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?