Ed Marx Ferdinand Velasco, M.D.
Texas Health Resources is a 3,700-bed 14 hospital system in the Dallas/Fort Worth Metroplex with more than 18,000 employees. With almost 100 percent of its practicing doctors working as independent community physicians, the organization needs to be nuanced in its push to get EHRs into their offices. Working on that project, in addition to every piece of inpatient IT, is CIO Ed Marx and CMIO Ferdinand Velasco, M.D., along with the 525 FTEs that make up the IT staff. An annual operating budget of over $100 million helps grease the wheels, but that only goes so far with physicians who take their independence very seriously. Recently, HCI Editor-in-Chief Anthony Guerra had a chance to talk with Mark and Velasco (who he linked up with on Twitter @anthony_guerra, @marxists, @ftvelasco) about their plans to connect the acute and ambulatory worlds.
GUERRA: Tell me about some of the things you’re doing around HITECH.
MARX: We’ve decided to take a very strategic approach to this, so it’s not an IT thing. I’m co-chair of our Stimulus Task Force; the other co-chair is our senior vice president for government affairs, so he’s our political advocacy leader, if you will. The task force reports to the board. That’s a very unique feature. We didn’t want to get stuck in the bureaucracy that can happen at a large organization, because we have a lot of committees and it can be hard to get things done. We felt that this would not operate well under the weight of a lot of bureaucracy. So we report to the board, and our membership has hospital presidents, finance people, clinical people, a good mix of individuals that you would normally think of in such an endeavor. That includes education because some of HITECH includes not just the meaningful use component, but also we are very interested in pursuing grants. So our research organization is prominent in our Stimulus Task Force, and we meet monthly. Ferdie (Velasco) may have shared with you that CNBC was here a month ago to do a feature that has yet to air. So it’s pretty well organized, well run and had good participation.
The next thing we have that came out of the Stimulus Task Force at the high level is a subcommittee focused on meaningful use. So this subcommittee is getting down into the details of meaningful use, and we’ve created a – actually Dr. V created – a matrix or readiness assessment, which basically includes everything that has been said and put out so far. We know it’s all subject to change, but it compares where we need to go with where we are.
There are five major areas for meaningful use, and so there’s a primary and secondary executive in charge of each one, and they are charged between meetings to do this gap analysis.
So it’s pretty well organized. We know that the gap will be very small for us because we’re almost done with our electronic health record implementation. However, we also have HIE plans and personal health record plans, those sorts of things. So we don’t have very far to go fortunately, but we do have this committee so eventually the gap analysis will be done and we’ll have an action plan as to how we’re going to address the gap and when it would be filled. That gets reported back up to the Stimulus Task Force, which then reports that back up to our board.
GUERRA: I’m interested in the genesis of the Stimulus Task Force.
MARX: I think we do have a very well-organized approach to meaningful use, and the way that it came about is that we knew there were lots of dollars at stake, not even counting the grants. Again, everyone is so focused on meaningful use, but we’re looking at the whole package. There’s the meaningful use dollars, and then all the grant dollars available. So a few of us started talking, myself and this government affairs senior vice president that I mentioned, his name is David Tesmer. We wanted to make sure that our organization had this stimulus in its planning and realized what was at stake and that we were making moves towards it. We figured that it would be best to take a proactive approach.
So he and I got together; we had discussions about what could happen if we didn’t take a proactive approach. We could easily miss out on something, especially as we’re going into the 2010 budget cycle and contemplating the right projects for 2010 that would help us achieve meaningful use. For instance – health information exchange. So the idea of a task force started to make sense. We approached our bosses and decided it would be best to formulate this Stimulus Task Force so that we had a group that was charged, responsible, accountable, and transparent to go after this.
So then we worked with the COO and other senior executives in terms of developing a charter. We try keeping things pretty simple. We have a one-page charter that includes our objectives, our organization, who’s involved, how do we know we’re successful, what are the desired outcomes – all in one page and that essentially was presented to our executive committee, our C-suite, for their blessing.
Again, they offered feedback and then they said, “Okay, this has to go to the board.” We are asking for fairly immaterial dollars in the big scheme of things, but we wanted to make sure we had some funds available if we needed to get any outside support or whatever we might need. We also didn’t want to be stuck, as I said, in the bureaucracy, which is not a negative term but, again, big organizations have lots of committees and meetings, and so this did go to the board and the board approved it.
So we’ve been meeting now since March on a monthly basis, and the meaningful use subcommittee started about three months ago. I’m not saying this is the best practice, but this is one that seems to be working very well for us and, because of this, not only are we on target to collect all of our funds regarding meaningful use, which for an organization of our size is fairly substantial, but we’ve also increased our capacity to apply for grants.
