Caritas Christi Health Care System – the largest community-based hospital network in New England – is in the second phase of its EHR rollout. A few weeks ago, the organization completed an extensive nine-week training regimen with its 1,200-member physician group to lay the groundwork for CPOE adoption and proper use of the EHR. Recently, HCI Editor-in-Chief Anthony Guerra had a chance to talk with Rothenhaus about how the current federal policy initiatives were effecting his plans.
GUERRA: Tell me about your health system.
ROTHENHAUS: We have six hospitals, two of which actually have house staff and graduate medical education programs; plus St. Elizabeth’s Hospital (Boston), which is actually a tertiary-care hospital. We do hearts there and most other stuff; we don’t do super special neurosurgery and stuff like that, but it’s a regular tertiary-care hospital.
We have about a total of about 15,000 beds throughout the health system. We have about 12,000 employees and about 1,300 doctors … actually our physician landscape is a little funky in that we have four flavors of doctors. We have about 400 employed physicians, about 1,300 physicians who are affiliated with Caritas, in one of seven IPAs. So we have a total medical staff of about 2,300 when you add it all up.
GUERRA: How many physicians have privileges at one of the hospitals that aren’t part of the big IPAs you mentioned?
ROTHENHAUS: Well that’s about 1,000. So there’s 2,300 physicians … 1,300 of them are in the IPAs and another 1,000 are not in our IPAs, so they’re just in somebody else’s IPA, whether they’re part of Partners Healthcare or Children’s Hospital IPA or whatever, but they admit their patients and have staff privileges at our hospital.
GUERRA: And that’s not including the 400 employed doctors.
ROTHENHAUS: Right. And out of the 1,300, 400 are employed.
GUERRA: So you’ve got the full spectrum to deal with.
ROTHENHAUS: Exactly. As customers, that’s what I call the four flavors of physicians. One of those I don’t think we give a lot of attention to these days is physicians whose patients come to the hospital but they’re not even part of our medical staff.
There’s a lot of physicians out there who don’t even pay to have staff privileges or they may be on somebody else’s staff but their patient lands in our ER and gets admitted to our hospital. From an IT standpoint, there is communication that should go on with that group but doesn’t. So I’m thinking a lot about it because I’m thinking a lot about customer relationship management, and there’s that group of people we know exists, but we haven’t really identified because we don’t know what their names are.
GUERRA: So these people, these doctors are not in an IPA, they don’t even have privileges at the hospital, but you’re talking about how you can better be prepared when one of their patient lands in your ER.
GUERRA: That is interesting.
ROTHENHAUS: Right. So if it’s an employed doctor, we can use some inter-provider messaging, or they’re just going to log onto the information system and they’ll see that the patient was in the ER the previous day.
We have a contractual relationship with the IPA’s affiliate physicians through an entity known as Caritas Christi Network Services, and those folks I have an interoperability solution with, in that we get them discharge summaries in one way, shape or form. We are trying to make that an electronic process where it goes to the EHR.
And then there’s this third group of people who are on the medical staff, they get the discharge summaries too for the patients that get admitted. This is a fax thing. They have another EHR, and we are trying to solve that integration piece as well.
And then the fourth one is, for example, let’s just say you’re a Beth Israel doctor here in town and your patient gets admitted to Caritas; there’s a communication that should occur when that patient leaves the ED or leaves the hospital after an admission. In that case, it requires the medical record going out, and we don’t like to do that unless we have a preexisting relationship. So those patients don’t get the benefit; it would be the patient’s responsibility, or their doctor could call medical records and request that discharge summary. But that gets complicated under HIPAA.
So I just think it’s an interesting thing. We had been thinking a little bit about CRM in the classic sense and thinking about how it’s about patients, but it’s also about our referral base, and that last segment is a group that I think is under-recognized. We haven’t done the study yet, but when we finally do the analysis, there are a lot of people who get admitted whose doctor doesn’t pop up as a coded entry in one of our lists.
GUERRA: Interesting. Why don’t you give me an idea of your overall plan. I know you’re in the second phase of an EHR roll out. Why don’t you take me back to the beginning of that.
