that of the clinic renamed in her memory
Photo: Asayo’s Foundation

If someone wanted to help you with this project, what else do you need?

I actually haven’t yet bought anything for it. I’ve been trying to concentrate on my school work right now. I’m a junior and I’m taking organic chemistry and it’s not easy, so I’ve been really focusing on my studies right now. I’m not leaving until July 1, so I have a lot of time once school’s over to start getting into it.

I’m going to be needing four computers, two printers, a laminating machine, the solar panels that I’ve already purchased over in Kampala, and any kind of electronic medical record software that I can install on the computers. I’m focusing on MEDENT because my dad’s friend has used it, he’s accustomed to it, and his office likes it, so that way I can get a feel for it from him.

I kind of need everything, but I do have the money for it, so that was really cool and I’m so happy to have this grant.

Other than the fact that the patient carries the record in Uganda, we’re not all that advanced in the US, where your record is in a manila folder on some shelf someplace and people debating whether it should be in a computer instead. What are your thoughts about that?

It’s a debate and there’s a lot of sides to it. I’ve discussed this with my dad because his office runs on those manila folders. They have the hard copy paper and that’s what their patient files are. He has files full of them.

The doctors I go to personally have the electronic medical record software. I work in the ER and that’s what all their systems run on. It’s definitely faster and more efficient, but you also lose the personal aspect of sitting down with the doctor and having them actually writing things in front of you and taking those notes.

It is a difficult debate, but I would have to side with the electronic medical software because it’s permanent and it keeps things safe. The personal aspect of it can be accomplished by doctors actually learning the computer rather than just dishing off information to a nurse or something and having them try to interpret their writing and put it in. If it becomes more familiar to people, it will be really good, but you can’t lose that personal connection between the patient and the doctor. That makes people comfortable and that’s why we’re doctors.

You’ve made time for a rigorous academic curriculum, hockey, and volunteer work. Are the people you know equally involved or are you different?

I never actually thought about that before this whole story started coming out. Recently I was nominated for the Hockey Humanitarian Award, which is given to the best hockey humanitarian student, male or female, from any Division I, II, or III college. That’s what got me thinking that I guess I’m not really normal. I really thought, don’t other people do these things? I really didn’t think it was that uncommon, but apparently it is.

I just do it because I love it. I love to travel. I fell in love with those kids I got to work with last year, so that’s why I really want to go back to this part of Africa. I just really loved the kids there and I’d love to help them.

My pre-med studies are going pretty well right now. Organic chemistry is not easy for me, but it’s OK. My other classes are fine. I’ve been playing hockey since I was four years old. My dad was my coach. That was my first love and I’ve been doing that forever. That got me into school and pretty much filled up my life and who I am.

I found this other volunteering stuff. I volunteer at High Hopes Therapeutic Riding center in Old Lyme. I got there every week once a day, usually Saturdays, for two or three hours. I lead horses around and we help mentally disabled or physically disabled children learn how to ride horses. It’s a therapeutic technique and it’s actually really, really exciting. I love doing that. I started doing that my freshman year and that really got me into volunteering. I coach younger children’s hockey camps and stuff like that in the summer and girl’s lacrosse camps. I like to do all that because I love kids and helping people.

What kind of medical career do you hope for?

There’s so many options. At first, I was thinking I’d like to be a pediatrician because of my experience with these kids over in Africa. That really put me toward that path.

Right now I’m not really looking to settle into a practice anywhere because my primary goal is to get into med school and work with Doctors Without Borders for a few years before I actually grow up or anything. I would love to work with them and travel with them wherever they need help. I would have gone to Haiti in an instant if I were an actual doctor right now.

Then maybe after I’ve had my fill of traveling around and adventure, I’ll settle down and be a pediatrician or maybe a primary care provider.

Does your father approve of your going into medicine?

At first, he didn’t really have much to say about it. He didn’t think that was a choice for me because you really don’t really have a life until you’re out of school, and still you’re a doctor and don’t have a life except for what you do. He wasn’t thrilled about that, but as I’ve been doing these things, he’s really come to see that this is what I want to do. He’ll bring up a topic like, are you doing these things right now and how are your grades and are you ready to do this? He’s really come around. Our entire family thinks this would be great for me, so I’m glad to have the support from them.

What schools are you considering?

Right now what I’m thinking is that my GPA is not exactly stellar. I’m at like a 3.0 right now because of this organic chemistry. Hopefully by the time I graduate I’ll have it up to a 3.3 or something, but medical schools want 3.5 or higher from what I’ve heard.

I’m probably going to do a post-bac program. Drexel has a good program. I think you get a master’s in public health and then they ship you off right into a medical school program from there, assuming you do well on your MCATs and do well in the classes. I’ve been looking at the University of Buffalo. Their medical school is where my father went.

I would like to stay closer to home, just to have that support, but I’m seven hours from home right now in Connecticut. I like that aspect of being away, too. It’s a difficult decision, but I will go anywhere I get in. I don’t really care what part of the country it’s in. I just want to be in med school.

If anyone wants to get in touch with you or offers help, I’ll forward their information to you. And if you have an interest in writing something up or sending pictures, I’m sure people will want to know how you’re doing over there.

First of all, I’d love the help if people would like to help. I have $10,000 in grant money so far and I’m going to be fundraising a little bit more, just to gain a little money for the orphanage itself and try and buy a lot of medications for this clinic that I’m going to be at, because other than this system, they really need the drugs to make everyone healthy again. I’m going to be doing a little bit of fundraising and a little bit of extra money would be helpful.

The electronic medical records software, if anyone comes up with an idea or wants to donate something about that or a simpler version of one of these high tech ones, that would be really helpful.

I’ll definitely get back to you by the end of August or the beginning of September. They actually don’t have Internet where I’m going to be and I’d have to have a lot more money to get it shipped in if I wanted Internet. I am two hours from an Internet site, so obviously my parents aren’t happy since they can’t talk to me very often, but I will be going back and forth from this town to get supplies because there’s basically nothing where I am. It’s just like a store, your orphanage, your clinic, and a whole bunch of homeless people, but I could be able to get in touch with you.

If someone is inspired by your story and would like to make a difference like you have, what advice would you give them?

Do what you love to do. That’s all I’ve been doing. I started out loving to travel, and then that got me out to Connecticut, and then I ended up in China, and then I ended up in Africa and fell in love with a bunch of orphans and taking care of people and volunteering. My advice is just do what you love and follow that because your potential is completely unlimited. Go for it.

HIStalk Interviews Amy Andres

Amy Andres is chair of the Ohio Health Information Partnership. She was interviewed for HIStalk by Dr. Gregg Alexander.

You have a diverse background. What do you bring to the table for OHIP’s (Ohio Health Information Partnership) Health Information Exchange and Regional Extension Center projects?

I know that a lot of people refer to my background working in the health IT industry, both at Allscripts and for CVS ProCare. I did some work for some software development companies.

Honestly, in this particular project, I think the area where I can be most helpful is my background and experience in the public sector. Bringing people together who may have diverse agendas or may be in a competitive situation, or an adversarial situation, and helping them come together for something that’s for the common good for everybody to cooperate in that environment.

I’ve had some experience with that, both at the Department of Education and also at the Department of Insurance. We have a lot of people with a lot of health IT experience at the table, and although I have it, I think the thing that I bring to the table is helping bring everybody together and see what the long-term good can come out of this particular effort.

OHIP is a public/private partnership. Maybe you could explain that give an elevator pitch on what OHIP does.

The thinking when this project kicked off was that there were the two main funding streams from the ARRA funding. One of those funding streams was intended for states to apply for those funds, and that was to support constructing a health information exchange. The other funding stream was designed for the regional extension centers. 

I think the way the feds thought about it originally was they would have this patchwork throughout the country. Not necessarily within state borders, but just throughout the country, there’d be a support system to help physicians adopt EHRs.

The way we thought about it is two-fold. One, it doesn’t seem like a great idea to have one group working on implementing the support mechanism for the physicians and another group building the system that they’ll be connecting to. It really made sense to bring all of those things together. The federal grant requirements allowed for the states to delegate the authority to apply for the HIE grant if they chose to do so.

