Jacksonville, Fla.-based Baptist Health is one of the leading providers of healthcare in Northeast Florida and Southeast Georgia. The organization provides its acute services through a network that includes four medical centers (Downtown, Beaches, Nassau and South), the area’s only children’s hospital (Wolfson Children’s) and a number of outpatient diagnostic and therapeutic services. Heading up the IT for sizable enterprise is CIO Roland Garcia. Recently, HCI Editor-in-Chief Anthony Guerra had a chance to talk with Garcia about all the projects in his pipeline.
GUERRA: Tell me a little about your organization.
GARCIA: We are an integrated delivery health system in Jacksonville, one of five in the Jacksonville area and the largest with about 30 percent market share. As a health system, we’re composed of five hospitals, one of which is the only children’s regional hospital in the area. Additionally, we have 40 or so primary care, family practice centers, a home health agency, and retail pharmacies. We have our own inpatient as well as outpatient clinics. So, we cover pretty much the whole spectrum of healthcare outside of nursing homes or long-term care.
GUERRA: And you said the organization owns about 40 physician practices?
GARCIA: Family practices. In addition to that, there’s some specialty practices and then some of the urgent care centers as well.
GUERRA: And there would be, also, a population of doctors in the area that are independent but admit to the hospitals?
GARCIA: Correct. The majority are independent physicians. We have about 1,600 physicians with credentials to our organization, and we may have employed about 135 or 140, something like that.
GUERRA: So, vast majority are independent?
GARCIA: The vast majority of the health and medical staff are independent; that’s how we operate.
GUERRA: Are all five hospitals on the same electronic medical records/CPOE platform?
GARCIA: Yes. Let me give you some background on the technology. We have three of our five hospitals running fully digital, and our definition of a digital environment is discreet data element documentation, not only nursing documentation, but also physician documentation, which is different than many other settings. Obviously, CPOE is mandatory and par for the course. So, out of the five hospitals, three of our facilities are running with that environment. In those, there is literally no paper in the nursing units. So if you walk into the nursing unit, you do not see those metal binders that you typically find.
Beyond the hospital setting, we have pretty much automated our whole health system. Again, we have clinicians that are, at any given time, treating about 700 patients in the community. We have clinicians that go take care of these patients with laptop technology. So they have the ability to not only download the information for the care protocol that’s expected for that patient, but also document that information. After that, it’s all coordinated with the billing system.
In the physician practice world, when we began deploying EMRs two and a half years ago we had 23 primary care centers. We have grown to 40 today and continue to grow. So the challenge has been to keep ahead of that curve. Out of those 40 or out of the 23 original practices, we have 15 practices running on EMRs. These are outpatient clinics. There might be anywhere from two to eight physicians per clinic.
So when we hear about EMRs and the $19 billion opportunity with HITECH, it is not something that is new to us. We’ve been at it now since February of 2005 when we opened a brand new hospital with that footprint.
GUERRA: Tell me which vendors you’re working with.
GARCIA: For our hospital operating units, our primary vendor for the repository and the EMRs and those kinds of applications is Cerner. However, they’re not the only vendor that provides technology to support the digital environment. Additionally, we have GE for our PACS solution which is integrated within the EMR. We also have ProVation which is our standard across all of our hospitals which provides support technology for endoscopy centers and those operations. We have Philips which provides our obstetrics and delivery monitoring. Now, those technologies are deployed throughout the health system. All five hospitals have PACS. All five hospitals have same pharmacy system with McKesson cabinetry and medication-distribution system. The only missing component in the two hospitals that we say are not digital are CPOE nursing documentation and physician documentation.
GUERRA: Now, that’s done through Cerner in your other three hospitals?
GUERRA: You mentioned that you use McKesson for medication cabinetry, explain to me what’s going on there between Cerner and McKesson.
GARCIA: Well, first of all, when we deployed cabinets years ago, Cerner did not have the cabinetry available and, to this day, they do manufacture some cabinets but just don’t have that market. It’s fairly new to them. So, that’s how we ended up with McKesson cabinetry in there. So, the physician enters an order based on order sets or whatever protocol – they can enter individual orders or they can enter based on order sets – et cetera. That’s the function of the CPOE workflow or the order entry mechanism. When that order is entered, it should be handled within the pharmacy system, which is a Cerner solution. So, the process within pharmacy then takes over, which is the validation and all the stuff that takes place for pharmacists to sign off on that as well.
Once the pharmacy signs off on the order, that information is sent to the McKesson application which manages our cabinets out on the floors, which has the inventory of the medication. So once the pharmacy system, which is part of the (Cerner) Millennium architecture of products, communicates to McKesson, “Roland Garcia to receive the exact antibiotic,” let’s say, it’s clear to do that. Then the nurse, once they get that, goes through a cabinet, they identify the patient and the medication, confirm that, and the drawer opens and she has access to that particular drug or medication.
