Alan Aviles is president and CEO of the New York City Health and Hospitals Corporation (HHC), the largest municipal healthcare system in the nation. The $6 billion New York-based corporation includes 11 acute care facilities, four nursing homes, six large diagnostic and treatment centers, more than 80 community-based clinics, a large home care agency, and a Medicaid managed care plan with more than 300,000 enrollees. Early EMR adopters, HHC won HIMSS Davies Awards in 2002 and 2006, and Aviles was awarded the HIMSS CEO IT Achievement Award. Healthcare Informatics Senior Editor Daphne Lawrence spoke with Aviles about the importance he places on an EMR in his organization, and the challenges of managing such a large system.
DL: I don't usually interview CEOs for HCI, but many people call you an IT visionary. Where did that vision come from?
AA: I've been with HHC for a little over 12 years. When I came into the system, it was on the managed care side at Elmhurst Hospital. And within a short period of time I became a more senior manager responsible for ambulatory care business development and ultimately the development of our clinical information system, because at that point Elmhurst Hospital was just rolling out the EHR. We actually started to do this at two places and Jacobi Hospital was one of the pioneers within our system, too. At the time I came in, Elmhurst was first implementing this seriously - across all of ambulatory care initially. For me, it was just so apparent that electronic health record technology would have such a revolutionary impact in ambulatory care in particular.
DL: Isn't your EHR basically a homegrown system?
AA: Yes, the basic product is largely a toolkit with basic functionality. We actually worked with the vendor (QuadraMed) and some outside consultants to develop a lot of the functionality over the course of the last 10 years or so.
DL: You won two Davies on that developed product. Are you now moving to a core enterprise system?
AA: Well, one of the downsides to being an early adopter is you get to this point and you're on a platform that is somewhat dated. Notwithstanding all the work we've put into it, I think we've probably squeezed most of the functionality out of it that we really can develop. The vendor is actually working on a next generation product to transition to a Cache version of this application, and we are certainly looking at that. We are also in the middle of a competitive procurement process to determine whether or not we should transition to an entirely new system.
DL: Oh, well I bet your phone is ringing off the hook.
AA: They're not allowed to come to me directly while the process is in place, which is probably fortunate. We are still very much exploring a variety of possible pathways here. If we really felt there was an ideal EMR out there for us that was financially feasible, we're certainly prepared to consider that, but we are also prepared to consider staying with our current vendor and transitioning to their Cache version, at least for the short term. We are prepared as well to look at the possibility of a best-of-breed approach where we focus on the outpatient side, if we were persuaded that the new integration technologies would really allow us to go in that direction. But all of those remain open possibilities that we're going to be considering seriously during the balance of this year.
DL: So it's really key for you to be able to integrate your ambulatory side into the hospital?
AA: We clearly want to maintain the benefit of having an integrated EMR that crosses not just the inpatient and outpatient setting, but also the ED, long-term care and behavioral health, which are all critically important to us. We have managed to develop the current product so that it is, in fact, in use at several of our EDs, and we also created a prototype for the behavioral health settings.
DL: Your vendor started out as HDS, became Patient One then most recently it was Misys and then QuadraMed. How did you manage to keep on improving patient care with all those changes?
AA: I really do believe that it has been a very critical tool in terms of our ability to raise the quality of care across the system, both from the standpoint of patient safety but also from the standpoint of chronic disease management, because we've used it to create an electronic disease registry. The product we have is not the easiest product to extract data from or write reports with. So we actually worked with another vendor to create a data mining application that allows us to mine data out of the EMR in order to populate a data warehouse. Every evening, data gets downloaded from the EMR, select elements of data that are relevant to populating our electronic disease registry. We have one for diabetes - just this year we went live with one for non-diabetic hypertensives, and we are about to roll out one for patients with high cholesterol. On a smaller scale, some of our facilities are using it for asthma as well, but we haven't rolled that out enterprise-wide. For diabetics, we've had it up and running for a couple of years across the system, with 50,000 adult diabetics being monitored. Not only does it allow individual practitioners to drill down and get all of the relevant information in a snapshot for a particular diabetic, but it also allows chiefs of service to run reports that show how each clinician compares with the others in terms of the health status of their cohorts.
DL: So you're on the way to pay for performance?