What we did in Ohio is said, let’s reach out to the different stakeholder groups that truly are going to be the main participants of not only constructing this, but managing it long-term, and let’s all come together under one organization and do this together. For that reason, the Ohio Hospital Association, the Ohio State Medical Association, the Ohio Osteopathic Association, and the State of Ohio started in talks. BioOhio, who was already a non-profit entity and did some work in the space, also came to the table and offered up help to us get started and help us form such a public/private partnership.

Within a few months’ time, we really pulled that together and had those five entities get started with things. Then, in the fall after we applied for the grants and it became clear that we were going to be receiving some form of funding, we expanded to a full 15-member board that includes payers, behavioral health, federally-qualified health centers … We have consumer advocacy perspective, hospital members, and more, just really trying to bring together a diverse group that could not only give us the perspective for decision-making, but really help pull their communities together along with this process.

Are the other Regional Extension Centers (RECs) across the country working similarly? If not, how do they differ?

We’re not completely unique, but pretty close. I’d say the closest organization to us is a group in New York. Other than that, you mostly have the RECs and the HIE grants being made separately. We have had some feedback from some of the other RECs that that’s already starting to cause them some problems.

We’re one of the largest RECs. In most cases, you didn’t have a whole state form as a group. One thing I will mention about the regional extension center side is OHIP originally applied to cover the entire state of Ohio. So did an organization in the Cincinnati area called HealthBridge. HealthBridge covers the Cincinnati region, also part of Kentucky and a southeastern segment of Indiana. So they took their existing marketplace, both an HIE and they do REC-type services. They applied as well.

So what the feds ended up doing is they ended up reducing our grant slightly and awarding HeatlhBridge as well. For Ohio, it was a good thing because we ended up with substantially more funding, so it requires some level of coordination between OHIP and HealthBridge, which is not a problem. We’ve known those folks for years, have worked with them for years, and on a weekly basis have calls to make sure that we’re staying on the same page.

That’s one aspect that’s a little different, but for the most part, having all of one state covered by a REC is not common. Having it coupled with the HIE, I think there’s only one other circumstance. I guess Wisconsin, I believe is also that way. Other than that, it’s split up.

Is this the uniqueness that you mentioned one of the reasons you think OHIP received such a large chunk of the first-round funds?

I get that question a lot. Lots of people ask, “Who do you know in high places to receive this award?” I have to say this wasn’t a lobbying effort. The effort, really, just stood on its own of the model that we presented.

I do think that it helped that the administration found, and the stakeholders on the physician side came together and agreed to use, some funding that was leftover from a previous program to put up as a state match for the federal dollars in a time of a very tight budget. It was unheard of that entities would come up with that level of money for a match. I think that helps, that we were showing that we were committed to it as well.

I think the real reason that the feds gave us such a strong award is I think they see the merit in the model of having all of the stakeholders’ representation groups sitting on the board, and the level of involvement, not just rhetoric, actually, truly becoming involved. I think the feds recognize this is a model that could actually work and be propagated throughout the country. I think that they made a decision to make an investment in this model to see if it works.

EHR adoption and use timetables are exquisitely fast — very accelerated. Do you think that’s going to increase the odds of making bad decisions or failed implementations as the RECs across the country try to roll this stuff out?

There’s no doubt about it. It’s an extremely aggressive timetable. So aggressive, in fact, that some RECs … There’s definitely been some feedback and folks asking to adjust the timetables.

Here’s what personally I’ve observed in working with folks at the federal level. The interest to adjust timetables is not there. That’s going to stay, but what they have done is absolutely worked with us to try to remove the barriers that are getting in the way of getting there.

Although there was a lot of consternation, especially when everybody recognized at the same while we were in Washington that the timetable for this was really two years, not four years, I have to say that all of our board members — our initial five Board members were there — we didn’t have the same heart attack that some of the other folks had because we know our model. If any model’s going to get us there in this time period, it’s the one that we have.

Concerns over hasty decisions? Yes. When you speed up a project like this, that’s always a concern because you don’t have the time to run down every possibility and mitigate every single risk to meeting a successful project. When you’re in that situation, I think what you have to be open to is making adjustments once you recognize that perhaps a path that you were heading down may not have been the perfect path, and be willing to make adjustments as you go.

I think the other thing that’s key when you’re on this type of time period is to be really open and transparent with everybody about the risks of moving at this speed and establish trust with everybody so that when they see that maybe we made a decision that is not helpful in the process, that we’re willing to admit, yep, a change needs to be made and everybody moves on. I think that when you’re working at this pace, everybody’s got to be open and honest with each other and be willing to make adjustments when we realize they need to be made.

Some have expressed concerns that the RECs are not going to be transparent about how they’re making their decisions for choosing their partners, perhaps leaving some EHR vendors to be shut out. How do you address those concerns?

In our particular REC, our situation, we’re using a competitive process. As a matter of fact, that competitive process is going on right now. We’ve just released an RFP for preferred EHR vendors. We don’t know exactly how many we’re going to select, but we do know it will be more than three and probably less than ten. What we’re trying to get to is allowing for a manageable implementation and pricing that’s attractive for physicians right now.

Probably even most importantly, we’re looking for a commitment from vendors to Ohio. Right now, these EHR vendors, I’m sure, are expressing these concerns. They also have a market of the entire country that they’re trying to grab right now. As a group that has responsibility to make sure that this project doesn’t fall apart, we need to know that they’re not going to overextend themselves in our market, and that they’re going to be here. Once they get started here, they need to finish the job here and really be around to support it long-term.

It’s important for us that we work with vendors that are willing to make a commitment. We’re going to hold up our end of the bargain and do some things to support their efforts as well. There will be, absolutely — and there is already underway — a competitive process and several competent individuals scoring those responses to make our selection. If you’re an EHR vendor and you want to operate in Ohio and you’re not one of the preferreds, you’ll still absolutely be able to operate in this market so long as you meet the ONC certification standards. But we feel it’s important to use a competitive process to select a group of vendors that are willing to make a commitment to Ohio.

Are you saying the selection process is a transparent?

Oh, absolutely. Even though we’re not a state entity, even in the state system — which has probably a very high degree of transparency in the process — while the actual competition is going on, that information’s closed because if that information was released during the actual competitive process, it would give people an unfair competitive advantage. But after the process is completed, all of that information will be made public.

Will there be enough qualified people to help with the implementation, support, and training for all these REC projects? What kind of employees are you going to need with what skill sets and where do you think you’re going to find all these folks?

I have to tell you that that is probably, of everything that is happening within this project, that’s the thing that keeps me awake at night the most. The federal government awards grants to help with that over the long term, and in this project long term means three or four years out. That will be wonderful for long-term sustainability of workforce, but the problem that we have is that the mechanism that they contemplated to implement that through the two-year and four-year colleges does not produce a workforce when we need it, which is during this two-year push. We’re going to need it long term, but we really need some of those individuals right now.

When we were in Washington, it became very clear that the timing of that was going to be a problem. So when we got back to Columbus, the first phone call I made was to the Department of Development and the Board of Regents to see if we couldn’t put together a program for Ohio over the summer to produce, at least, the workforce that’s needed for implementation right now. We met with those folks, as well as a federal program that runs through Job and Family Services called the One-Stops. It’s a retraining program.

We’ve got a full team of people from each of the regional partners, from all of the two-year colleges in the state, the Board of Regents, the Department of Development, and the One-Stops. We’re putting together a very intense summer program to train individuals to do the office assessment and workflow support. Then, those individuals will either be employed by the regional partners — the regional entities that are part of our REC — or, they’ll be employed by the vendors. But, we know we need to create that workforce in Ohio. There’s some of that workforce, but not enough to get this job done and it’s a country-wide problem.

As we’re speaking about this, the other thing that we are contemplating is that we don’t want the EHR vendors coming in here bringing people from where they’re headquartered. We really want the workforce in Ohio to be Ohioans, and be people that stay here and support this long effort as systems are implemented. In part of our EHR process when we’re talking about vendors to partner with, one of those requirements would be that they’re hiring Ohioans to do this work. Our role in this is to make sure that there are competent Ohioans to hire for this process.

