Lutheran Medical Center (LMC) is part of Brooklyn, N.Y.-based Lutheran HealthCare, an organization which also includes the Lutheran Family Health Centers network and Lutheran Augustana Center for Extended Care & Rehabilitation. LMC is a 476-bed Level I Trauma Center providing ambulatory surgery, cardiac care, neuroscience services, obstetrics/gynecology, spinal surgery, perinatology (maternal/fetal medicine) and oncology (cancer diagnosis and treatment). Recently, HCI Editor-in-Chief Anthony Guerra had a chance to talk with CIO Steve Art about his facility’s plans to implement the VA’s VistA open-source software supported by MedSphere.
AG: Tell me how your open-source journey started.
SA: I’ve been here eight years now and when I first got here, we did a long-range information systems plan. When I write those things, I try to go out five years. The guy I replaced, his title was CIO, but he had never been CIO before; he had been an implementer, and the guy before him had actually been a salesman and became a CIO. So they had not done a lot of the infrastructure work that needed to get done in any hospital. So my first couple of years were spent building an infrastructure, and then laying on top of the infrastructure the different systems we needed.
I’ll give you an example. The first system we did here was a payroll system. We put in a payroll system in three months because the company that we had as our payroll company was sunsetting its product, and I walked into that. We really did a lot of fundamentals, building-block kind of systems. We had a McKesson STAR implementation that was half done and the operation guys were going crazy with it, and we had to finish it. There was a lot of that kind of catch-up work. The plan had in it that we were going to get all the way up to CPOE with the electronic medical record, barcode med administration, all the stuff that everyone is talking about now – that was in the plan. We built a pyramid – laid the different layers onto it, and when we got to top, we were going to have the electronic medical record.
AG: And that was eight years ago?
SA: We laid that out eight years ago. We knew that’s where we had to go. I told the boss when they hired me how much I thought this is going to cost because she was relatively new and she wanted to know. I said there is so much to do here that it’s going to cost you a lot of money, and you're going to either spend the money all at one time right now or you can spend the money over a number of years, and we’ll get to the same point either way, but it’s going to cost that much money.
I don’t remember the number of years right now, but that’s immaterial. It’s just going to cost whatever that number was. If it’s going to cost $50 million, it’s going to cost $50 million over four years or cost $50 million over one year, it depends on how fast you want to get there. So the sooner we can get the money in, the sooner we can do some of the things that we had laid out and prioritized – the IT steering committee would prioritize what had to get done first and what was most important. As the years went by, prioritizes changed somewhat, but our goal was always to get to this point.
The reason we needed to get physician order entry was for patient safety. That was the reason. We got to the point where we had most all of the other stuff on the pyramid done – we had an OR system, the lab system was in place, the pharmacy system was in place, all the ancillary departments, we got a PACS in place – we did all that preliminary work to get up to this point.
AG: Was this mostly a best-of-breed environment at this point?
SA: We did mostly best of breed, although we were a McKesson shop. McKesson had an opportunity to bid on everything that we did. They, for some reason, never could beat the price of the best-of-breed guys. Now, we didn’t do best of breed in terms of the most expensive vendor. We did best of breed in terms of the one who had a good product that we could buy and we could afford.
We ended up with AMICAS PACS. Of all the PACS vendors out there, AMICAS at that point was not the most expensive PACS and it was a relatively new player in the market. We bought them and they were giving us some great deals. They beat out the company that McKesson ultimately bought. It ended up being the two of them and AMICAS beat their price. We weren’t best of breed in the sense that we were buying the most expensive systems. I don’t want to mislead you. We were doing best of breed in terms in the sense that we did not drink the McKesson Kool-Aid.
AG: So would you say that you picked products from different vendors based on your needs and then you decided that you would deal with interfaces and integration work afterwards?
SA: Correct. We have our own interface group here, so we write our own interfaces and I prefer not to develop software, just as a principle, but we do build our own interfaces. So doing interfaces was not horrible for us and that was the route we took. But best of breed implies you're buying the most expensive product or the top one of the market. It wasn’t a Cadillac. I was buying Chevy, but I was making it work.
AG: I understand what you’re saying.
SA: After that, the emergency room was a big system we had to put in, and the PACS had been a big system. Once we put those two in, we were now at the point where we were ready to start looking for something more. Because basically, the ED system had in it all the components of the electronic medical record. We were ordering online. We were seeing results online. We were documenting online. According to our vendor, I think we were the 44th hospital in the country to come up with their electronic medical record in ED.
AG: Who are using in the ED?
SA: The company is called ECDS out of Illinois, and the name of the product is EMpoweR. That product was really working in the ED.
I realized, at some point in time, that as we started talking about electronic medical records, we were all talking about different subjects. You talk to the COO, CEO, CMO, CIO, anybody – we all had a different view of what it is and most people think it is what it was in the last place they worked. So somehow, we had to come together as a group. What I did is I brought in three or four vendors to actually give us a demonstration. They understood that we were just kicking the tires, but everybody at that point was willing to show it to us. We brought in a couple of vendors to show us what they had for what they called an electronic medical record or CPOE. It was really eye opening because we finally got a common language to talk about this stuff. Everybody came to understand that no two systems looked exactly the same, but they all do pretty much the same thing.
AG: You said you essentially found yourself having an EMR for the ED. Do you think that’s a situation that happens at hospitals where all of a sudden they have these little pocket EMRs in different units? Do you still need an enterprise core EMR when you have pocket EMRs?
SA: That’s actually a good point. Let me take it back a minute to the beginning of the conversation. When I got here, this place was full of what I call fiefdoms. Radiology ran their system. Laboratory ran their system. Pharmacy ran their system. Because of my predecessors, and I blame them frankly for this, they let each individual department have their own say about the systems and, frankly, the vendors were still trying to sell to the individual departments because the vendors have a much easier time selling to the radiologist than they do selling to the IT guys.
So early on I had to break down some of those fiefdoms and break down the walls so they started sharing data. The pharmacy system, for instance, didn’t have an ADT feed. So they were entering new patients by hand into the pharmacy system every day. That was stupid. Just plain stupid.
So we built them an ADT interface. Over time, I got their trust and I was able to break down a lot of those walls. But you’re correct, the systems grew up in different places because they had different issues or different requirements at the time that were unique to their department, but we’ve tried to incorporate them into the whole system.
Now, in the case of the emergency department, our emergency department was growing really rapidly. In the paper model, we couldn’t handle the volume we were getting, so we had to do something. That’s where we chose to spend some of our money. So there, even though long range, we were going to do an EMR, it was important in the short range to have a system for the ED. Now, in the end, I’m going to end up converting that to become the real EMR that’s going to be used in the ED also. So I’m going to replace that system ultimately when I get my EMR up. I will replace it.