At the end of September, 13-hospital North Shore-Long Island Jewish Health System announced it was subsidizing up to 85 percent of the cost of implementing Allscripts ambulatory EHR in the offices of its more than 7,000 affiliated physicians, constituting a $400 million investment. Specifically, the plan calls for North Shore-LIJ to provide physicians with individual subsidies of up to $40,000 over five years. To learn more about the project, HCI Editor-in-Chief Anthony Guerra recently talked with CIO John Bosco about the strategy behind this massive tactical move. (Read a related interview with Allscripts CEO Glen Tullman)
GUERRA: You’ve signed quite an interesting deal.
BOSCO: Yes, it is. A few weeks ago we had our first, of what I’ve been calling, community forums. We had it in a catering hall, and we brought together a bunch of community physicians. I think 50 or 60 of them made it, and we’re going to be doing this twice a week for the next few months. At the first one, there was a lot of excitement and a lot of interest. There were good questions, so it was very positive.
GUERRA: What’s are your goals for these meetings?
BOSCO: There were three main things that we spoke to. The first was – and these are our credentialed physicians, voluntary physicians, the ones who could participate in this program – to educate them about the program itself and the vision for the program, so that they could understand what we’re trying to accomplish and why.
Secondly, for them to actually see a demonstration of the Allscripts system, and so we had Allscripts there and they actually walked through a lot of those screens and did some workflows based on sample patients. And then in the middle of those things, we actually give them a little bit of information in a few slides about HITECH and meaningful use. That was productive also because we’re finding it really runs the gamut as to physicians’ awareness and knowledge about the incentives and the stimulus act. So I was surprised. I had two quick slides. I was going to race through them, and I think we wound up spending about 15 minutes talking just about the incentives and meaningful use and certification and all these concepts. So they seemed very engaged.
GUERRA: Were you pleased with the turnout?
BOSCO: I think it was good. A few weeks ago we already had almost 400 docs that had registered for one of the forums. So considering that we only went to press a few weeks ago, we thought that was a really good sign. We were doing this twice a week in our various communities around our hospitals and different locations. You know, 400 in a week is a good number; 50, 60 a night I think is a good crowd.
GUERRA: Four hundred is a good number, but it’s quite a way from 7,000 which was the number of licenses in the deal. How do you plan to extend your outreach?
BOSCO: Since they are credentialed physicians and we have essential credentialing system that we use to establish and maintain their credentials, we have all of their names and addresses and fax numbers and email addresses and everything. So we have actually multiple marketing tools that we are using, and we’re intending to scale them as needed.
Initially, the focus is just to drive physicians to one of these forums – I think we’re calling them, “Program Information Sessions and Demonstrations” – so that they can get more information and see a demo. So we’ve started off with just some correspondence from our CEO, and then Allscripts and our marketing departments, to drive them to the Web site to register. We have a new Web site that we put up and a new hotline number for the initiative. We can escalate that all the way to a team of full time dedicated salespeople that are both from Allscripts and Henry Schein (one of the partners in the deal). So we’re gauging what the response is and what tools are best for getting their attention.
GUERRA: It’s always fascinating when you have to convince people to let you buy them something, isn’t it?
BOSCO: You know it really is. A few weeks ago was the first community forum, but we’ve already done at least 50 or 60 demos, I would say, because we first had to do all of these to our own internal committees and medical executive committees and medical staff societies and all the various groups that are internal to us. We did that to make sure that within our own health system, all of our physician leadership and others are aware of what we’re doing. We’ve also identified, and we have a phase for, early champions, so we’ve been running around doing demos for them also.
We’ve been pretty good at predicting what the big questions are going to be, but it’s interesting to see that they’re waiting for us to tell them what the trick is. And at one point, when we got to the end and I did some closing remarks, I had a slide up that said, “Why choose the NS-LIJ program,” and then one of the bullets said because you’d have the backing of the major health system that can demonstrate a proven and replicable process. I said, “You know guys, there’s no trick here. There’s no hidden meaning, there’s nothing that you need to be trying to figure out.”
But they come in with a certain level of suspicion, wondering, “What’s really going on here that I’m not catching yet,” but I think by the time it was over, we did a pretty good job of making them understand what it’s all about.
GUERRA: What were the major concerns?
BOSCO: Data ownership and data access I think is the big one. They want to understand what data we will have access to, do we own the data, can we do anything we want with it, can we send it to payers, can we use it to judge their productivity or judge them against their peers or all of these different things. And I really think that was a big question, and we’ve specifically designed this whole program in a way that we are removed from their relationship with Allscripts.
