Playing it safe doesn’t seem to be the most important concern for Hackensack University Medical Center’s CIO Lex Ferrauiola (left) and CTO Ben Bordonaro. If that was the case, they’d almost certainly leave well enough alone, and Siemens and GE in place. But the duo has other plans — turning HUMC from a medical center held together with interfaces to a truly integrated organization, promoting data transfer across the continuum of care, from inpatient services to ambulatory physician practices. To make that dream a reality, the organization has settled on Epic. And while its vendor of choice comes with a high price tag, Ferrauiola and Bordonaro say you get what you pay for.
AG: Give me an idea of your IT environment, your core clinicals. I think you’re with Siemens now.
LF: Well, actually we’re mixed. We’ve been on GE LastWord. It’s now being sunset. GE’s trying to get everybody to move to the Centricity product. But that’s really our clinical information system. We’ve been on it since 2000 for nursing documentation and CPOE and pharmacy, etc. and so forth. We’ve been on SMS or Siemens Invision since 1990 to do all outpatient accounting.
We had the vision about seven or eight years ago that we really wanted to move to integration, including not just the hospital facility, but also the community physicians. We really wanted to do a model that would be able to host practice management, EMRs for the community physicians as much as we could within the constraints of the law.
We were going to go in one direction but we had to change paths. We are very close to finalizing a contract with Epic. The plan is to go full-force with Epic for everything, the inpatient, the outpatient, host the community physicians, give them the service to ambulatory and EMR practice management. That’s pretty much what our plan is.
We have a certain degree of integration now between SMS and GE, and some of the environmental systems. We really want to have full integration.
AG: So just to be clear, the Epic implementation would be a replacement of Siemens’ products?
LF: It would be a replacement of GE, which is our clinical system now, and it would also be a replacement of Siemens for the patient accounting system. It would be replacement for different vendor systems for different applications. For radiology, we have GE. For the ER, we have LogiCare. All that would be part of the Epic system.
AG: The two main systems that you would be replacing would be Siemens and GE, plus a lot of ancillary systems, so you're going to be an Epic shop.
LF: Yes, that’s the vision. It will happen in phases, it won’t happen in one big bang. We have to do the inpatient clinicals first. We have to replace the GE system, because that product is being sunset by GE.
AG: Can you tell me a little bit about what that takes to move from one large vendor to another?
LF: You have to have a clear vision of what it is you want, what the end is going to look like. In our case, it’s full integration so that the community physician will have access to the same information; the patient would have access to their information from home. It would really be a foundation of one patient, one record that would be accessible all the way around. First of all, it takes a lot of money to move in that direction. When you make a decision that the platform that you’re currently on is either going away or needs to go away, you have to do the assessment.
One of the vehicles that was valuable to us was the KLAS report. We looked at the KLAS report heavily. You’re very familiar with it, the marks that Epic received are much higher than anybody else. That was helpful. But we really needed to have a collaborative, interdisciplinary team from the medical center, with heavy physician chairs on it, nursing people, operational people to look at different products and different systems, site visits. Then there’s the support and for the money, Epic is very, very expensive.
AG: So you had to make a case to the board?
LF: Sure, of course. It wasn't necessary to make a case that we need to move in a direction that will be fully integrated, because people are aware of that. They know the product base in healthcare has evolved over the last 10 years. But most of the clinical systems that are out there are second-generation systems, like the GE system, the Siemens’ system, and the vendors are moving towards products that have integration. For instance, Siemens is moving towards Soarian, Epic has that integration already. Eclipsys is buying a lot of companies and creating a sort of pseudo–integration. They’re trying to put those systems that they’re acquiring around a central database, but they’re still separate systems, but it is a form of pseudo-integration.
Even our board members understand that the future is integration and the present situation is that most systems are not integrated. Healthcare has a very heavy dependence on interface engines and interface technology. Interfaces are resource consuming. They’re error prone and that’s not the real world anymore. The technology has moved.
AG: There’s a fundamental decision many make between best of breed, accepting interfaces, versus an enterprise solution. Oftentimes it’s thought that if you go enterprise, you suffer in terms of functionality on some of the ancillaries. Obviously you’ve gone the enterprise approach. Have you had to fight battles with some clinicians that are focused on getting exactly what they want for their specialty?
LF: Let me give you an example. We have the chairman of our ER who is very progressive, very technology oriented. He's very, very strong on getting an ER system that would do everything for you. He looked at a couple of vendors. He looked at MedHost, he was very, very impressed with them. But he sees that there are issues. If you have a system that is interfaced, there are problems in the ER. How do the ER physicians enter orders? How is their integration with pharmacy? If you don't have that, you have to rely on interfaces, and it’s difficult.
He was willing to really look at the enterprise solution. And he went on site visits, and he saw that the Epic ER system would really meet the needs that he had. It might not have all the bells and whistles that he saw with MedHost, but it was adequate and the value he would get from that integration outweighed any of the extraneous bells and whistles that might have attracted him in the other direction. Ben, do you want to add to that?
BB: I think that’s the ultimate battle. When you’re looking at strategy, do you go best of breed or do you go integration. And there are definitely pros and cons to either one of them. If there was a perfect solution, then you would look across 1,000 hospitals across the country and they would all be doing it. But nobody’s doing it only one way or the other. It’s really a tossup. I think sometimes that comes down to what you’re applying it to.