So even though we do have a good research organization, and certainly they’ve been applying for grants and winning grants, with this additional emphasis and this committee, we’ve been applying for more grants than we would have in the past.
So far, we haven’t received any, but that’s partially because the government has been fairly slow in doling those out.
GUERRA: When you talk about health information exchange, are you specifically thinking of an HIE that would communicate with outside hospitals or are you talking about integrating with independent practices?
MARX: It’s both. To answer your question specifically, I’m taking about an HIE, not just for independent docs or our affiliated docs but other hospitals in the area and other ancillaries in the area. Of course, exchange is one of the five main areas for meaningful use, and so that has spawned a capital project for 2010, and we were able to leverage the stimulus situation in order to get funding for our HIE. We’re pursuing it on multiple levels.
GUERRA: Have you done much under Stark? Do you plan on underwriting, or have you underwritten, EHRs for the independent practices?
MARX: To Texas Health’s credit, once the Stark laws were relaxed about three years ago, we already had started a program where we were subsidizing physicians under the Stark provisions to adopt EHRs. So we’ve been doing that for a good two years. So we included the physicians in the selection process. They ended up selecting three. We added a fourth, which was Epic because we use Epic in-house, and so as long as they adopt one of those four, they have varying degrees at which we subsidize them.
GUERRA: What are the other three?
MARX: The three that they’ve selected were eClinicalWorks, Allscripts, and NextGen.
GUERRA: So you give them four options.
MARX: They get a higher subsidy if they choose Epic, because obviously it’s advantageous to have the whole ecosystem on Epic.
GUERRA: Four seems to me like a lot of integration work. I’ve heard one, I’ve heard two, occasionally three, but four seems like a lot to handle.
VELASCO: The insight I would share is that Texas Health tends to historically have been – eclectic may not be the right word – but open to multiple options, particularly when it comes to physicians. In fact, our CEO, Doug Hawthorne, uses the phrase, “a house with many rooms,” to describe our physician group, which suggests a lot of flexibility, a lot of options for how physicians may choose to participate in this physician group.
Some are opting for a fully employed model, where they basically turn over to the health system all aspects of the practice, where basically all of your salary comes from the health system. Now, that may not be appealing for a lot of physicians in the community, but many are still interested in some form of integration. So one of the things that we are looking at, as I’ve mentioned, is this concept of an MSO-type service where they will still remain independent, but increasingly some back office capability will be provided by the health system.
To make that attractive, our senior leaders felt we couldn’t really afford to just have Epic, which is what we’re rolling out in our inpatient environment, our ambulatory hospital-based clinics and in our own practices. They felt it would be necessary to have some options.
Some of our physicians are very independent, particularly here in Texas. So the concern was that they would not buy into a program where all the data would essentially be owned by Texas Health Resources, but that would be the case if they signed up for the Epic platform, because it would be our instruments in Epic and wouldn’t be a separate database.
It was felt that only offering that option would not be attractive enough. So since eClinicalWorks and Allscripts were the two predominant office-based EMRs in use by the independent private practice physicians, we thought making that offering available would be attractive alternatives to the Epic-only solution.
GUERRA: Ed, I would imagine if you had your way, from an IT perspective, they’d all be on Epic.
MARX: Yes, one of our principles, since that time, has been simplification. We’re undergoing a project right now called “Application Rationalization,” because we grew through M&A activity and allowed a lot of different choices. So now we have 450 different applications, which is expensive to maintain. So our focus now is actually to reduce the amount of apps. I wouldn’t personally have offered four, but to Ferdie’s point, if you want to work closely with your medical staff and your customers, you definitely have to listen to their opinion. So the answer is probably somewhere between one and four.
VELASCO: That would be the other thing I would add, there are some local IPAs that are doing the same thing, that are trying to offer these physician offices EMRs at a discount. So they were also looking at the same three that Ed mentioned, so we felt obliged to keep up with them to be competitive.
The reality has been that we signed up quite a number of physician practices, and all of them have opted for the non-Epic solution. They’ve opted for these separate clinical vendor systems that are not part of the Texas Health inpatient or ambulatory rollout, again consistent with not wanting to have their EHR basically owned and controlled by Texas Health.
GUERRA: Why would selecting Epic be any different than selecting one of the other vendors, in terms of the ownership of their data? I wasn’t under the impression that would then mean their data was owned by the health system.