Every aspect of this project is truly going to have to be a partnership with everybody holding up their end of the bargain. I do, personally, see a lot of jobs being created out of this project. It’s not really something that’s talked about a lot compared to a lot of the other stimulus programs. What more is talked about is the tight timelines and bringing this up, bringing health information exchange structure and EHR adoption up to speed. But, out of all of this, jobs will absolutely be created. We just want to make sure that those jobs go to Ohioans.

A common theme within OHIP is the discussion of community. Why do you see that as being important, and how is the OHIP model addressing that approach?

I think that the OHIP model itself is the epitome of establishing a community around this.

Yesterday I had a speaking engagement with HIMSS. The discussion ended up turning into an hour of questions and answers, in a good way. People were very engaged. They were very excited.

I was there for another hour afterwards just answering individual questions and talking to folks. One woman said to me, “You know, this reminds me of a movement.” She’s like, “This is like you’ve got people coming out of the woodwork looking to volunteer the time and pitch in.” She said, “This truly has the makings of a movement.” When she said that I was thinking to myself, she’s absolutely right.

This is a situation where a lot of people who have wanted this to happen for quite some time see that if this is going to happen, this is it. This is our chance. People on a macro level across Ohio are coming together. What I think we need to make sure happens from this point is that same level of grassroots movement starts to propagate at the individual, local communities level. I think that that is the key to getting this done in not only an aggressive time period, but with less money than truly is needed to ultimately implement this thing. We have to contemplate a different model than the model that’s been used up to this point that, frankly, hasn’t been able to get us there.

The model that not only I believe, but several individuals who are working within OHIP believe, is getting that community level of involvement — getting physicians within their community working together on this and leaning on each other. The idea of bringing together groups of single practices, bringing those individuals together as a cohort and working through this together, it makes it more cost-effective for us to support that effort in that manner. But even more importantly, it gives them a peer group to work with as they’re working through their own problems. Certainly they can identify with each other going through this at the same time. We absolutely think that’s going to be the key to success in this project.

The next step is really bringing those communities together and helping them not only understand where we’re going with this, but understand that there’s support to help their community.

Are there any other points you’d like to bring up?

I guess just the final point, and perhaps I have spoke about it throughout this discussion, but this is one of those situations where you don’t see something like this very often. Where people who normally either are very strong competitors or have very different positions on how they see the world and how the healthcare system should work, or how health information technology should work — to see all of these individuals come together, not just rhetoric, not just the way that they’re speaking to each other, but truly their actions are showing that this is a partnership.

I’d say in my 20-plus-year career, I have never seen anything like this. It’s quite an honor to be involved and to be participating in this. I think a lot of others feel that way, and I think that’s what’s going to bring us to the dedication that’s needed to get this monumental task done on what is a very aggressive timeline. It’s just a pleasure working with folks on this project.

HIStalk Interviews Arien Malec

Arien Malec is coordinator for the NHIN Direct project of the Office of the National Coordinator.

Give me a basic overview of NHIN Direct.

NHIN Direct is a project to expand the set of services that are available on the NHIN, but to expand them in a way that is accessible to the majority of providers. Particularly, the majority of the primary care providers practice in practice sizes of five or fewer. The lingua, the interchange, the health information exchange/interchange for those providers currently is fax. The major aims of this project are to create a set of standards that enable those providers to essentially replace the fax with electronic forms of interchange.

There’s really nothing new in the kind of health information exchange that we’re trying to do. We’re not trying to break new ground so much as standardize existing ground. A lot of HIOs get their start in provider-to-provider or lab-to-provider direct communication. Essentially, what we’re trying to do is standardize that and make it easier to plug in EHRs into exchanges and make it easier for HIOs to develop standard services for that kind of direct communication.

I’d also note that level of direct communication aligns very well with the criteria for Meaningful Use; particularly the requirements to exchange information at transitions in care, as well as receive lab data electronically and provide electronic information to the patients.

How would you characterize the differences between NHIN and NHIN Direct in terms of who will use them and for what purpose?

I’m going to carefully separate NHIN, as in the NHIN Exchange, from NHIN, as in the set of standards and services that are available. There’s some confusion about what’s what.

Both define the NHIN Exchange as the network of networks, as the network in the middle with standards that enables large, national health information organizations to exchange data with each other. A great example of where the NHIN Exchange would be useful is in coordination of care between a provider who’s using a state HIO and a patient treated in the VA system or in the DoD system.

All three of those organizations are, essentially, extraordinarily large IDNs. They are nationwide health information organizations because they cross and transcend state boundaries. That’s the core use case for the NHIN Exchange — coordination of care and information discovery across large, nationwide health information organizations. The core standards that are in use are common standards that can also be deployed within an HIO context, so if I wanted to discover where else a patient has been and what information is available about that patient, I would use the core NHIN services. They’re essentially the IHE interoperability stacks, particularly the XDS, XCA; that stack.

The way that I describe it, I’m going to paint two pictures. Picture one says that I’m a provider who is in an exchange that offers both services and I’m referring to a provider who only gets the simpler kinds of services, the direct services. As a provider with access to both services, when a patient presents, I may do a query to find out where that patient has been seen since the last time I saw them, and discover information with the patient’s consent that helps me inform the care of the patient.

Then at the end of that encounter, I might publish the updated physician information into the repository in the sky for future care providers to discover information. Those are great uses of the NHIN specifications and services.

Then, at the conclusion of that encounter, I want to refer the patient over for care. Let’s say it’s for care that isn’t served on the same EHR, where I can’t rely on the EHR’s capabilities to have the chart available. So I want to push a referral transaction over to, let’s say, the cardiologist. Then at the conclusion of the cardiologist’s care, I really want them to push me an update to what happened to the patient.

That transaction, by its very nature, just doesn’t fit the “publish something in the sky and then grab something from the sky” model. I mean, you could do it that way, but the semantics of that transfer are directional. I want to give the referral over to that provider and that provider expects to receive it in his or her inbox. Same thing for a lab. You might publish the lab to a lab repository in the sky so that all people can have access to it, but the ordering provider wants to get that lab result in his or her EHR directly as well. So you’ve got both publish semantics and push-to-provider semantics.

Pretty much all we’re about at the NHIN Direct project is to create the standards, the specifications for that push-to-address case in ways that allow an HIO or lighter weight organization to be able to provide an address for a provider or for a patient, and for the routing of a transaction to go to that address. So, there’s a lot.

Many of the HIEs created their business models around charging for that type of service. Will they use some aspect of NHIN Direct or is this a replacement or a competitor for it?

A lot of HIOs, I think for very good reasons. It drives a lot of business value. You get started with simple direct services. Nothing that NHIN Direct is doing should, or does, conflict with that desire. NHIN Direct will, hopefully, make those services easier to deploy because there will be a set of standards around them, and EHRs, hopefully, will have their standards embedded within the EHR so it will be easier to get services up and running.

Now if your business model is, “Well, this stuff is hard, and so our business model is to do it because nobody else can and we don’t want any competition and anything that makes it easier to do is a threat to our business model,” then sure, it could be a threat to the business model. I don’t believe that. I believe that making it easier, making it more scalable, actually makes it easier to offer those services at a profit for exchange sustainability.

As I said, I think if you look at the example of successful HIOs, they pretty much all solved this problem at the cost of some blood early on, and they’re able to offer these services. NHIN Direct is going to give them a way of scaling that service offering more, but I don’t think they think it’s a threat to their business. I think if you look again, if you look at the example of HIOs that are up and running and doing well, I don’t think any of them are scared by NHIN Direct. In fact, I think they think of this as something that makes their work easier to do.

What about those EHR vendors that have their own exchanges?

A lot of the EHR vendors — and you can go to the NHINDirect.org website and look at the implementation group to look at the current members of the implementation group and you’ll see a number of the leading EHR vendors out there — many of them are participating in this effort. I can’t speak for them, but if you look at the strategic situation, I think many of them would like to offer a set of value-added services on top of their EHRs for simple connectivity.

Many of them are in context where if you look at the state of HIT in the United States, very few providers operate in a service area where it’s all one vendor and where you can mandate and lock down a single vendor model. So, many of these EHR vendors have customers — oftentimes large health systems — who are asking them to enable interoperability within their products, but also across other products.

