By
GUERRA: Tell me a little bit about your organization. I know it’s a three-campus integrated health system.
CLOUD: Three campuses, one hospital on each campus. We do have a behavioral health, or a psych hospital, I should say. We employ hospitalists. Total beds would be just under 800. We also own practices. We’re developing an ambulatory care strategy where we are inviting physicians to become a part of our organization. We have distributed diagnostic centers. It’s pretty much the gamut of what you would see in an integrated health network. We serve about seven counties, and we are the largest employer in our city, with about 4,600 people.
GUERRA: How many physicians do you employ?
CLOUD: I think it might be somewhere around 40.
GUERRA: And about how many physicians have privileges that are independent and don’t work for the actual facilities?
CLOUD: Just over 500.
GUERRA: Tell me about your software environment.
CLOUD: I’m very fortunate because my CEO is married to the idea of integration. Now, integration for us doesn’t necessarily mean the same vendor – although most times it does – because it’s very difficult to achieve integration having a multi-vendor shop. But integration essentially means the idea of a common interface, a common database, common architectures. Anything you put the word “common” in front of, for us, is what integration is about. And so, every once in a while, we may find a reason to step outside of our primary vendors strategy.
Our primary vendor is McKesson. We are on their Horizon platform and beginning to move any products that we own of theirs that are not on Horizon to Horizon.
In terms of what we’ve accomplished, we have barcoded meds administration. We have paperless EMR after discharge. So essentially, any medical history is only accessed through the computer. All of our physicians engage our portal to access patient records.
I would rate us somewhere around 85 percent down the EMR road. We intend to complete that journey over the next three to four years. We’re going to implement CPOE and physician progress notes, so that would round out our EMR efforts. Obviously with the stimulus stuff going on, we’re trying to figure out how to do some of the things that are being asked for in meaningful use. One of those is we have plans in the coming year to go down the HIE road. We are, in cooperation with 11 other hospitals in surrounding counties, working together in a very interesting cooperative to join our communities through an HIE strategy. So that’s going to be very important for us in the coming year.
On the financial side of the house, we’re a Lawson shop and well automated there.
GUERRA: Regarding the owned practices, do you have them on a McKesson product? It looks like Practice Partner was their old product.
CLOUD: Yes. That’s a great question. We’re in the throws right now of evaluating what would be our two recommended EMRs. And our strategy is to pick two and then pre-build any interfaces and integration to those two. We would become the recommender in the area, because a lot of our docs have asked us to serve that role. Some of them are holding back on making a selection in order to see what the hospital does. And so if we can become the recommender, even for docs that are not owned or employed by us, we create great integration in the region. We also have an owned clinic and we’ll probably install the HAC (Horizon Ambulatory Care) product, which is tightly integrated with the hospital EMR.
Basically the ambulatory care product would share the same database with the hospital EMR. And we think that is a best fit for our clinics. But for our outlying docs or remote docs and their practices, we’ve narrowed the field down to about seven products, and we’re going to get it down to two that that we would recommend to any of those physicians.
GUERRA: Can you name those seven?
CLOUD: I’d love to, but I don’t have it in front of me. Let’s see if I can give you some of them off the top of my head. GE’s Logician product is in there. McKesson’s Practice Partner is in there. eClinicalWorks is in, Allscripts is in. Those are samples of what’s in the seven at this point. Over the next two months, we should have it narrowed down to two and become the recommender of those products. And, of course, we have to work with those vendors and create any necessary interfaces back to our systems.
GUERRA: Let’s talk about the control issue there. The interesting thing is that under Stark you had some control, but under HITECH, they can do what they want. Is there a loss of control now?
CLOUD: Well, I think there may be a loss of control, but not a loss of influence. Physicians recognize that it’s in their best interest to be in concert or coordinated with a hospital, especially physicians who admit frequently to our hospital. So, I do think we can exert some appropriate influence and provide some movement toward standards and integration, but yes, there is definitely loss of control. But, we believe that’s less important if we achieve an effective HIE, because really the idea of thinking that the whole world is going to move towards a single anything is a pipedream. So I really believe that the appropriate strategy is to put ourselves in the position where we can accept all comers, and an HIE strategy helps us do that.
If a doc rejects our two recommended systems which offer tight integration to us, we can at least get them connected through some type of regional communication strategy. So it’s a two-tier, if you will, a two-level connectivity approach that we’re employing. Actually, three-tier I would say, because our own clinic will be tightly integrated with the hospital EMR. All the surrounding physicians that accept our standards will be loosely integrated with our EMR through interfaces, and then docs that totally reject the two above will be connected through a health information exchange. So that’s the strategy we’re employing.
GUERRA: It sounds like your CPOE and physician documentation timeline is a bit further out than the meaningful use timeline being floated. Does that mean you’re going to have to move things up a bit, and is that disruptive to your overall plan?
CLOUD: It is putting pressure on our plan. We believe we will meet that timeline because, if I read the legislature appropriately, you have actually two years. So, if you make it by 2012, you could still get full stimulus reimbursement. So we’re hoping to make it by late 2011. We feel sure we’ll make it by 2012, which still puts us in a good position. But it has definitely put pressure on our plans.