VELASCO: Oh, it would be. The way it works with eClinicalWorks is basically it’s an ASP model, where the vendor hosts the technology and the customers are accessing the EHR in the cloud. We’re just basically sponsoring a relationship in that case, so that they’re not having to pay the vendor full price. The benefit to us is that we’ll have that relationship with both the physician practice as well as the vendor, so that when we are now ready to implement the HIE strategy that Ed spoke about earlier, we’ll be positioned to do that as opposed to having to deal with these one-off hundred different practices.
Now, with Epic, they’re not in that mode yet of delivering EHR in the cloud, so the way it would work is – not just with us but with any system that can offer Epic – the ambulatory patient data would reside in the same database that is supporting the hospital environment. Now they would be segregated through the facility structure, as they call it in Epic-speak, but there is one database and it would be controlled by the sponsoring health system.
GUERRA: You mentioned that segregated aspect. In that case, the data would be housed by the hospital and hosted by the hospital, but still separated out?
VELASCO: Yes, but even that earlier disclaimer that you’ve said, that it’s still hosted and owned by the hospital, would be enough for some physicians in our community to not want to opt in.
GUERRA: In the Allscripts and NextGen models; the data doesn’t reside in the hospital.
VELASCO: That’s correct. It’s a totally separate install.
GUERRA: It’s very interesting that none of the practices have chosen Epic, even though you’re providing a greater subsidy for it. What is the difference in subsidy levels?
MARX: It’s about 25 percent for non-Epic and 80 percent for Epic. Now, one of the reasons why they are not choosing Epic (we do have physicians that are choosing Epic, but they’re the owned physicians and that’s part of the package they get) is culture. There is a very different culture in this part of the country. It’s not called the Lone Star state for nothing. It’s a very independent state.
The second thing is there is this fear, although not founded, that we would have access to their data, and people don’t want that. Again, it goes back to the culture.
The third thing is, even with that subsidy I mentioned, Epic is a pretty expensive product. It’s a great product, but it is expensive. So even with that differentiation, there is not a material difference in price between the two.
GUERRA: It seems that no matter what guarantees you give them of privacy and security, they just don’t like the idea of that data sitting in your data center.
MARX: Yes, it’s a cultural thing.
GUERRA: Very interesting. So, in that case, you have to deal with interfaces. How nicely does the Epic inpatient system play with non‑Epic ambulatory systems?
MARX: Well, the plan is we’re only doing one way at this point, and that’s out of our Epic system to these other applications. We do not have a plan on this side of Dallas to allow the non-Epic physician office EMR to come into Epic. So we are just pushing one way.
GUERRA: Can you explain that a bit more?
MARX: We share information today with a big IPA. We push information out, and they can get basic things like ADT, lab results, basic notes, but they’re not getting the full functionality or all of the information that’s inside Epic. But they do get all the things they would probably be interested in, those that I’ve mentioned.
GUERRA: I can’t imagine Epic is too excited about this set up. I had heard they might not be interested in a mix-and-match arrangement.
MARX: I think they’re showing lots of flexibility.
VELASCO: I would echo that. I think that there’s a difference between the reputation and the reality. Before we signed up for Epic, we certainly had heard the rhetoric that they’ll only let you do it one way and they’re basically unbending as far as being willing to accommodate the customer in whatever special needs they may have, and that hasn’t been the case. Oftentimes, when we have butted heads with them and we decided to do things against their recommendations, we’ve regretted having made that choice. They are usually coming from a position of having some lessons learned and that’s why they’re recommending things a certain way. But they have been accommodating as far as our approach to HIE.
GUERRA: Ed, you said that currently you’re only doing a one-way information flow between the inpatient and the ambulatory systems. Do you plan on doing a two-way flow?
MARX: We are planning a two-way flow, but not to the practices, at this point, that are using some of these other ambulatory products. We are planning to exchange two-way information to the different parts of our HIE, including hospital to hospital. We’re working with our hospital counsel and some individual hospitals, particularly those that use Epic already. We’ll be looking to do two-way exchange here shortly.
The reason that we’re not doing it on the ambulatory side to some of these foreign EMRs is not because of technical issues, but right now it’s just the issue of who’s going to validate the quality of information coming back in the other direction. It’s not that we don’t trust anyone, but you can only do so many things at a time, and we just haven’t given a lot of thought to the governance of that. Because right now, we have direct control over our Epic database, our in-house system, we have direct control over the quality, we hire the employees, we have quality controls and those sort of things. People are appropriately rewarded for appropriate use of systems, but once you go outside of your walls and into an independent practitioner, you don’t have that same level of control on the quality, and so you want to make sure that you’re operating a pretty clean database.