I think many of these EHR vendors see this as a way to fulfill their customer’s business needs in a way that is standard, and allows them to offer standardized services. I think the EHR vendors, by and large, have looked at this as an opportunity much more than they look at this as a threat.

John Halamka likes the idea of a health URL where individual data can be pushed. Would this support that, or is anybody working on that?

Absolutely. The notion of an address that you can route information to is a core principle of the NHIN Direct project. In fact, John’s recent blog post describes the work of the addressing working group in NHIN Direct. He’s a participant of the implementation group and he references, explicitly, the health URL concept in the context of what we’re trying to do.

What about privacy and security?

I’m going to back up. If you look at the record locator kinds of transactions — where has this patient been, what information is available about this patient — those are the transactions for which specifications and standards currently exist. There is a significant set of policy issues around that because the information holder is receiving a transaction basically requesting information and needs to decide, on the fly, whether that’s an appropriate information request, and whether the PHI disclosure that’s associated with that is proper and legal. Any of those systems that are up and running have put in place consent models and put in place policy models that ensure that data is only provided when it’s legally appropriate to.

In the set of push transactions that NHIN Direct is all about, the information holder and the initiator of that transaction are one in the same person or organization. The best way to think about the NHIN Direct kinds of transactions is that the data are going to flow, regardless. I’m going to send the summary of care to the provider via fax. I’m going to send it via paper. I’d love to be able to send it electronically.

The legal responsibility is pretty clear for this. It’s the information holder’s responsibility to determine whether the disclosure that they’re making is appropriate. Appropriate is defined by any of the HIPAA exemptions, as well as by explicitly getting patient consent to do the transaction.

What we need to make sure of in the transactions and in the policy framework around health information exchange is that if there is a disclosure along the way, that we know exactly where that disclosure originated from, we know who the legal entity responsible for the disclosure was, and also that we protect the health information and make it secure all along the way so it doesn’t inadvertently get exposed. We’ve got a privacy and trust working group that’s focused on those exact issues.

I think John’s post mentioned that it will be the same framework that’s used by the full-scale NHIN, not a lightweight version.

Exactly, so we’re going to be using TLS on both ends. We’re going to be ensuring that all the data are encrypted in transit. We would recommend that HIOs encrypt it at rest as well, and ensure that they’ve got the appropriate security policies.

The other part of this is that we’re just doing the transaction semantics. We’re just doing the specification. Somebody’s got to take those specifications and run them. The organizations that run them need to run those transactions within a policy framework. That policy framework needs to have much more in it than just transaction-level security rights. You absolutely have to encrypt the data in transit, but then you also have to make sure the exchange has the security policies in place; does security audits and remediation, has good quality assurance policies in place; has good operational controls in place to make sure that … you’ve got to secure the entire system and not just the transactions.

There’s a lot of policy work to be done. We’re closely coordinating the technology work that we’re doing with the policy work that’s being done, both at ONC as well as within the NHIN workgroup and the HIT Policy Committee.

Maybe you can expand on that thought because I’m not sure I understand. What you have is a set of policies and practices, but someone has to actually run it.

Exactly. The metaphor that I’ve used is that you’ve got cake? Cake is good stuff. You want to eat cake. Cake adds value.

We’re not making cakes in the NHIN Direct project. Somebody’s got to run a bakery to bake some cake. What we’re doing in the NHIN Direct project is creating a recipe for cake, and we’re making sure that recipe is well-tested and making sure it works across a variety of settings. That you can use a small bakery or a big bakery to make your cake and the cake’s going to taste just as good, regardless of where you bake it.

But, as an organization, our project is to create a recipe. You’re not going to get any cake from the NHIN Direct project. You’ve got to get your cake from a bakery.

Is there any centrally hosted infrastructure or services?

Not so far as we’ve discussed. There has been some belief — which we’re still going to need to explore this — that there are a couple of potential services that the federal government may end up hosting. One might be a central certification body, as well as a certificate authority to make sure that people who operate on the exchange are carrying correct policy frameworks. That’s the one potential role for the federal government.

They are, essentially, assuring trust. That’s a role that the federal government’s already taking on and is actually legally responsible to take on with respect to the NHIN Exchange, to the extent that the NHIN Direct services get incorporated into the NHIN Exchange. The federal government and ONC have a legal responsibility to create a policy framework for that. That’s one role that the federal government could play.

There are potential other roles the federal government could play, particularly around potentially using some of the information that we have around NTI; as well as that CNS is going to have to have a lot of paying providers for Meaningful Use as a way of making directory services that people might offer more valuable. But, we still have yet to explore or decide on those capabilities.

By and large, the NHIN Direct project will exit with a recipe and not so much with infrastructure.

Do you think the EMR products that are out there will be ready to share data once the platform is available?

With everything else in software, there’s a software development life cycle. There’s a set roadmap on capabilities. What I’m encouraged by is that so many of the EHR vendors are participating in the project and have committed to do real-world implementations. Not necessarily full-scale, real-world implementations, but have committed to doing real-world implementations. That encourages me that by 2011 we’ll have exchange capabilities at a broader scale to support.

What this is all about is supporting providers, both in terms of their obligations to get the money for Meaningful Use as well as supporting providers and patients in the quality and efficiency goals that we’ve set out for the HITECH Act. My hope is that given the participation that we’ve got that we’ll get a good amount of support for providers in 2011.

How would you turn all this technology concept into something that patients would understand? What would you say the outcome would be and when will they begin to see it?

As a patient, what we would hope to see is that a patient has interoperable access. Again, I think John Halamka’s posts on the health Internet address called the health URL are as good a place to start in understanding what this is all about. As a patient, I should be able to get a health Internet address. I should be able to give that health Internet address to my provider and say, “Hey, I want my information posted here.” The provider should say, “OK, no problem. I’ve got all the capabilities for doing that.”

As for when that will happen, I expect it will be in essentially limited operations by the end of this year. I would expect us to be in wider-scale operation by the end of next year.The way that I would judge this project being a success would be the number of providers who’ve got an address.

The other side’s the patient experience. That when I get referred over for care, get treated by a specialist, and then go back over to primary care, that the thing that I expect to happen — which is that specialist knows why I’m there and knows my health information necessary for treating me and that my primary care provider knows what happened when I went to the specialist — that all that exchange has happened behind the scenes with my consent, appropriately.

I think those two outcomes would be the way that I would judge the success of this project. My beliefs and hope would be that we’ve got a decent amount of availability to service it by the end of 2011, and then rolling on to wider scalability in 2011-2012.

What also makes me feel good about this is there are a lot of organizations that can do parts of this, and really all we’re doing is taking the best practices that a lot of these organizations are doing, and saying, OK, that’s great. We know how to do it. We know how to do it, even at scale. Well, we don’t know how to do it and do it interoperably so that you can share information between systems, so let’s focus on that.

Any final thoughts?

I think that if you’re asking about the fact that we’re not hosting, we’re not running any services. I think that’s the thing that people get extraordinarily confused by, and understanding that is real useful.

Another common question that comes up is, “What are you doing about content?” The project itself is focused on transport, but we’re sitting and working with all the other work that’s being done around content to make sure that the payloads that people exchange are interoperable payloads; and all the good work that’s in the IFR to help us constrain down to CCR and CCD, but also constrain down to terminology. We’re relying on that work getting better and more stringent over time so that we can share information, but then we can also understand the payloads.

HIStalk Interviews Pam McNutt

Pam McNutt is senior vice president and CIO at Methodist Health System of Dallas, TX.

What would you say are some of the good and bad points in the proposed Meaningful Use criteria?

Well, let’s start with the good. What’s good about this whole HITECH legislation, I think, is that HIEs, or Health Information Exchanges, are going to be planned out at the state or regional level in a little more solid form than they have in the past. I think that’s good. Prior to that, we had HIEs being formed in regions, in cities, and sometimes even multiple HIEs being developed inside a single metropolitan area. Now with the grants, the states will be putting some thought and planning into what their state’s health exchanges will look like. It will bring some order to things.

Now what’s going to be difficult about the regulations that came out, I think there are a few main points there. First is the all-or-nothing approach that was laid out by the Meaningful Use regulations. Both AHA and CHIME have commented pretty strongly on that; that we think it should be more of a building block approach, rather than all-or-nothing. Meaning that if you can achieve so many, and that number could be debatable, of the objectives laid out, then you could be deemed to have achieved Meaningful Use, rather than having to do every single objective and every single quality measure. We’re very hopeful that will be given serious consideration by CMS. We hope.