ROTHENHAUS: I’ll take it up a little higher. Right now, we have a few major projects that we’re doing. We’re doing hospital information systems – what we call advanced clinical systems roll out. So we’re doing CPOE, we’re doing staff documentation and bedside medication verification with barcoding. Those projects are ongoing at Caritas and we’re moving through with a completion date for that project in March of 2010.
We’re also doing a pretty substantial cardiology imaging project. We already have regular PACS installed, and we’re doing the C-PACS portion. We have our EHR project which is what most people want to talk about these days. And then we also have some business intelligence projects and some pretty substantial interoperability projects that get the systems to talk to one another. So that’s my portfolio right now.
From a strategic perspective, principally we have the traditional information systems applications approach to the portfolio. You’re just trying to get stuff out there. There’s a second piece which is interoperability, a third which is business intelligence. The fourth is around customer relationship management.
I spend about half my time worrying about the inpatient project and about half my time worrying about the outpatient project in terms of keeping the wheels moving.
But on the ED chart, Caritas started in 2005.
We were one of the three – our Brockton market where we have our Good Samaritan Hospital and the Good Samaritan IPA – that were awarded one of the MAHEC grants in Massachusetts. That grant, that IPA group – like all the other IPAs – chose eClinicalWorks as the EHR. As we decided that we’re going to install an EHR in all our other markets, the decision to use eClinicalWorks was pretty much based on the fact that it was such an overwhelming favorite of the physicians.
We did some roll outs in 2007 and 2008, and we were doing about 40 doctors a year, and when my new CEO, Ralph de la Torre, who is a heart surgeon, joined Caritas about a little over a year ago, he looked at all these projects and he said, “You know, at the rates you’re going, it’s going to take forever. So let’s really ramp that up.” And that was about the time I got the job as the CIO, and we went back to the drawing board, scratched our head and asked how we were going to double or triple or even quadruple the rate of what we were doing.
This is when I brought in Concordant. They have a track record of doing EHR implementations locally. It’s just so hard to find talented people and put together such a large team to take that on. So we brought them in to help us initially. What we’ve been able to do with them is as we recruit new people who are part of our team, they gracefully will reduce their staffing so that we can maintain what’s a pretty tight waterfall of kicking off two practices a week for the next couple of years.
The EHR project itself has gone pretty well, though it’s had a few bumps and bruises. I think the principle thing that makes it most difficult for Caritas is the fact that we have such a distributed environment. Amongst our employee group, we have about 100 sites where those 250 or 300 physicians work and then amongst our non-employed-but-IPA-affiliated physicians the median number of doctors in an office is really one or two.
So it’s a lot of work just getting out to these sites. To handle that, we did a couple of things. The EHR project could be run as part of the physician organization and we pulled it into IT, and what we did is essentially created hot zones around our different hospitals and created a more distributed approach to how we do the roll outs. We did this because of our map – we have a hospital within about 10 miles of the New Hampshire border and one within 10 miles of Rhode Island, so it’s 110 miles between the northernmost and southernmost hospital, and you just can’t do it completely and sensibly with a centralized team.
The other thing that we’ve made a fairly conscious decision to do around the long-term strategy for EHRs is developing and working on long-term support for these physicians. So it’s a little bit different from some of the stuff you’ve seen with these demonstration projects around EHRs. If I have one pet peeve, it’s that there are all these for-profits and nonprofits out there that will help physicians implement EHRs, but what it takes to support somebody long term and what it’s going to take to help those groups get meaningful use out of their EHRs and those types of things has not been addressed because we’re so focused on implementation.
So we have four verticals in our EHR program. We have an applications group, a training group, a helpdesk group and we have an implementation group. We’ve been pretty successful at keeping this team moving forward and doing the best we can to support the physicians.
We do tier 1 through tier 3. We do tier 1 support for all of our physicians, including our non-employed docs. We’ll handle the tickets, and we’ll work the tickets with the application vendor. We’ll actually even work with them on their break-fix support for the hardware; that’s actually been the more complicated and challenging piece of the puzzle. I think it’s almost easier to implement EHRs than it is to support them in a cost effective fashion long-term.