Inova Health System is a not-for-profit healthcare system based in Northern Virginia that consists of hospitals, emergency and urgent care centers, home care, nursing homes, mental health and blood donor services, and wellness classes. With such a plethora of offerings, it’s no wonder Senior VP and CIO Geoff Brown wanted to tie some of the pieces together. In fact, Brown recently contracted with GE to offer the vendor’s ambulatory EMR to local physician practices. Brown, who says Inova will take advantage of Stark relaxations to underwrite the costs, recently talked with HCI Editor-in-Chief Anthony Guerra about his plans for the future.
Inova Health System Key Stats:
Licensed hospital beds 1,725
Licensed nursing home beds 377
Hospital admissions 100,946
Total surgeries 79,886
Emergency room visits (includes Inova HealthPlex and emergency care facilities) 391,611
Home health care visits 103,417
Physicians practicing at Inova facilities 2,991
— Source: Inova Health System Web Site (www.inova.org)
AG: Let’s start with the GE deal. At the end of February, I saw it announced that you were going to offer the Centricity Ambulatory EMR from GE to the practices in your area that refer patients to the hospital?
GB: That’s correct.
AG: Let’s start at the beginning with that whole process. Were you waiting for the regulations to play out and the IRS to clarify things?
GB: Our journey really started probably a year or so before that. Our percentages pretty much tracked the national trend just over double digits and we were just starting to invest in EMRs. So we actually formed a partnership with a third-party organization that allowed us to interface those practices that had EMRs, which exchanged electronic information that was previously faxed or reports that were sent out either electronically, mailed, or patients carried them around, for example: radiology reports, laboratory results, and information.
Also we went around with imaging; we’ve got a PACS solution we implemented during that time and also medications. And so, as a result, our original plan was based around, if physician practices invested in EMRs, we wanted to exchange information with those practices. That was a small group of folks that was starting to become mature in it. Some of them were just starting up, others had been online with the middle size and larger practices, and some smaller practices had been online a couple of years. We’re experienced working with that solution set; and now this was a level of efficiency that we could add to their day; particularly those that did a fair amount of business with Inova. That was the original vision goal, coming up with a strategy on the ambulatory-care side of the world, and the outpatient side of the world and to link those practices into our system.
AG: When was that, approximately?
GB: That was in 2006. We went online with that, and we used a relationship with a firm called Novo that helped make that happen, and that has gone on well. We have several practices that we exchange data with electronically. Then the relaxation of the Stark guidelines began, that was actually in late ’06, early ’07, if I’m not mistaken. So that conversation went on, but it was for the first time that there had been an opportunity for healthcare systems to, in any way, underwrite, subsidize, or participate actively in connecting the community.
Again, one of the talks I did with our governor’s group was about the mandate from President Bush at the time, that all the facilities, all the physician practices, and all the clinics will be moving in that direction. We were all focusing on this whole thing called CCHIT certification, with educational sessions that both use internal physician committees and external community committees and educate them about what was happening at the national level, and talking about some of the local work that was being done. In fact, some of those sessions were for qualified medical education credits. So when they attended these things, they were able to get educated about EMRs. ‘What is it, and how do I prepare, what do you have to do to be ready, who were the primary vendors in that market,’ all those kinds of things.
We actually surveyed our physician community and shared with them the results of those surveys, for instance, the top five vendors to have made traction here in northern Virginia around EMR solutions. What timelines people were expected to come online, what were some of the factors that were driving it from their perspective, challenges, etc. It was a very good exercise and that all played out through late ’06, early ’07. When I say late, I mean to say second half of ’06 and early ’07.
And then there was a period of time where we began to prepare for that with the business plan and those types of things. But we were waiting on the final ruling on the regulatory side, and we were also waiting on clarification from our reps around how that would be treated. We had our legal team involved and others, to get an opinion, and significant research occurred out of Novo, just as it has all around the country, around our interpretations of what can be done and what couldn’t be done, and the right approaches around it.
So we did that, developed a business plan around how we would proceed so that we could communicate and document our approach and assumptions around it, so that if anybody were to ask about it, clearly we could justify to the IRS or to the CMS folks around anything we did. But again, we were consulting with other organizations, as well as the legal interpretation folks, and we were able to come to a conclusion. So we made an announcement and I guess everything was finalized, I want to say in September or October, around the guidelines last year, for everyone.