What changes do you think will be incorporated from all the thousands of comments made?

I think we’ve already seen something occurring. The issue about eligible providers. In many cases, outpatient clinics of hospitals were excluded under the current definition. My understanding is that there’s been legislation that has passed both House and Senate now that fix that problem and should make physicians who practice in outpatient clinics of hospitals eligible for the stimulus funding. So, we’re already seeing that change.

I think we will also see some changes in the quality reporting requirements. Asking providers to be able to install and use systems that electronically calculate all of the quality assurance measures is asking too much. The CMS has been asked to hold off on that requirement until they’re ready to accept it and process it in that fashion. I’m hopeful that we’ll see some relief on that front. I think those are the biggies.

Then the third item that I think everyone’s concerned about is the basic timing compression that’s going on here due to the delay in spelling out the certification process. Since providers must use certified records, that’s kind of your entry point to even be considered for stimulus funding. We’re going to need to have our system certified, potentially, as early as October 2010 for hospitals, January 2011 for providers — eligible professionals, physicians. Yet the certification rules and process will not be finalized until perhaps as late as June of this year.

That’s going to make it very difficult for hospitals and physicians to potentially have to upgrade their systems if their vendor’s requiring that to comply, or to get the certifications from their vendors. This also puts, I think, a lot of pressure on our vendors as well; having to go back and get their products re-certified, if you will, through a process that’s going to be different than the previously required CCHIT certification process. This presents some real challenges in timing.

What are your impressions about the proposed rule for creating the certification bodies through the EHR certification and testing?

I’m working with the CHIME Policy Steering Committee. I’m actually the Chair of the CHIME Policy Steering Committee, as well as serving on the American Hospital Association IT Advisory Committee. In both cases, these committees are concerned with any provision in the certification process that would drive more providers — hospitals or physicians — to have to go and obtain certification for their portfolio of systems on their own, rather than being able to rely on vendor certification.

In particular, there’s language in the NPRM on what constitutes a self-developed system. We are going to be commenting on that and asking that that be more precisely defined, such that a provider’s minor modification or enhancements to a certified system doesn’t throw them into the category of self-developed.

The fact that they’re opening it up to other entities — is that a step in the right direction?

It’s hard to say. There have been criticisms of CCHIT and there’s also been kudos to CCHIT. It’s difficult to say whether, in the long run, introducing more competition into that certification process is a good thing or a bad thing. They are adding, though, more rigor in the permanent certification process that’s being proposed; which is that you go through certification, then you have to go through testing and the introduction of a concept of a certification body needing to do some field surveillance to make sure that the product is actually being used in the field as it was intended. These three components together could make the certification process quite complex in the future.

Given all these questions that are still out there, do you think vendors and providers will be ready?

I would be very surprised to see any provider, hospital or physician, qualifying much sooner than perhaps this time next year. I’d be very surprised.

I hear many of my colleagues say that they will not qualify for Stage One stimulus funds until 2012 or 2013. Kind of towards the tail end of when Stage One is still in effect. I think that’s going to be pretty common.

What seem to be the biggest hang-ups?

I think it just depends on where the provider or the hospital is at right now with their IT implementation plan. Many people are just starting an implementation of a larger integrated solution. Some people have some pieces firmly in place. Like ourselves, we have many pieces of an integrated electronic record system in place, but we have implemented the modules in a different order than the Meaningful Use criteria are dictating.

We’re having to change our strategic IT plan to go, for instance, and elevate CPOE to be something that has to be done within a year; and perhaps, drop some of the other plans we already had to expand nursing or OR documentation into other areas of our operations. We’ve had to switch our priorities because of this. Any time you switch priorities, it takes some time to start up and get that project going. I think that’s what people are challenged by.

Will you be ready in time?

I really believe that in our organization, we will be able to achieve Stage One. Now whether its next year at this time, or whether it’s a little bit later, is not totally clear to me at this point. But I do believe we will obtain it within the next two years.

How do you see healthcare reform and the ARRA legislation? Are they competing with one another, or do they actually complement one another?

We were just talking about that exact topic this morning in a meeting. I think we have three different initiatives out there right now that are on a collision course. Those initiatives are this rush to adopt electronic health records by 2015, the ICD-10 conversion that’s to occur in 2013, and then the IT implications of healthcare reform. Specifically, in regards to the new reimbursement models, such as bundling episodes of care and accountable care organizations. You have all three of those pretty much converging at the same time, and they all have IT implications.

I do believe that some of the things that are being done in the HITECH Act to bring about standardized adoption of electronic health records could help with the new reimbursement model. However, there’s so much more needed to do that than what’s in the HITECH Act. So while they are complementary to some degree, trying to do them all at the same time has me very concerned, especially given that we have heard statistics of a shortage of over 50,000 people across the industry via the healthcare IT industry.

It makes you wonder — where are we going to get the human resources? If money were no object, where would you even get the human resources to do all the work? Plus, we also know that introducing too much change into your HIT applications and infrastructure can cause instability in their operation. That’s concerning — introducing too much change at once, not to mention all the process flow and workflow redesign that need to occur for healthcare IT to be used effectively.

What, in general, do you think Meditech hospitals are going to have to do to get ready for Meaningful Use?

I think, again, it depends on where they are in their software upgrade cycle. For us and for many others that were staying current with the MEDITECH products — I am on the most current release level, which is 5.6 — that will be able to deliver the Meaningful Use criteria from Meditech.

For other hospitals that have not upgraded recently, I think it’s going to be more difficult. It’s not just the Meditech hospitals. Really, you look at any vendor. The queues for people wanting upgrades are very long. We’re hearing 12-18 months just to get a project started. This isn’t just with Meditech. This is with any vendor, because they’re being overwhelmed by upgrade requests.

I think that in the long run, Meditech hospitals will be in good shape; that Meditech is going to see us through these Meaningful Use requirements. But it’s not going to be easy, especially when it comes to the quality metric reporting. This isn’t a technology issue, this is, in some cases, a workflow process issue back at your organization. You can have all the fields in the software that you need to populate to produce a metric, but how are you going to ensure that those data points are collected? How are you going to instill that discipline in your workforce?

What were some of the conclusions that you drew from the HIMSS conference?

As many have probably observed, the conference was largely about Meaningful Use. Some conclusions that I drew personally, was that data analytics are going to be incredibly important over the next 3-4 years.

On top of all these other things we have to do to meet Meaningful Use internally, we are going to have to start, if one hasn’t already, to dive deeply into your clinical data to understand and engage in the creation of dashboards and alerts and other things to keep your progress towards achieving your quality metrics at the forefront of everyone’s attention in your organization. That is going to require, I think, some very sophisticated data analytic tools.

That was probably my big takeaway besides Meaningful Use, Meaningful Use, Meaningful Use.

What are your biggest challenges and most important strategies at this moment?

For Methodist, we decided three things that we’re very actively pursuing. One, no surprise after what I just said, is really looking at our quality data analytics. Two is ramping up to do CPOE with our hospitalist group as our pilot. Of course, that is to meet Meaningful Use. Then the third really important strategy for Methodist is to reach out to our physicians and help them achieve Meaningful Use by offering a hosted electronic record solution to them. We have ramped up in a very big way to be able to offer that to our physicians. We are hosting NextGen for our affiliated physicians in the community and are gearing up to have 100 or more on within a year. We’re growing very rapidly.

I would say those are our three main strategic IT initiatives. Throw on top of that that we are building new hospitals and we are completely integrating one that we acquired last year and converting them to our HIT structure.

I don’t think that’s that unusual. I think a lot of us have all the other challenges. A lot of people have all the challenges we’ve already been talking about, but on top of that, I think many larger organizations across the country are being approached, as Methodist was, by standalone hospitals that are looking and saying, “I can’t navigate through all the complexity that’s coming at me. I need to partner with somebody that can quickly bring me solutions.” I don’t think I’m unique in having that challenge on top of all the other ones.