GUERRA: Have you found the independent physicians receptive to doing CPOE/EMR? Do you have an overall plan for fostering physician adoption?
CLOUD: Yes. It’s interesting. We did an area survey and we were quite surprised at how many docs are interested. Something physicians have figured out is that this is coming whether they like it or not. It’s not just about getting the stimulus dollars; it’s about them trying to achieve some automation that they know is going to be important for the future. As docs are getting younger and they’re part of the circuit board generation, they already understand and comprehend the importance of automation and workflow in their practices.
We’re getting a mix, but I really believe that the majority of docs in our area have an interest in moving forward, which was a good and pleasant surprise for us. We did that, like I said, via survey; so this isn’t just a guess, but we sent out surveys through several counties and to docs that would be participating with the hospitals that work with us on the collaborative.
Now, the issue is -- and this is really quite interesting -- that we have a lot of rural physicians, and their level of technological sophistication is problematic. So you have a two-doc practice in rural North Carolina and they have a single PC at the receptionist’s desk. Clearly, that puts them in a challenging position, and what those types of docs are going to be looking for is help. And to the extent larger organizations or collaboratives can come together and assist these physicians, to that extent we will be successful with this movement toward national automation. But I think those are the targets that will be difficult.
We have some docs that have their own IT departments – those guys aren’t going to be a problem. The key there will be to achieve a level of integration, connectivity, and interoperability. But our real challenge – and that’s what we’re trying to pursue here with the 11-hospital collaborative -- is to reach out to those physicians that are less sophisticated, less equipped in the information management arena. I think we have a unique opportunity here. We work with a group of physicians that represent about a third of the docs in North Carolina, and their leadership is well onboard with what we’re trying to do.
GUERRA: For the non-IT-savvy physicians that you just mentioned, do you think a Web-based, remote-hosted set up would be most attractive?
CLOUD: No doubt. An ASP model is right on top of our list of methodologies. One of the things we’re struggling though is trying to determine whether the hospital, or a hospital, should host that or whether some spin-off organization that functions somewhat independently should host that. Because, as you could well imagine, there isn’t – how should I put it – some docs won’t feel as comfortable having the hospital manage their information as they would having a third party do it.
The collaborative that we’re a part of -- CCHA (Coastal Carolina Health Alliance) -- could be the hosting organization, if we so decide. But we’re still early in those decisions right now. We think it’s going to be a phased approach. We believe that, in the initial offering, it will be wise for area hospitals to offer something to get it going.
GUERRA: Whenever you get into something like that, you run smack against the issues of data ownership, privacy and security, as well as funding. So who’s going to pay for it? Have you run up against these things?
CLOUD: Yes. I mean, we certainly are exploring that. We’re exploring getting involved with employers. We could offer premium programs to employers that could potentially help pay for this. And, most importantly, the payers. Some of us have begun charting a plan to talk to area payers and see how they might participate. It’s interesting; I see the dialogue strangely quiet with payers in this whole thing but they’re going to be tremendous beneficiaries.
GUERRA: Maybe that’s why they’re being so quiet. (laughing)
CLOUD: That’s kind of uncanny. But yes, that’s typically referred to as the sustaining model. So we’re looking at what are the right sustaining models. But strategy, in and of itself, can support it as long as the budget can support this kind of connectivity. The closer you align area physician to the hospital, the more efficiencies you pick up, and the more likely these docs are to refer in your systems. There are some justifications to take some loss-leader type of approach to this too. That’s not going to be enough though; it’s going to take a combination of things coming together to figure out how to sustain this. It can’t be a total giveaway.
GUERRA: I want to ask you a McKesson question, and be as frank as you can. McKesson is one of the companies I hear about when people discuss the fact that though you may be buying from one vendor – because of acquisitions and that type of thing – the products under that vendor’s umbrella may not be all that integrated. Is that something you’ve had to contend with, and how does the CIO deal with that type of thing?
CLOUD: That assessment is, in fact, true. And that is the reason I said earlier that you have to have a clear definition in your mind of what integration means. Because buying from a single vendor doesn’t necessarily get you there. McKesson, historically, has been one of those vendors where you could buy three products from McKesson and two integrate and the third does not. And then you have a situation where the integration was slight of hand. It was really a bunch of sophisticated interfaces hidden under the covers. But the customer experience suffers because of the inefficiencies or the lack of performance and stability of those approaches.
To give McKesson a pat on the back and also to give McKesson’s customers, if you will, a pat on the back, I can tell you that their customers exerted sufficient pressure to make them listen. And they are beginning to fix that problem. So we are hopeful that our integration goals will be met through McKesson. They’re introducing a new platform. They call it the Enterprise Release 10.X where they are fully committed to solving that problem.
And so, as every one of the customers move to 10.X, they will enjoy the benefits of full integration. Of course, McKesson has committed all of their products to 10.X over time. So I don’t think it is a surprise to McKesson that their customers have been disappointed in the level of integration achieved in the past, but I think they’re to be applauded that they’ve finally heard us and are doing something about it.