We began in all earnestness to go out to the market and look at solutions and make our selection process and we chose GE in this market, primarily because there were several test systems locally here that had gone with the product. I don’t know if you know much about the Centricity EMR solution, but it was probably the widest used application in this region by physician practices and several health systems at the time. We ended up having some of those folks come in and speak to our medical staff as we were doing demonstrations back in August of last year.
And some of the folks down south, I want to say Carilion, and I’ve got a run list, Bons Secours, and up in the region here in the Maryland area, if you really want to look at total physicians online with the product, they have more than anyone except Kaiser. I don’t know if you know that at Inova, we have close to 3,000 physicians connected that work in our facilities and many of them are two, three, four, or five physician practices.
We have some large ones as well, but Kaiser is probably the number one player in that market, but they don’t sell to small practices and our community physicians make up most of our medical staff. So we are looking at 90 percent of our physician relationships being community based. We do have our own practice for the other 10 percent staff physicians that are part of the Inova system.
So, again, as it relates to that, we have a slightly different model where we weren’t able to say, ‘Okay, we can force decisions around the best selection process.’ We had to establish a standard for Inova. Our strategy was simple: we wanted to have a high-end offering that would be widely used and, again, the GE solution is number one amongst independent, smaller/midsize practices in the country. Number two overall, and it was widely dispersed with, I think, over 20,000 physicians within this region and the Southeast. So we felt very comfortable with that decision.
Also, our inpatient clinical information system is GE’s Centricity Enterprise. The whole process was that we would offer a solution that we could subsidize and make it attractive for our community physicians to use, but we would also make provisions, if they selected other applications — like Allscripts, Misys, eClinical, or some of the others that were in the market — that they could interface with us.
The good news for them is that if they selected GE, most of the interfaces would be done and would be part of the offering; whereas if they bought a separate EMR, we would work with them, but they would obviously have to cover most of the costs of the interfacing on their vendor side. We would subsidize up to 50 percent of the cost with a cap, and we have a cap on, but we would, to promote efficiency, look at the community patient relationship. Inova was spending and committed to several million dollars to get the community connected for all the benefits that you already know about.
AG: Let me ask you another question to make sure I have it straight. Currently, if they selected GE Centricity product, you subsidize 85 percent which is the max under Stark …
GB: I don’t want to give you a percent that we subsidize, but we made it so significant that we were offering to them at well under 50 percent below what they would have been able to do on their own. I won’t give you the exact percentage for publication, but I will tell you we are subsidizing it significantly. And the value proposition is we’re doing so at well below … that’s the whole bundle of implementation. Not only will that cover just the licensing and all that, but it covers helpdesk maintenance. We are actually the first system in the country that will be doing this as a remote application.
AG: What do you mean by that? It’s an ASP model?
GB: It is an ASP hosted solution, but we actually have a first-level helpdesk solution set. Currently, what happens with that particular product is if you own a GE Centricity product, they typically also sell through partnership relationships. So you’re always getting a pass through and not always getting an opportunity to dial directly into a GE supported helpdesk, and that has a variety of challenges for small practices and other practices that just didn’t have the clout to get into a better support workflow with more knowledgeable people at the initial call. So, again, it’s an enhanced helpdesk.
This is how we use it. It covers a variety of products, including the document scanning solution sets that will allow people to automate their existing records. For example, say I wanted to put in two years of my current records. It brings me the tools to facilitate that happening. It also covers product management, giving you a readiness assessment. There were several factors enabling this so that a physician could come and have the resources around, and for a monthly fee, get wrapped up in an average implementation that was accelerated to occur in a 12 week period of time, instead of what was, traditionally, a six-month process.
Again, we actually brought all of those things to bear and they didn’t have to put out any capital. There’s the monthly fee, and there is a series of bundled solutions put together to make that work.
AG: A number of CIOs have decided to only offer one EMR product to their associated practices. How would you describe your position on that?
GB: Our choice is Centricity. If you buy something else, you’re on your own. But we are doing a Plan B to that. We have agreed to subsidize up to 50 percent of the interface cost for them to link electronically with us, with a cap. I can tell you there is a cap of $8,000. So what that means, so that you’re clear, let’s say that that a practice already has an EMR or they’ve made a selection to go in a different direction, with a different product, say Allscripts, we would actually subsidize the cost of them working with Allscripts, working with us to interface the Inova Health System into their EMR, up to $8,000.