HIStalk Interviews Sanjaya Kumar

Sanjaya Kumar, MD, MPH is president, CEO, and CMO of Quantros.

Can you give me a two-minute summary of hospital-based pay-for-performance programs and how your applications help manage them?

It’s interesting that you say hospital-based pay-for-performance programs because I think the overall industry graduated into pay-for-performance, from the managed care all the way down to the physicians really having to basically be working within those programs. Now, definitely the hospitals are in the fringes of that, but I think, firmly, in my opinion, pay-for-performance now is moving into pay-for-results and pay-for-better-outcomes.

The way that our applications help support those needs for the hospitals that are participating in those programs is that we allow ready capture and aggregation of all of that data, either from secondary data sources, or they can actually input it into the applications for the different metrics that are supposed to be reported for the pay-for-performance programs from either CMS or Joint Commission. Primarily CMS. That data is reported quarterly.

The added benefit for our clients is that they can review all of that data in near real time, as well as compare and benchmark themselves with other hospitals in a blinded fashion, very readily. That’s one of the added values that we provide, so even before they’re able to see their results publicly reported out there for pay-for-performance, they can gauge and see how well they’re doing in comparison with others.

What impact do you think the publicly reported hospital quality and outcomes measures will have on the industry?

In the way that the information currently is made available, I think the impact is relatively slow in terms of its uptake. However, what it is a doing is that it’s increasing the degree of transparency around the reporting of all of these metrics and measures and education to the consumer of healthcare, in terms of their importance and their significance. Really, the metrics aside, I think the overall programs are helping to influence consumers in the way that they seek care, or where they seek care from.

I think it’s going to continue to shape that industry in terms of the transparency that needs to be there. It’s going to drive and motivate more and more hospitals to actually disclose some of all of the results to their local constituents and local marketplaces in order to influence purchasing behavior of either employer groups or health plans, in terms of how they’re contracting with them or in terms of where the consumers are seeking care from.

I think it will have a bigger influence, perhaps five years down the line, as this data begins to get even much more attention and begins to get publicized that much more. Today, the healthcare consumer is still very naïve about some or all of this.

Do you think they know the data’s out there and just don’t have much of a choice of where they go? Or, do you think they’re really unaware that there even is such a thing?

To a large extent, I think the awareness is coming about, but I think it’s slow on the uptake and slow on the marketing of some of all this information. The government could do, perhaps, more, in terms of highlighting the availability and where the data is made available from. More has to be done. I think more people need to get onto the bandwagon, in terms of shaping consumer attention to this.

Several years ago, the MedMARx database was used to generate a report suggesting that CPOE was creating quite a few medication-related errors. What are you seeing now from the database and with the FDA’s apparent interest in overseeing the whole safety issue with electronic health records, how do you see that playing out?

As you perhaps, know from the background, we actually acquired the MedMARx database about two years ago from the USP. We now currently manage that data registry. It’s got over 2 million records on medication errors and adverse drug reactions.

The same patterns that actually used to be there are still pretty much very evident. Meaning, although one of the patterns that has actually emerging and interestingly, we did an analysis for somebody that was actually writing an article in The Wall Street Journal a few months ago  that indicated that errors that basically are implicating CPOE systems definitely do occur, but the more serious type of events are being averted.

I’m meaning that more incidents that actually lead to major fatal harm are actually on the decline with the utilization of CPOE. Although, CPOE is still leading to a number of errors that are basically there within the medication error profiles.

I think that a real interesting conundrum over here is that there are multiple vendors for CPOE systems. I think CPOE systems need to be very carefully evaluated. I know that the Leapfrog Group, for example, has a CPOE evaluation tool that is made available to hospitals. For example, if they’re participating in the Leapfrog survey. I don’t know how much you know about the Leapfrog Group, but they’re all about transparency for safety and quality, in terms of practices that are out there and how safe institutions are. They actually make available a CPOE evaluation tool.

I think the FDA needs to look at tools like that very, very collaboratively, in terms of really encouraging the use of those tools to identify CPOE solutions that are right, that are fit, that are actually ready for use within point-of-care environment. There are a lot of CPOE systems out there that are not necessarily right that actually are leading to a lot of errors, or that are not catching errors, necessarily.

When we implement systems like CPOE, we automatically are almost aligned with clinicians just like a child with a calculator who doesn’t necessarily think through the computation they’re performing, but just believes in the answer that they are getting. That is the biggest problem with automation systems. We’re actually blinding the provider at the point of care with systems like that in order to believe them without having to really think through whether something is right or wrong.

I think utilization of CPOE evaluation type methodologies; critical review of those, the kind of errors that they lead into is very, very important as a go-forward strategy; especially if we are mandating that solutions like this be implemented, which is really pretty much what the ARRA, the HITECH Act, is providing for.

EHR adoption is going to create tons of electronic patient data from all these systems at some point. What do you think the best use is, both at the organizational level, and the population level, for all of that data that we’ll suddenly have available?

I think it will be a blessing for monitoring specific populations of interest. It will be of benefit to actually apply continuous quality improvement methodologies in place. It will be very, very important for organizations to actually utilize some or all of that digitized data to be able to tell more — regarding their own environment, regarding where care is actually being provided, how well care is being provided — from a combination of dimensions of interest: patient safety; quality; compliance with clinical care protocols; and adherence to certain standards of care from the perspective of providers, in terms of their outcomes that are actually occurring; and finances.

I mean, we shouldn’t forget that care should be really provided in a very cost-effective fashion. Today, it’s very, very difficult, for example, for an institution that is actually collecting all of the quality data, to actually even determine what the improved quality-to-cost ratio is. If they’re collecting all of this data to monitor and improve upon care for heart attack patients, if that is actually influencing a decrease in cost or length of stay for the institution, it’s very difficult for them to do that very readily today with the availability of data across all of these different dimensions. For the population-based level, it will become easier and easier to allow for such evaluation to occur.

I know that you have some products that relate to real-time surveillance. What are the results? What are hospitals doing with that?

Real-time surveillance, again, is applicable to only institutions that have good, digitized HL7-formatted data that is regularly available. Naturally, of course, that precludes the utilization of those tools today to perhaps less than 10% of the institutions within the United States. Those kinds of solutions really are easy to use, very readily configurable solutions that allow a clinician to set up rule sets — different rules that are very, very clinically sound, in terms of really what they’re looking for.

For example, a drug-bug mismatch. Based upon the data feed that is coming in from the lab, if a particular microbiology result basically indicated that a patient had a particular bug and was sensitive to a particular medication, it’s now going to look into the pharmacy order entry data set coming into the system to determine whether the right drug was actually being ordered for the patient. If the right drug is not being ordered for the patient, it will raise an alert. It will raise a flag. That flag is brought to the attention of the care provider.

Today, EMR systems do not have that degree of robust decision support rule sets built into them because it’s extremely customized and cumbersome to manage and maintain. The surveillance solutions that we provide take the HL7 data feeds and the clinician configures whatever rule sets that they want and have the alerts go out to the people that really need to be taking care of the patient.

I had one question about one of your products, your Clinical Café. Can you tell me about that?

That’s sort of like a pet project of mine that got conceptualized about three years ago at one of the IHI conferences. Really, the premise behind ClinicalCafe.com was to provide an environment … because Quantros services over 2,000 hospitals, we have a very rich collection of very like-minded people around quality, safety, compliance, operations, CMOs, and the like, that are basically part of the user community.

The idea was — how do we bring all of these people together in an environment where it can provide for them to connect with each other, be able to share best practices or information with each other so that they can collectively learn? Because what is working in one organization will probably benefit another organization. How can they be able to inform each other proactively, by setting up, maybe peer groups and things like that, so that they can collaborate? It’s sort of like creating an environment for utilizing social networking to really provide for a very rich collaboration for learning purposes and improvements in safety and quality. That was really the premise of Clinical Café.

It took about two years to actually gel the idea together. We launched ClincalCafe.com at the last IHI conference in December, the last one that was actually held, in 2009. We launched it over there and now we are integrating it with our applications to invite each and every user into the Clinical Café environment so that they can begin to interact with each other. It’s an open, shared, learning platform. It’s really not a proprietary platform. It’s really for any clinician, any provider, anybody interested in safety and quality, to be able to learn from each other as opposed to, perhaps, going to disparate sort of places.