GUERRA: Let’s say a patient comes in to one of those three hospitals and is treated, I would imagine their information is captured in the Cerner system, in their EMR. If they come back into the main part of the hospital again, someone would be able to call that up. But what if it’s a woman who was in the hospital before and had her information captured in the Cerner system, but now she’s having a baby in that part of the hospital which is handled by the Philips obstetrics system – will the clinicians be able to call up that Cerner record, or are those two systems separate?
GARCIA: Well, first of all, they do have access to the Cerner EMR in the labor and delivery unit. So their workflow calls for being able to access the EMR and look at that, and look at the history of the patient that they have or search for a patient who’s been to any one of the five hospitals.
GUERRA: Would be they’d be looking in Cerner at that point?
GARCIA: Yes, in Cerner at that point. But they do have to work also within the Philips system. Philips, though they’re great at the obstetrics in labor and delivery, have not developed sophisticated enough interfaces. That’s been the subject of one of our large battles with them for the last five years.
We have many systems populating our EMR which is, again, part of the Millennium architecture. We have transcription that’s done in India and/or locally with a Dolby system that interfaces to our EMR. We use ProVation which is standard across the health system for cardiology, that is interfaced. We have our imaging standard across the health system and that is interfaced. The one area where we have struggled with integration is the Philips technology.
So to answer your question, that nurse does have access to that patient’s prior history. They just need to go into the EMR. So, they have two sessions going on in their workstation.
GUERRA: And they would toggle between Philips and Cerner?
GUERRA: So it’s not the ideal state but it’s workable at this point?
GARCIA: Yes, it’s been like that since Feb. 15, 2005 when we opened that facility.
GUERRA: You mentioned a number of technologies that you’ve got in there. I don’t believe you mentioned voice recognition. Are you using any of that to cut down on transcription cost?
GARCIA: Well, funny you mentioned that. The reason I make that statement is we just finished evaluating products, and we’ll actually implement a voice recognition system for radiology only next year, beginning in October. What we do use is voice recognition in the ED, for example, but we use Dragon to interface with the EMR Millennium architecture.
GUERRA: Is there any other product that’s really competitive out there with Dragon from Nuance?
GARCIA: Nuance certainly has a technology that we’ve tried and we’ve done a detailed analysis of that technology. In fact, we powered it up at our Baptist Medical Center South facility. However, at that time, the end result was that the technology was not quite there for enterprise deployment, at least when we looked at it.
GUERRA: Do you mean the voice recognition transcripts had too many errors?
GARCIA: No. When you have thousands and thousands of workstations spread throughout our wide geographic area and you have to install that technology at the workstation level, it can be problematic. If I’m a physician and I walk to a workstation, I want to do dictation right there, but maybe that’s not the workstation I normally use. What if I happen to be in a part of a hospital that is quiet, so I want to catch up on some of my dictation? In that case, that client technology needs to go down to that workstation or be present in that workstation, so you have to consider the whole overhead of managing the client application.
GUERRA: So are you saying that you have to install the application on every computer a clinician might want to use?
GARCIA: Yes. And that’s difficult in terms of manpower required to do the installations and maintenance. It’s very costly.
GUERRA: Because you need so many licenses?
GARCIA: Well, not necessarily the licenses, though that’s a cost. It is the total cost of ownership because I have to keep track of that client across a large population of workstations. That’s what we found when we did our evaluation.
GUERRA: Can you explain a bit more.
GARCIA: Well, let’s say you had two computers and you had a network in your home, and in one workstation you had voice recognition, Dragon. Now, you go to the workstation that’s in the kitchen and you want to do some voice recognition. You would have to bring the application to that workstation in the kitchen and put that same software on the computer so you could do your voice recognition on it. At home, if you’ve got two workstations, you go from one end of the house to the other, that’s okay. But when you have thousands of them over a wide geographic area, to distribute that application to all of them, and keep track of them, it just requires too much overhead.
That is not what usually has to be done with software for enterprise-wide deployments. Think of Amazon.com. The last time I was on Amazon.com and bought some stuff for my daughter, I didn’t need to download any app to my workstation at home because the software is all on Amazon.com servers. All I see is the screen with my options, et cetera, and when I enter the information, it goes back to that server, wherever that is. I’m not storing anything in my workstation. In the case of this particular voice recognition system, if I go to that workstation, my personal profile with my voice, basically, has to be present there. So, if this workstation doesn’t have it, it has to go out to the server, find it, and bring it back down to the client. All of that is overhead, all of that is time consuming in terms of quick response. It’s not simple.