Part I

GUERRA: Basically, you’re offering unlimited services to these independent practices, at least for a certain period of time. What’s the ROI there? How do you make a business case for that, unless you say that this essentially guarantees the patient flow from these practices?

TODD: Well, you have to be careful with that, no matter who you’re talking to. I’ll tell you the way this works. Here at Caritas, we’ve made a commitment to fund the EHR for our IPA-affiliated physicians to the full extent we can under Stark. We feel that is a critical commitment to creating a cohesive, clinically integrated physician group to care for patients in eastern Massachusetts. I know that sounds a little like an advertisement.

Caritas’ strategy in healthcare is to be a cost-effective provider with equal or better quality than all our competitors. It is a very competitive medical marketplace, so we’re trying to compete on cost as well as on quality, and in order to do that we have to create and leverage IT to be as clinically integrated as we possibly can, so we can deliver on things like patient-centered and medical-home teams. Thus, we have tight affiliations with nursing homes and skilled nursing facilities. We also have our ambulatory practice groups, and we have hospitals. So we’re pretty much in the whole loop of inpatient- to outpatient-type treatment, and what we’re really trying to do is get these technologies to bind everything together. If the systems don’t talk to one another, if they’re not completely interoperable and they’re not actually being used by every provider in our organizations, then it’s not going to work. So, to me that subsidy makes sense on so many levels.

Regarding the long-term support piece, I wish to be clear that the cost of the ongoing support and maintenance is borne by the practice, so we’re getting them started, and I am charging them a support fee. I happen to be more competitive than most of the other groups around me. I undercut them in terms of that. But I already have a data center where we host our EHR customers. I already have a helpdesk, I already have technicians in the field in all of our markets. So it’s very cost-effective for me, and far more cost-effective for me to supply those services than it would be if they went out to somebody else and tried to get a monthly maintenance contract.

GUERRA: Does this, in fact, turn into a revenue stream?

ROTHENHAUS: Well, we’re not for profit. So I’ve costed out my support to recover costs and I’m not making a profit on it, but it is a revenue center. I’m in an IT department that actually has an accounts receivable.

GUERRA: You can make a profit and still be a non-for-profit; it’s just what you do with that money, right?

ROTHENHAUS: Absolutely. I will tell you that we are thinking and talking a lot about offering the same services to physicians who are not in our IPA and for that, we could certainly think about making money. But we have very close relationships with our IPA colleagues, so I don’t feel comfortable making a profit off of those guys.

But you’re right, I could certainly move into adjacent markets and do EHR support. Right now, I have the volume and capacity to do the project plans that we have, but we are talking about expanding because it actually is a pretty cool opportunity for us going forward.

GUERRA: It seems to me that projects like these necessarily mean the CIO’s job at a hospital has gotten infinitely larger than it used to be. You used to worry about what went on inside the four walls, but now it’s so much more than that. Do you think the position has gotten larger than it was a few years ago?

ROTHENHAUS: Well, I wasn’t one back then and I come from a clinical background, I’m a physician. I did electrical engineering as an undergrad and then I became a physician because I thought IT wouldn’t be a way to distinguish myself, but then I certainly graduated back to IT once I started to realize that emergency medicine wasn’t the best way to distinguish myself.

GUERRA: We’ll see what the next phase is.

ROTHENHAUS: Exactly. If I could just work the slopes as a ski guy, I think it would be better (laughing). So I came to the CIO role from clinical which, I think, gave me a little bit of a leg up when it comes to the down and dirty on the project plans for the roll outs of clinical systems, which is what everybody is doing. And I certainly am conversant in all of the clinical technologies.

For me, I think the challenge is a little different. For me, the challenge has been deftly supporting the financials and the business applications. It’s actually been one of the holes in my portfolio which I think isn’t the case for most people who came from more traditional lines. And financial systems have been there for 20, 25 years and I’m looking at them and saying, “I’m not exactly sure what these things do,” but we have to support those as well. But you’re right, I’m part of senior staff at Caritas and Ralph de la Torre is so committed to IT that I have a seat at the table, and I really enjoy that piece and being involved in helping support strategy.

