Maimonides Medical Center is among the largest independent teaching hospitals in the nation, training over 450 medical and surgical residents annually. Widely recognized for its major achievements in medical technology and patient safety, Maimonides has 705 beds and over 70 subspecialty programs. Recently, HCI Editor-in-Chief Anthony Guerra had a chance to talk with CIO Walter Fahey about his long list of projects, and what it takes to be an effective CIO in today’s HITECH-fueled world.
GUERRA: Tell me about your main projects.
FAHEY: We’re upgrading our infrastructure with Verizon as we speak, both wired and wirelessly. We’re actually upgrading our PeopleSoft financials to the current version, and it’s a full suite of products. We are currently upgrading our clinical application from the Eclipsys e7000 to Sunrise Clinical Manager. We just completed an upgrade to a single radiology platform which is a Siemens product for RIS. We are in the process of installing all new cardiac monitors throughout the entire enterprise that actually run over the hospital enterprise network. And the list goes on; how much more do you want?
GUERRA: So essentially, you’re working what … 10 to 4?
FAHEY: Yes. (laughing)
GUERRA: Explain the thinking behind the infrastructure upgrade, how much of an upgrade did you need and how did you decide on that? Is there a cost/benefit equation? Is it just a matter of envisioning how many more applications are going to be running on the network? What’s the strategy behind an infrastructure upgrade?
FAHEY: It’s a combination of all of the above. The equipment itself was reaching end of life. We were running an APM backbone which is really not supported anymore. We needed to get to a gigabit infrastructure. We have 128 closets we deliver technology from. So in doing that, we had to look at how our infrastructure was handled. We basically run some redundancy in different areas because we want fault tolerance, even though all the Cisco gear comes as a health grade network these days.
It really is the intent of the organization to have as much power as possible. So we have duplicate switches in some areas, we have duplicate core routers, things of that nature. So we have fail over in case one side goes down for some reason. We provide pretty good up time. We’re probably in the 99.999 percentile with our up time for the infrastructure. And we need to do that.
I mean if you look at us organizationally, we run everything over the enterprise infrastructure. So we have all the clinical applications, we have the OR applications on it. We are going live with an anesthesia application in October. We’re doing some parallel testing next month. We’re actually taking feeds from our monitors, and we will be putting that into electronic records. So all that runs over the enterprise. So we needed the bandwidth to be able to handle that capacity. We didn’t want to run a duplicate infrastructure for all the new cardiac monitors, and we have well over 400 monitor beds within the hospital itself. So we ran that over the enterprise infrastructure as well.
From a wireless perspective, we did some work to expand out all the technology, to handle the biomedical bands as well as 802.11. We did find some conflicts between Bluetooth and 802.11 which is a known problem – the Bluetooth actually floods the channels and can cut off some of the wireless devices. Also, in some of the areas we had microwave ovens that weren’t shielded; that actually caused interference as well, so we had to make sure all the microwaves were shielded in all the areas. Outside interferences have to be dealt with, and when you’re in a city with a population of 2.5 million people, there are a lot of areas that have interference. We have a train down the street that’s above ground, you get a lot of different devices and electronics that actually can cause interference within a wireless network. So we’ve probably put more wired capacity in rather than wireless just because of the interference issues from outside.
GUERRA: Are the application upgrades being driven by HITECH?
FAHEY: We actually started before HITECH. We’ve had electronic records for the inpatient side of the house and ambulatory well before HITECH was even thought of. We’re now actually going to the latest generation of technology. So, for instance, with NextGen we just converted the system. We bought it in 2000 and we just converted it from their standard system to their knowledge-based management system. So that was a major upgrade that took several years to convert all the data over.
With the inpatient side of the house, we’re doing all the order entry result reporting. We never did full documentation in the e7000 products. So we’re expanding that now, and that was part of the goal from the onset. We did change some of our philosophy and timelines to meet the meaningful use criteria that was announced in August of this year. So we’re really trying to work well with what’s being developed from the outside and mesh that with our vision of a good clinical record on the inside.
GUERRA: You’re using NextGen for the ambulatory practices?
FAHEY: Yes and primary care. We haven’t rolled it out yet throughout primary care and in psychiatry, but we’re going to start this year. One of the reasons we wanted to go to KBM (Knowledge-Based Management) was they had developed a significant amount of specialty knowledge, so we wanted to take advantage of what they have developed rather than build it from scratch. So we’re going to use the 80/20 rule with developing software. If it meets 80 percent of their need, they’ll use the system as it is, and then we’ll visit back once they’ve really have some experience with the system a year later to see if we need to do some customization to better meet their needs and better serve the physicians.
