Not to be outdone by his neighbors at Partners HealthCare, John Halamka, M.D., CIO of Beth Israel Deaconess Medical Center (BIDMC) and Harvard Medical School, is hard at work integrating his acute facility with associated physician practices. The undertaking is a massive one requiring the build out of infrastructure and plans for ongoing support. Recently, Halamka chatted with HCI Editor-in-Chief Anthony Guerra about his plans to electronically ink the acute and ambulatory worlds.
AG: How are the responsibilities and obligations being split up between the Medical Center and the IPA?
JH: The physician organization and the hospital have come together in a purely collaborative partnership — it’s a 50/50 contribution. So what’s interesting is that I have two kinds of docs I need to serve. The first is the owned, affiliated, in my four walls practice that I support. For them, we have mandated the use of electronic health records — it happens to be electronic health record we built — e-prescribing, health information exchange, all that wonderful integration and data sharing.
Then there’s the second type. And what do you do with the doctors in the community who you don’t really have any governance control over. Do I try to put them on my network and force them to use the hospital-provided electronic health record? Or do I produce a hosting facility that’s all Web-based that makes the guy in the community really reduce the barriers to entry. If it’s just a Web page, you don’t need a host server, you don’t need to be a DBA, and we’ll subsidize your adoption of it, we’ll do best-practice clinical templates; we’ll help you with implementation and workflow transformation. That can be, for that non-owned referring doc, an easier partnership road to travel.
AG: But you are taking a different route than Partners, correct? They are requiring the non-owned docs to adopt an EHR, you are not. (To learn more about Partners’ acute/ambulatory EMR project, read HCI’s February Cover Story).
JH: We mandated some docs but have not mandated the community docs and are instead subsidizing and helping them. We’re doing it with an outsourced kind of model, where we’re outsourcing some infrastructure support, the data center itself. I’m also providing a set of insourced practice-transformation services to really help them with the implementation.
AG: Tell me about working with the physician organization and the dynamics of that. Do you have to be very collaborative, and do you ever have a difference in opinions?
JH: What’s been very interesting is that in the last couple of years, we’ve worked through all those differences and now have joint governance. So, I am on the steering committee for the project that also includes the CEO of the physician’s organization, has some of the opinion leaders in the community doc environment, but then has IT professionals and network development from the hospital. We actually are making the decisions jointly and funding it jointly. So I think you’re probably right that, in the past, physician organizations have been somewhat at odds with hospitals. And here, we’re really unified, joined at the hip to make this happen.
AG: Stark allows you to pay for up to 85 percent of the implementation costs, but you describe a 50/50 split in spend. How does that work?
JH: Yes, Stark allows an 85/15 split, but the whole project, when you think about it, is both implementation and the initial practice transformation and ongoing maintenance. Now Stark obviously says hospitals can fund 85 percent of implementations, but docs need to pick up all those maintenance costs. And so what we did is we did a financial model that says let’s look at what Stark allows us to do — we can’t fund the hardware in the office, we can’t fund the maintenance cost to the licenses, but what we can do is all the implementation. And so therefore let’s work it out that the hospital is actually paying 85 percent of implementation cost. That gives us 15 percent to start with. So when you look at the total lifecycle on everything you need to do, then it ends up being kind of 50/50 total lifecycle split between the docs and the hospital.
AG: What about the Concordant deal? I saw you hired them for infrastructure.
JH: So Concordant is the firm that did the 600 docs of the Mass E-Health Collaborative. That was a $50 million project. And what they ended up doing was all the wiring, all the network, all the desktops. If one of the docs gets a blue screen, I don’t have the core competency or the staff to deal with that every time it happens, I can’t deal with every Microsoft patch of every doc throughout 450 square miles, Concordant can. So it’s a really nice marriage where I’m providing the air traffic control, the design, the strategy; and they’re dealing with the tier-one support and the doctor’s office infrastructure.
AG: And for the actual EMR product, did you say it was homegrown?
JH: For these docs, it’s going to be eClinicalWorks. When we were looking at the marketplace, we said these docs really need a Web-based, practice management plus electronic health records product, something really designed for doctor’s office. If you look at our docs, on average, we end up having about 2.5 docs per practice. So when you look at the academic health center, BIDMC, where it’s all NIH-sponsored research in large, complex, multi-specialty practices, it’s not exactly the same kind of need as a community doc. But we have achieved a level of interoperability between these two systems (eClinicalWorks and the BIDMC inpatient HIS) that’s pretty good. I’m the chair of HITSP, and so I deal with all of the interoperability requirements and standards. We’ve created a pop-up button so you can be in eClinicalWorks, push a button and get all the hospital data on that patient, just within eClinicalWorks. So it really achieves a level of interoperability that doesn’t necessitate you to have one EHR for everybody.
AG: So they are getting eClinicalWorks for this program.
JH: That’s right, eClinicalWorks, hosted in a single data center operated by Concordant. Hardware support by Concordant, but all the practice models, the clinical guidelines, and all that stuff, my internal staff is creating.
AG: And what’s the main hospital information system over at Beth Israel in the acute facility?
JH: We built it. My feeling on build versus buy is that I want to own the front end. I want to give the doctors a fully integrated experience. It’s Web-based, runs anywhere on any browsers. And although there are fabulous PACS systems, lab systems, and various departmental systems, I haven’t found an enterprise, does everything, single sign-on, Web-based, acute care information system. But we built that over the last decade. And then, of course, through interfaces and Web services, linked it up with various departmental systems that we buy.
AG: So if you’re a doctor working in eClinicalWorks, you can click a button and can get into the hospital information system.
JH: Correct, and the way that works is it’s all Web services with single sign-on. You don’t have to sign on again, you don’t have to specify the patient again. It’s, ‘Hey, I looked up John Halamka in eClinicalWorks, and behind the scenes the Web services finds that I am known to Beth Israel Deaconess, highlights the button, you click the button, you’re able to view my labs, meds, allergies, any radiology tests, and place orders as well. Any order will then go into the Beth Israel Deaconess departmental systems.
AG: Is this a one-way thing? If a doc goes into the Beth Israel Deaconess HIS while in the hospital, can they see information sitting in their eClinicalWorks patient record?