When we look out what at we are doing, I think the biggest challenge we face now is that everybody is doing EHR. Everybody is doing clinical systems in their hospitals. So that doesn’t constitute strategy anymore, it’s really just some tactic that everyone is going to end up doing and it’s not a differentiator. So the challenge to me by Ralph was to say how are we going to be different, how are we going to leapfrog ahead, how are we going to be better than our competitors and frankly, our competitors are hospitals in Boston with outstanding IT infrastructure.

We’ve looked and said that the two pieces of that puzzle really were a customer relationship management strategy with our physicians and our patients, and data. Again, it’s hard to compete on that with the folks who have these big data repositories, clinical data repositories. We’re working really, really hard to do that stuff. That’s the coolest piece – real strategy and real long-term thinking is part of the job. And then you have to keep the lights on at the same time (laughing), that’s a challenge in its own right.

GUERRA: Let’s talk a little bit more about the IT environment. You mentioned that most (or all) of the outpatient, the ambulatory practices are on eClinicalWorks (eCW).

TODD: Yes, that’s right.

GUERRA: Do you have a mix inside, or do you have a core clinical vendor that you’re really focused on working with?

ROTHENHAUS: Caritas is a Meditech shop of four hospitals. We have most, if not all, of their suites and we’re implementing their clinical systems right now. Our Norwood Hospital, which is really only about two miles from Meditech’s headquarters, is essentially a (HIMSS) stage 6 hospital. We have full CPOE bedside medication verification and barcoding, and that’s all live there. As I’ve said, we’ll get those projects done.  But we’re Meditech through and through on the inpatient side, and we have an embedded managed master patient index in there, so it serves as a true clinical data repository for all hospital-based care.

Clinicians in our health system, when they logon to treat a patient, they’ll see records from all six of our Caritas facilities. Caritas also had an outreach laboratory called Caritas Medical Laboratories, so all of that outreach laboratory data is available to those clinicians as well as treating physicians. That project started back in the late ’90s. We’ve been very successful with Meditech, and I’m pleased at that the fact that we’re such a cohesive system.

We’re eCW on the outside and then our imaging is McKesson PACS, and we’re implementing their cardiology PACS now.

GUERRA: Have you done much with the Meditech/eClinicalWorks integration? Are any of the practices tied into the inpatient systems yet?

ROTHENHAUS: Right now what we’re working on is integrating it in a traditional way. The order set is in eCW, which sends both laboratory and radiology requests to the hospital-based lab, outreach lab or hospital-based radiology departments. Those results then come back into eClinicalWorks for review. That’s done in a standard HL7 messenger scheme. We’re also sending text reports, for instance  discharge summaries, op notes, consult notes and other various text reports, unsolicited, from the Meditech system into the eClinicalWorks system. We use Sun’s E-gate Seebeyond product to do our integration, so we’re able to filter on the attending physician and guide those discharge summaries into the correct buckets in the eClinicalWorks system.

This isn’t live yet, but we’re working to make sure that, for our hospital-based practices, we drop the clinic notes into Meditech. That’s a little bit harder because we don’t have an account for that, so there is some technical stuff to work out, but we’re planning to do that as well.

On the advanced interoperability front, we’re just getting our E-health exchange (EHX), the eClinicalWorks EHX live, and I’m hopeful that will start to pass CCDs to Meditech. And Meditech has done some work at the South Shore Hospital where they do request and display of CCD-type constructs, like in the triage module with their ED system. So we’re looking to get that live within the next year or so. It’s a little slicker that just passing the text-based reports. I don’t know that we’ll be doing the semantic interoperability piece here, but the request to display has already been done by some of our competitors, so we should be able to get that up.

Part III