With T&E trimmed, just as it is in all organizations, HCI editors rarely get a chance to interview sources in person. But when our source turns out to be a fellow New Yorker, it’s time to take a cab across town for some real one-on-one time. I was lucky enough to do this recently, and have one of my best interviews of the year as a result, when I linked up with NYU Medical Center CIO Paul Conocenti. The result? An engaging look at a major medical center overhauling its IT environment to completely integrate the continuum of care.
— Anthony Guerra
AG: From what I understand, you have the medical center, which is this building here, and the medical school, which are two separate entities. How many beds do we have here, approximately?
PC: Combined it’s about 1,000 beds across the three major hospital functional centers. There’s Tisch Hospital, there’s Rusk Rehabilitation Hospital, and then there’s The Hospital For Joint Disease. Those are the three basic entities that compose the hospital stay. There are hospital clinics associated with each of the three that comprise the ambulatory component of the hospital. Then — because NYU Langone Medical Center is an integrated academic medical center governed by one CEO and Dean that oversees the three missions of clinical care, research and education — the faculty group practices, which is part of the school of medicine, is also part of the clinical care mission. And the voluntary physicians, who have faculty appointments as part of the way we operate, and admitting privileges into the hospital, are being helped with their EMR adoption through the Stark provisions. We are helping them with the EMR clinical meaningful use requirements and issues, as part of our clinical mission.
Then we have the research mission, which is governed by a chief scientific officer, who reports into the Dean; and we have a whole host of research around here, a number of centers of excellence and research. I’m overseeing both the clinical as well as the research side because there certainly are integration points around research and clinical care, especially in the areas of clinical trials and personalized medicine, and these sorts of things.
AG: We did a story on that recently, a year ago, and the predominant vendor that came up there was called Velos.
PC: And we’re employing Velos right now, we also had InfoEd and we’ve got some tissue banking software called FreezerWorks, and we’re implementing a genomic lab processing system; so all of that is going on.
On the education side, we support all the education for the school of medicine and that’s a very important part of the mission. We are developing a world-class simulation center, we’ve used some OpenSource components – I think called Sakai, advanced learning exchange, and we’ve integrated iTunes into it and are doing all sorts of innovative things around research, because all three of these things integrate with each other. And so we really are one of the few organizations in the country, really, that actually have one leadership umbrella overseeing the integration of these three missions, and so that’s one of the drivers of our integration and our mission.
AG: What’s your main inpatient system?
PC: Our main inpatient system right now is Eclipsys Sunrise Clinical Manager, and we went live with that in March of ’07. We’ve been doing CPOE for 32 years; we were amongst the first three in the country to do CPOE. And so that’s in our DNA. We just, in March of ’07, upgraded to the more advanced summarized clinical manager platform of Eclipsys, which also has an integrated ED and pharmacy system into it.
AG: So doctors come here and they’re going to do CPOE, it’s not a choice. You don’t have to fight the fight, the fight’s already been fought. What about physician documentation?
PC: We are doing all electronic physician documentation. We just went live this past week, actually, where all of our medical records are totally paperless. We’re a fully paperless organization on the floors during care, we’re doing electronic notes; that’s in the rollout phase, probably 50-60 percent there. That’s the objective for by the end of year, that we’ll be paperless even during the stay.
So we’re paperless in our medical record department. It’s totally converted, digitized, so there’s no more paper records from a medical record point of view. What’s left of paper is scanned in to a new electronic medical record system which is integrated into our clinical system, so all of the signatures and documentation gets tracked.
AG: There is still a huge leap to be made for everybody between scanned in PDF-type stuff and discrete data …
PC: Without a doubt. We are now 70 or 80 percent fully codified and only about 30 percent of that is actually paper which comes in from other sources. During their stay everything is electronic, with the exception of a few physicians who are still doing progress notes on paper.
AG: The other ones are actually typing in their notes?
PC: Yes, absolutely.
AG: Do you think that is the result of the natural societal move towards the Internet; that they’re used to typing now? It’s hard to live your life without typing anymore; it used to be very easy.
PC: But there are some people still learning how to type, believe it or not, and we have a few of them, as I’m sure everyone does. It’s changing, but then you’ve got dictation, which is not really the codified part, but for that we use technologies such as like Dragon (Nuance), which does allow you to codify the data while using voice. It, in effect, is driving the mouse, as well as the voice recognition for the textural part of a note.
AG: What’s your percentage of employed physicians versus those with privileges from the community?
PC: It’s about 50/50, I mean, employees include the faculty group, part of our faculty group and practice, but our voluntary community is very large.
AG: I would imagine it’s much easier to get the employed physicians to accept some of the things you roll out. Is it a different process for bringing those two constituencies along with some of these projects?
PC: No. Within the walls of the hospital there is no difference between our voluntary physicians versus our employed physicians.
AG: The rollout is not more difficult with community docs?