You were talking (before the interview) about the differences in need between a150-200 bed community versus an eight hospital system. We’re kind of somewhere in the middle, but we’re a full acute-care hospital. We’ve almost come full circle, in that we were a somewhat integrated, best-of-breed system. Then you realize the shortcomings of that, because we have all these ancillary services. So if you’re a facility that is a massive facility, but say that you’re into cancer care, it might be a little bit easier to get best of breed because you’re getting best of breed for cancer care. You’re not going to be adding a Level II trauma center. You’re not going to be adding all the other diagnostic, the lab outreach program or a commercial lab. So when you start adding all those other ones I think we saw over time that we were going with the biggest, the baddest, and the best of everything in a single system, but the integration was really hurting us. And people would have to go into multiple systems for multiple things.
So for our model here, for us, our strategy is going to be more of an integrated system. So when you said before your big versus your big replacement, that’s kind of tough because to date, there is no top fully integrated system that can do everything obviously perfectly. You can take a MedHost or a WellSoft and they’ll do a little better in the ED. You’ll take a GE and it’ll do better in cardiology than maybe Epic will do, or in the lab arena. But we made a strategic plan by saying integration is going to be better for us. This is a five to 10 year investment, this is not a one year investment. When you’re doing a big for big replacement you’re looking 10 years out. And our feeling is that integration for our types of services is better for us to go with now than the best-of-breed approach, and all the integrations.
When you look at some of the other competitors, they might have some really, really good best-of-breed systems, but they lack some of the integration between the different systems, even between their practice management systems and their inpatient systems, for example, they lack some of that integration. They may get there, but we’re trying to match our strategy with Epic.
LF: A lot of the big academic medical centers are going in the same direction. You’re probably aware of what’s going on in this area. In New York, there are some really good places that are pretty much in the same position we are of finalizing discussions with Epic. So it is moving in that direction.
AG: Do you see a lot of momentum for Epic specifically or for large companies like Epic? We see about seven large enterprise-wide players on the vendor side.
LF: Both. I see, in this part of the country, there is a lot of movement towards Epic and lots going on.
BB: I think actually seven might be a little on the high side because of also the move towards integration with the devices. When you look at device integration, there’s not seven on the list that take care of all device integration also. When you look at a big one like Siemens, where they’re moving in their strategy is the integration between their CT scans, x-rays, everything else and their clinical systems. That strategy is a great strategy. (note to readers — HCI’s September cover story will focus on the integration of biomedical devices and core clinical IT applications) Epic doesn't have, per se, medical devices, but they’re further ahead on the integration side. It’s still a tossup, but there are not seven out there that have full integration and full medical device integration out there. Right now, there’s probably three or four.
Biomed was nowhere near talking with IT a few years ago. Now there’s no discussion without biomed and IT together in terms of the devices. As the software and technology is taking that turn/that shift, I mean we’re almost involved in every single conversation that’s out there, and we’ve just aligned that with the right strategy and the right product going forward.
AG: So you think some of these niche application providers, like WellSoft and MedHost, do you see an environment where they are going to get snapped up by the big players to make their offering more holistic and attractive, although you did mention that just because you buy someone, it doesn't mean you’ve integrated them on the back end.
LF: I think there’ll always be a market for these products. You have small centers that focus on particularly, cardiology, ER services, urgent care, you have the cancer centers, so there’s a market for that. But I think, in general, the large hospitals are going to be looking for integration. I don't know how that’s going to play out by these companies, if they’ll be bought and integrated in or if they’ll just fall by the wayside.
BB: A lot are being bought right now. A lot of little companies, from the little PACS vendors, GE just acquired a couple of them, to middleware vendors. They’re being snatched up. It’s going to be a tough business model going forward.
AG: So we haven’t gotten to the point, and I guess you don't think we’ll get to the point, where integration engine providers make best of breed just as good as enterprise?
LF: Where we want to go, the vision that we have, which we think Epic would afford us and other companies are developing, costs a lot of money. When you look at the state of healthcare and you look at the size of many of the institutions, they just can’t afford to put that kind of money into IT. So I think there’ll be a continued market for interfaces and for niche systems.
BB: The number of niche systems is always increasing also. We have more interfaces today, and I think we’re still going to have the same with Epic, just the major ones are going to go away. As you said, with the big for big replacement, there are so may niche systems, we run 400 applications here. I think it’s not replacing 400 applications, but the major ones, it is. And we’re going to really see that tight integration. You have your clinical trial systems, you have all these other systems that are run, so HL7 and those integrations are not going away anytime soon.
AG: Are you getting down from 400 to a lower number with Epic?
BB: Consolidation, yes.
AG: Any idea roughly?
BB: We’re working out those numbers.
AG: Let’s go back to what you mentioned about the head of the ED, and how this person was able to understand what you were saying and compromise. Have you come up against other situations and could you give advice to other CIOs and CTOs that come up against an individual that’s not so amenable to reason; that sticks with a, “No, this is what I want, make it work because I’m bringing a lot of money into this hospital,” attitude?
LF: I don’t know if Ben is going to agree with me or not. We may see the world a little bit differently, but my experience here is that we've got some really dynamic, very colorful personalities, but the people really are very collaborative and they are team players. They do see the bigger picture. The people that I’ve worked with, particularly on this vision to move towards integration with the inpatient and outpatient community, they have been pretty agreeable to work with us. Would you agree with that, Ben?
BB: I do agree with that.
LF: The cancer center is a really great example. We have a world-class cancer center. We’re building a physical building; I don’t know if you saw the construction across the street, we’re building a five-story facility. It’s a dynamic group, and they have really wanted to have an EMR and practice management. They desperately need it, they’re a big practice. But they have been very, very willing to wait, work with us and partner with us so that they can be part of this vision, rather than going off on their own and doing their own thing.
AG: Ben, what are your thoughts on that?