Normally, learning is amongst each other. We tend to learn from each other much more readily. We share a lot of information with each other. Hopefully, the environment will provide for that. I would encourage you to sign up and become a member.

Anybody can become a member?

Anybody can become a member. The way that I like to introduce it is sort of like a Facebook for professionals within the healthcare community that are interested in improving safety and quality. I think, as of the last count, we had about 1,500 people that had already joined. It keeps on increasing by about 30-40 people every day. Hopefully, we’ll have a critical mass very soon.

This may be a question that you’re not comfortable with answering, but I’ll ask. If a hospital, from your perspective, wanted to make IT investments right now, with patient safety in mind, based on what you know and what you’ve seen and what your data tells you, what kind of technologies do you think would make the most sense?

There are lots of technologies that people are proposing out there for the point-of-care environment that I don’t think are necessarily ready. I think there needs to be a lot more critical evaluation done, in terms of the technologies that are being proposed out there. Very, very few vendors out there have ready technologies that would allow for very effective solutions at the level of point-of-care. A lot of the EMR systems out there are documentation systems. They’re not necessarily aligned for collection of very good, discrete data elements that can be utilized in a very meaningful fashion. We have to still evolve.

We should be very careful because some of these purchases are going to cost millions of dollars and they’re not necessarily that easy to replace because you’re going to embed them within the fabric of your enterprise. A number of people will have to work with them.

The other issue with a lot of point-of-care systems is clinicians are very, very averse to any new technology or change management. I think adoption of these technologies, ready usability if you have some of all of these technologies, is very, very important. I’ll highlight one key important point. For example, if I’m a physician and I’m practicing at three different institutions, and all of those three different institutions are using three different EMR or EHR systems, I now have to learn three different systems to interact with and actual work with. How can that EMR system just basically take my credentials and, perhaps make that into a common user interface for me that is to my liking?

I think technologies like that have to basically be researched, and I think we’re still at the very nascent stages of that evolution.

Over the next five years, what are your plans for the company?

The plan for our company is to continue to confirm our position as an industry leader, in terms of what we provide for furthering patient safety and quality and transparency for some of all of the data that we help our institutions collect and report. Our focus is squarely in terms of how do we bring about more actionable information for key stakeholders within institutions to be able to address patient safety, quality, and their business? The outcomes for improvements related to the implementation of EHRs or EMRs is basically safety and quality. That’s pretty much what everybody is proposing out there.

Our focus is squarely on that, and as a company, we are hoping that we’ll be the majority industry leader, in terms of really providing that very soon, I’m sure that if you follow us you’ll begin to see some of all of that even come about further.

Any other thoughts?

I do want to again highlight the value of environments like Clinical Café. I think in the new day and age of younger people that are actually beginning to interact with learning tools, or collaboration platforms, I think social media has a long way to go with it. I think mobile technology has a long way to go, in terms of furthering some advancements within healthcare that we, perhaps, have not necessarily taken. The work being done by organizations like Cisco in healthcare, with their collaboration platform, is very, very innovative as well as very entertaining to see that come about from a provider of hardware solutions like that.

I think the industry is going to want to see more and more, in terms of solutions like that, because they will provide for the easy, shared learning that needs to be there. We shouldn’t be closeted about certain things that are working within our environment and not really have them readily shared because they will save lives and improve the care that we provide to people. We all need to be able to benefit from all of that very readily.

I think technologies and the adoption that is currently being driven by the ARRA or the HITECH Act, yes, they push it very good. I applaud the push; I applaud the benefits that the government is actually providing for some or all of that. But it could also provide for a very ready environment for very rash decisions that might not necessarily further an organization’s goal because they’re really being pushed to that. Each and every organization doesn’t necessarily have the core capabilities to help address or evaluate each and every solution that they need to be implementing that is being required to meet all of the ARRA or the HITECH Act.

Four years is not necessarily a very long period of time to implement some of all of these solutions. I’m hoping that through your blogs and your talk, you actually are highlighting some of all of that, because it could push the industry in the wrong way as well.

HIStalk Interviews John Halamka

John D. Halamka, MD, MS, is chief information officer of Beth Israel Deaconess Medical Center; chief information officer at Harvard Medical School; chairman of the New England Healthcare Exchange Network (NEHEN); chair of the US Healthcare Information Technology Standards Panel (HITSP)/co-chair of the HIT Standards Committee; and a practicing emergency physician.

How would you describe, if you had just a couple of minutes, how stimulus funding will change healthcare IT as an industry?

If I look at my own region, we have docs who were all waiting on electronic health record implementation because there wasn’t a value proposition. They said, well, gee, you know I can get this Stark safe harbor, I know the hospital can help out, but still, my office manager’s going to quit. I’m going to lose productivity for three months … what a hassle.

Now with the HIT stimulus funding, they say, “Wait a minute. I get 85% funded by the hospital and I get to keep the $44,000 when this is all done? OK, where do I sign up?” It’s truly accelerating physician adoption by motivating them to move forward.

What I really like about Meaningful Use is it is constructed so that the doctors are paid only when they’re done. That is, it isn’t go buy hardware and software and it’s going to be Christmas for vendors. It’s the fact that docs then have to e-prescribe, and docs are going to have to share data with patients, and docs are going to have to use quality measures. Only when you do that do you get paid.

The mindset of the clinician is, “Ah, I’m going to do it, and now I know exactly what I have to do. Help me out.” So I, as a hospital organization and my community, can work together to make all that happen. It’s an alignment of industry, academia, and practices like I’ve never seen before.

Do you think there’s a risk that they’ll get enticed enough to at least start the journey, but then because of usability issues or just lack of time, it will never really go anywhere?

I wrote a blog, which some people have criticized me for, that said I actually trust ONC. David Blumenthal and the gang he has put together are very good people. If what they discover is that, as we are actually rolling this thing out that there are barriers, then I believe they’re going to help everybody work through the barriers.

I really don’t think that this is a disconnected ONC that is going to force us to do things that are too hard and are going to first, people, as you described, to begin the journey and then fall off. What they’ll say is, “We’ll build the toolkit. We’ll help with the accelerators. We’ll break down the barriers. We’ll make sure you have the resources.” I actually feel good about people getting to the finish line.

Do you think it was a mistake to combine what should be a fairly thoughtful introduction of electronic health records with the urgency of stimulus funding?

My experience in healthcare IT is, unless you create a sense of urgency, nothing gets done. I would rather see us all move forward with great haste and get as far as we can, then along the way do a mid-course correction, than to say, “You know, we’re going to wait five years and then we can get it perfect.” There’s a lot to be said for moving the industry forward now.

These are not new products — they’re the same ones doctors didn’t want before. Do you think there will be some buyer’s remorse?

I love seeing the vendors react by creating new functionality. Certainly they’re much more open to healthcare information exchange and patient engagement than ever before, so in some respects, yeah. It may be products that have existed, but there are feature sets that have never existed.

Then with the modular EHR certification approach that’s been proposed, there’s a capacity for combining many EHR and EHR-lite together in a way that’ll get docs started. I think there’ll be new market entrants, but new features. I don’t think it’s going to be business as usual.

Will there be time for new market entrants given that people have to get on the train really quickly?

I’m now driving, actually, through Westborough, Mass. where eClinicalWorks is located. What I’m seeing these guys do is focus on patient portals. Something called provider-to-provider exchange. It’s like a Facebook function. They’re introducing all this new stuff very, very quickly.

I know the timeframes are crazy, but they have been able to innovate to adapt to ARRA requirements pretty rapidly. You’re seeing Athena move out its athenaClinicals product pretty rapidly. Software as a Service is becoming more and more common, and probably it’s because of thinner, Web-based Software as a Service architectures they can move fast enough to meet some of these deadlines.

What do you think is the majority of the work that needs to still be done to really get us down the path to getting potential benefits?

80% of what I do is people, training, workflow redesign, and process re-engineering. Only 20% is the technology stuff. When I write blogs about this stuff, I just focus on the workforce, focus on the people, and focus on the change management. That’s all the really hard work.