PC: Not inside the hospital. If you go to the ambulatory side, it’s a whole different game. We have the ability within our faculty group practices and our clinics to roll out technologies, standardize order sets and it really comes down to the standardization, which is what we’re all trying to drive for. We’re trying to have a standardized platform for best practices built into the clinical system. How do you build consensus around what best practice is? We do it by specialty. Our approach is, when we are going and attacking a specialty, we’re indifferent to whether it’s a hospital employed or voluntary, we bring the specialists together to govern the order sets and/or the smart sets that we do on the ambulatory side, and build consensus around that specialty.
On the voluntary side, however, and we have to remember the operative word is “voluntary,” it depends on the extent to which they agree with what we’re promoting. In the hospital, such practices are required, established for how you take care of patients, so there’s not an issue with our voluntary physicians. As I said, it’s because we’ve been doing it for 30 years. We’re a teaching hospital, so there are residents there and there’s a lot of help.
AG: Over a year ago, I did a story about how Partners was mandating that any associated physician who wanted to practice at Partners had to get on one of two or three ambulatory EMR’s. Many people say, ‘That’s Partners, that’s Boston, you can do it up there, they have the critical mass.’ Could something like that work here?
PC: Well, it could work with your faculty group practice docs because they’re part of that organization, but when you roll out to the voluntaries, in New York City, where there’s 80 or 90 hospitals on the island, just about, and there’s a very competitive marketplace, that’ll be more difficult. But I think what they will respond to more is the stimulus, is the HITECH stuff, is the fact that they know now, they have to go on an EMR in order to survive.
Five years ago when Partners was doing it, it was really more of a push; Partners is pushing this EMR technology on these physicians. Today it’s a pull, the physicians are coming to us saying, ‘Hey guys, help us out, we want to be part of the revolution that’s going on with electronic records and the whole reform of the American health system.’ They are pushing us in the sense of asking for help. ‘Oh we hear about this Stark Law, so how much are you going to help us with that?’ So, we have actually rolled out now with our Epic program — that is our one program that’s integrating the entire clinical mission and integrating with the research mission of the medical center. We’re making a very bold move here, and we are integrating everything across one platform.
AG: You are getting rid of Eclipsys?
PC: We’ve got a two-phase implementation — our first phase is replacing and implementing the EMR across all of our hospital clinics, faculty group practice and our voluntary physicians. We are probably one of the only hospitals in the city that actually announced the program to our voluntary community under Stark that we are going to roll out Epic to them at a very, very discounted price. The price per doc is … let’s just say it’s better than Sam’s Club. So, we know that’s one benchmark, and we’re cheaper than Sam’s Club. We give them more than what they’re going to get with Sam’s Club because they’re getting the Epic system, they’re getting the practice management system as well as the EMR. That’s Phase 1.
Plus, in Phase 1, we’re redoing our whole revenue cycle component, and it’s not just billing that we’re talking about; it’s patient access, registration and scheduling across all of our hospital, inpatient and outpatient. Everyone is going to be on the same platform that our faculty group practice docs are on, that our voluntary docs are on, that our clinic is on. Unless you’re able to identify the patient securely and accurately, the aggregating data is not going to work because you’re still going to aggregate in silos, and then you’re going to have to connect the silos through some other record locating or matching algorithm, which is not perfect.
We’re trying to get this upfront. At the front door, we need — within the NYU network of clinical care, which includes our voluntaries — to be able to have our patient access solution, which includes a patient personal health record called My Chart, across all of our community. With that, clinical data can be viewed across all of those practices, that’s Phase 1.
Phase 2 would be to replace our inpatient clinical system, Eclipsys, with Epic, so that the coordination of care from our inpatient setting to our ambulatory setting to our voluntary settings to our faculty group practice is all on one consistent platform that will improve the coordination of care amongst the NYU network. We are also the only certified inpatient hospital system by the State of New York, Department of Health State of New York to be compliant with SHINNY (State Health Information Network of New York). We just went through a CON process that included a very rigorous assessment and requirements process so that the Epic system that we are implementing is, in fact, contractually bound to be compliant with the SHINNY.
We’re not only trying to engage all of the NYU network, including our voluntary community, we’re going to connect that to the State Health Information Network. I happen to be the chair of the NYCLIX Technical Committee, and we’re already connected to NYCLIX. We are currently exchanging clinical information in an ED setting under all of the stringent consent process and forms. We were one of the first to do it, we’re doing it with St. Vincent’s, we’re doing it with NYU, with Visiting Nurse Service, with Mount Sinai, with Presby (New York Presbyterian) — we’re all part of this network, we’re the only ones actually using it in the ED. We’re leading the way on that.
We’re connected to the regional health information network, which is NYCLIX, we’re connecting to SHINNY, which is the state network, and we’re also connected through those mechanisms to the National Health Information Network. NYCLIX itself had done demonstration projects between state RHIOs, so we did a demonstration where we’re exchanging clinical data between NYCLIX and LIPIX, which is the Long Island Health Information network, and that was a successful demonstration project. We also participated in the National Health Information demonstration project where we exchanged data with North Beach, Calif., and Indiana.
We’re very, very much involved. NYU leads and supports interoperability, integration. Moving these technologies out to the community with voluntaries is really part of our leadership role, in trying to advance healthcare by the use of technology. But so we’re very active with that.