AG: Will interfacing all these products into your GE inpatient system open you up to a lot of complications down the road?
GB: It will not for me because I only have one EMR. My EMR is GE Centricity. That’s what I’m offering up. If somebody picks something else, in order to entice them, we will help get them moving in a direction that we believe is the right thing for the community. We’re willing to contribute, based on the new Stark guidelines, up to 50 percent of $8,000, or 50 percent of the cost they incur working with their vendor, to interface with the Inova Health System. The goal for us is to get the community connected electronically.
We want to offer a primary solution, because that’s what we heard when we surveyed our physicians — most practices don’t want to bring vendors in and go through picking, they want Inova to help come up with a standard — so we came up with a standard that integrates very well with our core clinical information system. But we realized that of the 3,000 practices here — clinicians that work here and the couple thousand other practices — one size doesn’t fit all. So we do have one system, and that’s GE’s Centricity Enterprise, but we decided that, if you didn’t have the GE application, we still wanted to work with you for electronic exchange of information.
We believe that is to the benefit of patients and physicians and will eliminate waste as well. Our goal for doing this was really more based on quality, safety, and community benefits.
AG: How have you structured the division of responsibilities in terms of the actual selection and implementation among Inova, the practice and GE (or another vendor)?
GB: We’re the only health system with GE, I mean the only health system with GE that offers the ASP. We actually have an exclusive here in Northern Virginia space for four years. So we developed a contract that we signed. First of all, they would commit to the financials, we review that with them, we give them a contract that we negotiated with GE that blows away anything that any individual practice can do because we can commit to the larger number of licenses, and commit to the revenue streams upfront. So we were able to get a very attractive offering.
The process starts with education; announcement about it, demonstrations about it. People then signed up and say, ‘I’m interested in learning more.’ I have a team of people that were already supporting the physicians around, if you will, mobile technology. We have a relationship with MercuryMD MData. We did a charge capture online as they round, if they’ve got WiFi capability or broadband of any type, they can get up and use their PDA, their mobile device, to check anything from their bedroom if they want to. We’ve got that process in place. So we developed an add-on support team to begin representing this process. We signed a contract with GE and their project management team directly to do the first 20 implementations together, and then our team takes it from there. But before, we want to make sure that we offer a good quality front-end process with them.
That was the way we did it. Then there was a contract, they have to review it, they have to make sure they could accept the terms around it, and we then sent a team out to do a randomness assessment. Part of that is to actually educate the partners in the practice around what the commitment will be, and the scope of hours. Then they choose to use it however they want, but here are the timelines and we lay out what we’re asking them to do.
After, we get it implemented online, we have some people here that will be knowledgeable about templates that can lead to some pass through, but they’ll actually have a direct number to the GE helpdesk. And we have some tools that we’re working with GE on to do first-level troubleshooting around infrastructure, so that the users only have one call. The clinical content experts and the application content experts will be at the GE helpdesk and we’ll have a secondary group of folks that have relationships with these practices already. They can deal with some of the underlying problems, but if there’s a problem at the practice, they’ll call one number and that number would be able to facilitate resolution.
That’s not something that’s been traditionally offered at any quality level. We believe that it’s going to be very attractive for the physician community here.
AG: How many docs do you have up and running fully integrated? Any yet?
GB: We just made the announcement. We have about 35 practices that are going through the next startup, and we’re picking five that we start up with here in the next 30 days.
AG: What would be your advice to peers? You’ve obviously been pretty aggressive, probably not the first, but I would say in the first group of health systems that are moving aggressively to roll this out. What lessons learned could you offer up?
GB: My lessons learned were that we were originally thinking about one solution, but if you’re a very large health system, you probably need to consider a good strategy around some secondary groups of options. It’s true that you want to have a primary offering, I couldn’t believe the complexity of offering two.
The second thing is that we are negotiating right now with what I consider to be an EMR-light solution. So for those practices that are not ready to take that deep dive into a fully loaded EMR, we’ll have a low-end entry into the process as well; one that really allows them to exchange information electronically, but not necessarily to automate their practice.