GUERRA: When you talk about rolling out NextGen, you’re talking about the owned practices?
FAHEY: We’re talking about the hospital-paid physician, the clinics, and in the faculty practices.
GUERRA: Do you have any strategy around the independents? Do you have any strategy of advising them, working with them, helping them implement, integrating them?
FAHEY: We’re looking at that. We have some ideas as to where we want to go with that whole thing. Unfortunately, healthcare is not as robust a financial cow as people think it is. There are a lot of hospitals losing money right now. So how can you take money that you don’t have and try and help the physicians that are in your immediate area? This year has been a very tough year; we’ll be lucky if we break even.
So financially, it would be nice to help them. What we’re actually doing is looking at other ways to get the technology to the doctors at a cost-effective rate. So we’re negotiating with NextGen and Eclipsys and others for volume purchasing agreements that will allow us to discount EMRs for the physicians, but they’re going to have to pay for it. And then we’re looking at possibly running an ASP model in which they would pay for the services.
GUERRA: Could that turn into real revenue for the hospital?
FAHEY: We would do it as a separate for-profit company because we can’t dilute the business itself. The hospital is a not-for-profit, so you have to be careful. Stark goes away in 2013 (until which time you can help physicians). We don’t know what the laws will be going down the road. It’s taking a long time to actually have clarity as to what meaningful use is. It’s been determined to a point, but I believe the official announcement is going to be in December of this year. You don’t know how the government is going to change things. We’re in times where it’s hard to determine exactly where everything is going to fit. So I think you have to stay flexible and be willing to look at different scenarios and create different models that will meet their needs, as well as determining what the organization can afford.
GUERRA: And being a nonprofit, sometimes you have to wait six months or a year before the IRS gives you clarity around something CMS has done.
FAHEY: That’s correct.
GUERRA: That can even extend things out further.
FAHEY: Yes, and that’s one of the conflicts with the Stark laws right now: what’s the IRS determination, is that taxable, do they have to look at it as income? There’s a lot of things on our plate right now that are really not clear.
GUERRA: You mentioned the Eclipsys upgrade; sometimes upgrading even within a vendor is just as painful as switching from one vendor to another, is that an accurate statement? And what is the situation with the particular Eclipsys upgrade you’re doing now? Is it a large painful one or is it a minor one?
FAHEY: I wouldn’t say it’s a large painful one, it’s a new install. With the new install, we’re looking at new technology and the benefits of the technology. It is building the system from scratch. We had taken the e7000 system and we had really done a lot of customization and used it to its maximum. Any technology that Maimonides purchases, we look to use every piece of it. If the vendor says it can do something, we’re going to use it. We’ve taken full advantage of all the applications within the technology and then we expand upon what we can do.
It is a completely new install. As I said, we didn’t have documentation. We’re actually building documentation for the physicians and for the nurses with automation. We will be taking the monitored information and electronically feeding it into the record, so that will be of some benefit to the nurses. There are a lot of new enhancements that we’re actually installing, and we have a very good team of people working with us. We have several physicians working with us. My team itself is one-third clinical. I have nurses, physicians, radiology techs, three pharmacists on my team, lab techs and other technology people on my staff that do medical informatics, and they all enjoy it. So, it’s interesting.
It’s about peer-to-peer communications and the ability to work together. They know how the hospital is run. A lot of the staff is homegrown. We’ve developed a lot of the people out of Maimonides into areas they wanted to grow, we’ve given them the opportunity to focus on what they were interested in.
GUERRA: So upgrading is definitely not something you do for fun; there has to be an extremely compelling reason to do it because you lose all the customization you had in the previous version. Is that fair?
FAHEY: It’s actually starting over completely, it’s not even tweaking. It’s actually building a whole new enterprise system. We’re going from a mainframe technology to a server-based technology, and it is totally different. You have more compelling issues with med-reconciliation and how you do your medication management, it has much more advanced functionality that you’re looking at within the applications because, over time, these companies have developed a lot of new technology, so the enhancements are tremendous. There’s a lot of benefit to actually going to a newer version of a system or a new application, but it’s a lot of work.
Part II Coming Soon