So the way our program is set up is that they are contracting, not with us, but with Allscripts and Allscripts is selling directly to them the licensing and implementation support, hosting, ongoing support, the whole deal. They’re getting all of that from Allscripts. Our involvement, as far as the physician is concerned, is that they are signing a subsidy agreement with us, and they are agreeing to the exchange of clinical information between patient care settings electronically and between EMRs, between our acute care setting and emergency department setting and various EMRs that are part of this initiative.
In one of the two models they’re also agreeing to share automated performance data but, other than those things, their relationship is with Allscripts, and we’re removed from that. Allscripts is the custodian of the data and the holder of the data. We explicitly don’t have any access to it or any ownership of it, and we point them to the subsidy agreement which specifically says those things.
So we knew data ownership was going to be a big issue, and we’re trying really hard – right out of the gate – to dispel any notion that this is some kind of a, “Big Brother is going to be looking over them and judging them and having access to all of their data,” thing.
GUERRA: You’re offering them a 50 percent subsidy if they don’t agree to share performance data and 85 percent if they do. Can you talk more about that?
BOSCO: Sure. The two programs are exactly the same with the exception of what you just said, but in both of the programs, what we’re calling the Connected Model and the Integrated Model, the physician agrees they will allow for the electronic exchange of clinical data for patient treatment purposes only between the EMRs that are part of these initiatives, and also through our local RHIO.
And so we’re just saying to them that only for the purposes of treating the patients, for example, when a patient shows up in our ED, we will pull any information that’s available from the office EMR so that we can understand more about the patient. We’ll also move data to the practice when their patient is discharged from the hospital. We’ll push a discharge plan and a discharge summary out to the primary care physician.
Now, in the Integrated Model, they agreed to participate in the development or the refinement of clinical practice parameters or care guides that are built into the Allscripts system. We are trying in a very collaborative way to allow them to come in and meet with the people who are going to be tweaking these things. Right now, we’re focusing on six or seven of the major chronic diseases, and we’re reviewing those care guides in the Allscripts system and, as necessary, tweaking them a little bit. We haven’t really even done that yet because the care guides that are in there are based on nationally recognized standards and NQF.
And so what the Integrated Model says is you can participate in the management of these care guides, you’ll follow the care guides and, on a monthly basis, you’re willing to report back to us your performance data anonymized – we don’t care about patient identities – but you agree to report that quality data to us so we can use it in the aggregate to measure the impact that we are having on the population health. That gets you the 85 percent subsidy.
GUERRA: Are you getting a sense of whether they’re generally inclining towards the 85 percent or 50 percent?
BOSCO: They are, for the most part, inclined toward the 85 percent, as we get them comfortable with the data we’ll have access to and how it will be used. I think there are some who just think it’s worth the money. There are some who want to participate in everything that we’re hoping to accomplish, and they believe in the greater good of that. I can’t really tell offhand how many are all about the money or how many are more altruistic than that, but most of them are leaning toward the 85 percent.
GUERRA: When we’re talking about pulling in the ambulatory data, how do you pull data that’s hosted with Allscripts or at the practice?
BOSCO: We are working with Allscripts to create that level of integration and, in fact, they have software called Connect which has that ability. That software had been out for a year or two. It’s not fully matured yet, but we do know of at least one other local health system that’s already doing exactly that, pulling in information from the office EMR. And that was actually one of the things we liked about the Allscripts solution because we, several months ago, purchased their emergency department information system. And so we are rolling out the Allscripts ED system into 10 or 11 of our EDs, so having the same product or the same vendor in our ambulatory EHR space, we really believe will be an advantage to us in terms of integration.
GUERRA: Can the practices host the data themselves?
BOSCO: The way we’ve built the program, the way we’re building the infrastructure, the pricing that we’ve been able to come up with is, in some part, based on the economies of scale that we get by them all being centrally hosted in a common infrastructure. And so right now, it’s an ASP only model, with Allscripts hosting the data.
GUERRA: Why might an ASP model not be attractive for very large practices?
BOSCO: I don’t know if it’s not as attractive. I think that practices can get up to a certain size – and we haven’t made these decisions yet – where the performance of the system could be more of a challenge in an ASP model. As they’re scanning documents and depending on the resolution that they’re scanning at, it can start to make a difference whether they’re going over the Internet to store and retrieve those documents or whether that server is hosted locally on site. Right now, we haven’t been talking to practices large enough for that to be a concern.