In the end, you start to get exposed to technology adoption, and then prepare to move to a more advanced stage with a fully loaded EMR. So you are able to capture the low end of the market, this solution is for those practices that really do need to move some of their formal management from the practice management into a formal clinical workflow structure with an EMR, but just don’t have the capital to make that call. Or they’re just not sophisticated enough right now to understand how to move forward.
So I would have a dual strategy, and a dual strategy to catch those that are mature, or that have been up and online for a couple of years. Those folks are ready, they researched the market, they understand the value proposition very strongly. When you’re getting people inducted for the first time, that is a significant education curve. I would have done actually more preparation on that end, on the education side, for those practices that did know they wanted it, and do more funding in there to get people lined up.
Right now, our pipeline is full enough for us to make it, but it would have been even fuller had we had a low-end offering and a high-end offering. We went with the high-end offering, which is the GE Centricity product, which competes internationally in the marketplace as the number two player out there. When I say number two, I like to talk in terms of physicians online, or clinicians using the product. So I talk in those terms.
Then the third area that I would say, would be before you launch communication about it, have it locked up because, I would say, once you get into it, you need to anticipate all the interest that comes in. We were inundated with people that were window shopping, versus people that were qualified buyers. One of the things I would have done was to put more of a qualifying process in place up front, so that we didn’t waste some of the hours of time with the window shoppers, just as a part of launching it.
So those would be the two strategies, in particular: have an introductory offering and then have one for the more advanced user. I would say that’s a lessons learned. We’re fixing that, and I think in the next 30 days or so, we’re going to actually go back out with a new announcement around a low-end tool — it’s not really a full EMR with all the clinical alerts and evidence-based practice built into it and those kind of things, but it really would allow them to begin to get their documents used in the office and online. It doesn’t change their workflow, but it gets them used to the dual process with the computer in place and, as they register patients, as they populate information about that patient, then they can begin to move towards an electronic capability. It will allow for immediate communication of test results, and it takes some of the delays out of the health system processes that occur based on manual paper and those kinds of things.
So those practices have to have that: some get faxes, some get mail, and some people have their patients bring their information from their visits. We’ll certainly increase the throughput pipeline in northern Virginia with every single practice we get exchanging information electronically.
I don’t know what some of the other CIO’s goals are, but my goal, the end goal was not vendor specific, it was really to get our community connected, and accelerating that process. The goal is, obviously, efficiency of faster response in our interactions and interfaces with patients. Getting information to the providers occurs in a much faster rate when you’re electronic. Then you have the cost side of it — wasted tests because information is not readily available to the clinician, so they have to order it because of our liability system.
So, there are a number of components to this, but those are the key things for us, and we believe that bringing in that level of efficiency and adoption, we have a fairly large concentrated area here in northern Virginia that we ought to provide a choice for. Upward of 50 to 60 percent of the community that we provide services for, that will be a huge benefit for citizens here in northern Virginia. In our cross states, we really will have a critical mass, and here’s an interesting thing: you would think that more people actually get their clinical work done through hospitals, but the truth is the largest source of information collection and service occurs at individual physician practices. That subgroup will be a very large new group introduced into this world, and it really started back with the Clinton/Bush/Newt Gingrich work and then Mike Leavitt appointed Dr. Brailer, who has now been replaced by a Dr. Kolodner. But the real work started a few years ago with some of the standards work that you heard about and it started to bring that into fruition.
Everything that is happening in northern Virginia, and I don’t know what it was like for Partners (Boston). But, I’m on the board for our northern Virginia RHIO, and we have a local RHIO initiative going on as well here, and we’re seeing if we can get granted some state funds around a pilot with the senior community here in northern Virginia called the Greenspring, a retirement community. They have health services on site, and when they have a very acute situation, they refer those patients into the Inova Health System. The community is wired in and they have an EMR as well. That pilot is being proofed out. So I think people have brought it to the model here and it’s been recognized, even at the state level, the work that we’re doing around this.
That’s really my mission. And I think our organization’s mission is really more around how we can leverage the Inova relationship in a way that makes us an attractive place for physicians to practice in, one that is safer and more consumer-friendly for the patients that plug in and out, and the physicians that refer in and out to our facilities across the state. So, that’s where we are and it’s been a very, very good experience up to this point.