AA: We have our own managed care plan, MetroPlus, which is quite large, 250,000 enrollees, and MetroPlus has a pay-for-performance program that is focused on chronic disease management and achieving better outcomes. So that's already something that's been used for the subset of our patients that are enrolled in MetroPlus. If you go to Bellevue Hospital for example, in their ambulatory pavilion in the adult medicine clinic, they actually post the health status of the patients by clinician on their bulletin boards. So those 12 internists at a glance can see how their adult diabetics are doing from the standpoint of their blood sugar, pressure, cholesterol levels. They can compare themselves to their peers, and they're a competitive bunch. So those on the low end can scratch their heads and wonder, ‘Why is that the case?’ And it does facilitate discussions among the clinicians about what they are doing that may produce better outcomes for diabetics.
DL: Any other IT projects you're working on? You were using smartcards at one point, right?
AA: We're actually moving away from smart cards at this point, because the technology to look at data exchange in disparate systems is getting better and better. We do have a RHIO initiative that started in Queens, and we participate in one in the Bronx. The one in Queens originally focused on the use of smart cards, but now it's focused on using a hub technology to exchange clinical data among institutions both within our own system and also with community physicians. And we have just begun conversations with the Bronx RHIO on how we might proceed along a path of convergence so we could ultimately see both those RHIOs coming together and serving a much larger part of New York City, encompassing the Bronx, Queens and even part of Brooklyn. So that's an exciting development.
We also have a software application called HHC Advantage that is used to exchange data with community physicians. A lot of that is separate and apart from the RHIO development, but we see it as a vehicle through which we can ultimately use RHIO technology to exchange a good deal of the clinical data that is relevant in the patient's medical record. Right now, HHC Advantage is focused mostly on exchanging demographic data, insurance data and things like lab results and specialty referral reports.
DL: There are not many CEOs so well versed in the IT of their systems. I know you have multiple regional networks within your system, each with CIOs. How do you manage the governance?
AA: We now have seven regional networks within HHC. The governance is multi-tiered, so we have an IT executive steering committee which is comprised of mostly our corporate IT executives, including our corporate CIO and our corporate CMIO, but also our network senior vice presidents and our corporate CMO. That body really looks at the strategic vision issues on where we want to make investments, and also the direction we want to take the system strategically, as it relates to our business objectives and organizational mission. Below that, there is a main group that our CIO presides over that includes the network CIOs, and there are two other groups that feed into that group - a group of physicians that functions as the local CMIOs, and then a group of nurses who are particularly interested in the application of clinical IT in the role of nursing. We use that to try and ensure we're getting both front line user input and concerns as we then move up towards making decisions that relate to the strategic direction of our development efforts and the overall management of our system.
For all the positive things we've done, one of our problems is that we allowed early on a somewhat decentralized approach to the development of the system. On the one hand, it allowed individual networks and facilities to be creative and innovative, and that did create a proliferation of good ideas and different approaches to enhancing functionality. But it also created some divergence across the organization which we're now trying to rein in by creating a much more centralized structure for governance and decision making, and much greater adherence to a standardized approach to development of the clinical information technology that we're using. We try and make a consensus decision that we're going to roll out across the entire system, for example, the embedding of a depression screening tool in the EHR for primary care clinics. That's something that we've done across the entire system. Or that we're going to build in decision support for screening inpatients for the risk of deep vein thrombosis, and attached to that we're also going to build decision support for clinicians to be able to use lab values that are relevant to the dosage for anticoagulants so as not to place the patient at risk.
So that is what we've tried to do in terms of what started out as a kind of sprawling system where we were theoretically using the same product, but where we had a lot of folks doing their own thing. And it's a hard balance because on the one hand you don't want to squelch the creativity and the innovation, but you also want to appreciate that this stuff is very expensive to develop and maintain. You really want to be strategic as to where you're putting the investment and make the decision for the system as a whole, because the way that we have the biggest impact in improving the health of our communities is to leverage the sheer size of our system and try and do things in unison.
DL: What effect might the stimulus package have on your organziation?
AA: We are very thankful that the federal government is making that investment in order to accelerate the development and use of EHRs. I think it's a very important decision. Even though EHRs are not a panacea and don't automatically solve your problems, they are a very fundamental foundation for a lot of what the Obama administration wants to see happen in the way of healthcare reform. For us, our best guess is that we will be eligible to pull down between $105 and $120 million. It's really what will allow us to move our system forward, because in the absence of those dollars we would have come to a screeching halt at this point, given how scarce capital dollars have now become and all the other fiscal pressures that we're dealing with.
I think frankly that some of what is likely to happen as a result of this major infusion of dollars in a relatively short period of time is that it is going to stimulate other competitors to potentially enter the field here with a slightly different approach to how the technology is deployed. What we're not seeing is much in the way of Web-based application for large systems; we're seeing it for physician office practices but not yet on a major platform that a system as large and complex as ours could readily turn to.