Yes, there are things that have to be done in Washington; and as you’ve seen coming out of ONC in the last week, consent models. How, if we’re going to do information exchange, do we ensure the patient controls the flow of their information? How do we do simple things like controlled substance e-prescribing, making sure that the workflow around writing Lipitor and writing OxyContin is pretty similar? How do we ensure that?

No interoperability’s ever going to be totally plug and play, but if it’s not USB drive kind of plug and play, can at least it be a couple hundred dollars, not a couple thousand dollars, to get a lab interface? It’s the work on specificity, on content, and transmission that still need to be done. All of this stuff on process transformation and workforce development, primarily, and then some of these things the Policy Committee and Standards Committee are doing on privacy, doing things like e-prescribing clean up and making the standards easier to use and more prescriptive.

Do you think federal funding makes it too easy to forget there are workflow changes involved?

I just met with these folks at Lawrence General and they had thought they were ready to go into a procurement phase. I said, well, let’s look at what Meaningful Use really requires. You know, what is your strategy for your local public health interface? What is your strategy for bi-directional data exchange for the community? “Oh yeah, this is a whole lot about workflow, isn’t it? It’s not about bits and bytes.”

As people begin to understand Meaningful Use, they really will understand the community and the workflow and not just the products.

You mentioned privacy. Are there currently debates going on about what form that should take or who should be involved?

I think there are two kinds of architectures that will protect privacy. One of my favorites, of course, is the idea that the medical home, the patient, becomes the steward of their own data. We send the data to them and they elect privacy preferences — who and what they’re going to share with.

Alternatively, of course, there is the clinician-to-clinician exchange. That is really going to require a persistent declaration of patient privacy preferences as to OK, if I the patient am not going to directly control it, how can I declare my preferences of those who do exchange data; whether it’s providers, payers, public health, etc. always use my declared privacy preferences when data is being exchanged?

The HIT Standards Committee, over the course of the next few months, is going to be taking testimony on what standards exist that will help support such a thing. That in combination with work on the policy side and such things as the consent white paper, I hope get us to a place where either EHR to EHR or EHR/PHR/EHR exchanges are ultimately controlled by patient preference.

You mentioned that a lot of data will be collected and exchanged. When will we start seeing the benefit of all the EHR-created data that isn’t out there now, and who do you think will use that to advance the practice of medicine?

Of course, 2011 is more about getting the data in electronic form to begin with; and 2013 more about getting data exchanged. But some beacon communities. some early adopters, I think, by 2011 are going to have substantial improvements in data sharing.

In the Boston area, I funded the creation of a quality registry for 1,560 providers that are loosely affiliated with Beth Israel Deaconess so that we begin to do all of our pay-for-performance, all of our PQRI and Meaningful Use reporting, as a community, rather than as a bunch of individual point-to-point connections. We’re doing public health reporting for the city of Boston in a common way as a community. All of this will be live in 2011. So for some, 2011. For many, 2013. For the majority, 2015.

Do you think there should be a relationship between having more technology and being able to deliver care less expensively?

That is a very good point. What we all want to achieve is high-value care where reimbursement is based on quality rather than quantity. I think the answer to your question is a couple-fold, but everything that I do these days is Software as a Service. I’m able to deliver an EHR at a lower cost than normal because the fact that I have so many clinicians sharing resources, sharing a data center, and sharing interfaces.

My hope is that I can at least, from my IT perspective, reduce the cost of implementing Meaningful Use. Then, we will gather data from a quality perspective that can be used in accountable care organizations and new mechanisms of reimbursement so that, as you pointed out, reimbursement will be fair based on the outcomes that are achieved.

Do you think technology is ready to help offset or mitigate in some way the shortage of primary care physicians?

This is an excellent point. What you hope, coming out of healthcare reform, is differential payments for primary caregivers and accountable care organizations. If I look at the Harvard Medical School experience, the number of folks going into specialty or procedural areas far exceeds those going into primary care. If you’re going to have effective reform, if you’re going to have lower costs, we need more primary caregivers.

Sure, as you point out, maybe technology can help us use extenders wisely so that whether that is some tasks can be delegated to nurse practitioners, physician assistants; some decision support can be offered in the Cloud so that we are delivering coordinated and better care more effectively by using technology rather than physician time for every intervention. All of this still presupposes that we have the primary caregivers who can actually be at the center of the medical home. In my view, you need to redo reimbursement so that the primary caregiver is the one making more than the specialist, not vice versa.

What about telemedicine?

We use telemedicine today to connect rural or community hospitals or emergency departments with downtown Boston for the provision of such things as stroke consultation in real-time for the administration of TPA in stroke. You’re able to leverage the academic health vendor in a far greater reach through the use of telemedicine.

I’ve had a lot of experimentation with remote visits, home monitoring, and again, leveraged telemedicine as a mechanism of making a primary care physician more efficient. Actually, the patients like it because they don’t have to travel into the city. Or, doing interventions like measuring blood pressure, measuring daily weight, and then having a team of nurses doing home care remotely and keep people out of the hospital. I certainly agree that telemedicine can have a role in reducing cost and using time more efficiently.

What do you think the Nationwide Health Information Network is going to look like and when will we start seeing it deliver benefits?

You’re probably familiar with the NHIN Direct efforts that have been kicked off over the last two weeks. The idea of a NHIN, obviously, it’s a set of policies and some open source technologies in reference to implementation to exchange data among various participants and provider, payer, government, etc. In NHIN Direct, the idea that there are some interactions that are simpler — pushing between two doctors, pushing to the patient.

Actually, what you hope is if this becomes a fairly thin, Web-based mechanism of sending data from point to point at very low cost. Here’s an idea. What if every person who wanted to participate in a patient/doctor exchange could sign up for a healthcare URL? Many people — Microsoft, Google, Dossia, who knows, various software vendors — could offer this health URL and all you need to use it is you take it to your doctor and say, “Doctor, here’s my health URL. Every time there’s an entry in my record in your office, push the data to this health URL.” There’s no HIE, there’s no transaction fee, there’s not a lot of complex business structure needed. It’s just an HTTPS post.

What I hope is that sure, for governments, for larger organizations, there will still be a NHIN that has quite a lot of security in its infrastructure, But you hope for a lot of connections that can be as simple as the home banking connection you have with an HTTPS post and it just bakes right in to every EHR.

Some of the folks that have gone into federal service work lately are interesting, like Todd Park and Don Berwick. What do you think that means that people who aren’t lifelong civil servants are popping up out of the private sector and going into federal work?

Knowing Aneesh and Todd and Don Berwick pretty well, these are people who have passion. They’re now able to see change is possible and resources are available. I think they believe that, in the current administration and the current time in history, it’s not business as usual and they’re willing to put in their energy and their passion to making change.

That’s why I write in my blog, these truly are the good old days of healthcare IT. I know I’m putting a significant portion of my time into state and federal efforts on a volunteer basis just because I believe I can make a difference.

You mentioned that you have a lot of respect for ONC as an insider to this whole process. Was the outcome what an idealistic person would have expected, or was this such an ugly compromise that nobody leaves happy?

I will tell you, sitting in the HIT Standards Committee and the Policy Committee and on calls with ONC; the amount of positive energy, as opposed to the amount of negative energy and compromise, is totally different than any other process I’ve been involved in in the past. People who have very different opinions come together and they say, “God, here’s what I want to achieve to improve patient care and quality and efficiency.” Everyone says, “Well, there’s two or three ways we could do it.” I’ve seen harmony rather than ugly compromise come out of each of these processes. That’s why I’m very optimistic.

When you look at your own organization, what are your biggest challenges and highest priorities at Beth Israel Deaconess?

I’ve laid out a 25-step plan to implement Meaningful Use across the organization. The hardest part of it is it is not just one actor. It is not just a hospital in an island. It’s ensuring that you have trust in your community so that you can do these data exchanges across the various providers, public health, payers, and government. It’s been relationship-building more than technology implementation, in my 25 projects, that’s my hard work.

Is there anything else you wanted to talk about?

I just have to say that you do a great service for humanity. Somebody has made this comment to me, that you have become not the National Enquirer, but The New York Times of our industry. It’s built on transparency. People, just like all the stuff I’m trying to work on, are no longer afraid of this special interest or that special interest. It’s everybody opening up and just trying to get the job done. I think you’ve been a big part of that.