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
GUERRA: When HITECH and meaningful use take their final form, some organizations may see they are on track, while others may find they have been taking their organization in the wrong direction. How do you see that playing out?
CONOCENTI: I think it’s going to play out for the best, but it’s also true there are going to be a lot of unhappy people. As you know, meaningful use has three basic components to it (A) you’ve got to be certified, and right now there is only one inpatient certified product, which happens to be Epic (EpicCare Inpatient Clinical System. On June 18, Opus Healthcare Solutions’ OpusClinicalSuite 2.3 became the second inpatient EHR with 2008 CCHIT certification).
And then the other part (B) is the interoperability thing, which I think is at the center of a big problem, and then the third (C) is reporting quality measures. So, those are the three things that go up into meaningful use, and embedded in the quality stuff is a lot of the decision support rules and things like that.
So, I think what’s going to happen is people out there under HITECH are going out, getting EMRs, not knowing the implications, not knowing that they may be purchasing something which won’t qualify them for meaningful use, and not get their $44,000. There’s a whole lot of marketing out there. I mean, I get pitched by five vendors a day — some reputable, some just came out of the woodwork, and they’re all making claims to the physicians about what their products can do. So the concern is there’s going to be a lot of people who have bought systems under the idea that they’re going to get this $44,000, and then all of a sudden the ruling of what meaningful use is is going to come out and there’s going to be a whole backlash around that. I think that will happen and then they’re going to have to back off of what meaningful use is going to be, because the grand national czars, after you do this for a period of time, you become immune to reality sometimes, and the reality is that if they say interoperability means that you have to exchange codified data, and you have to map X to Y and come up with Z, because Z is now the standard, magically, and unless you do that, you don’t qualify for meaningful use, you’re going to get a riot.
What they might be able to do is, instead, is just require the sharing of a document, the CCD, and we don’t need to actually import it as codified data. If they say that, I think there’ll also be a backlash, but it’ll be a more manageable backlash, because I believe that as long as we are able to say that the initial requirement is around sharing a document, they can up the ante in later years.
Because at NYU we have a large voluntary community, the demand for us to help our voluntary physicians is huge right now, and we have just redone our plans for our ambulatory rollout to meet the acceleration for 2011, which initially we planned as a normal rollout over three to four years, But these physicians want to get the stimulus, they’re signing up, they want us to help them, and so we’ve accelerated that. What about the physicians that are not affiliated with anybody? Who can really help guide them? NYU can help its physicians and other large organizations can help their physicians, but if you think you’re going to do that alone, you’ve got be really careful because there’s a lot of hype out there, and that’s how I think it’s going to play out.
The other interesting thing will be to eventually see if all this has really made a difference — we did it, we’ve implemented EMRs, who’s them going to be measuring whether or not the objectives have been met, and errors have been reduced and cost has been reduced and quality has improved and all that? Health information technology is not going to improve health. It's going to enable the clinicians who are caring for patients to improve health, but it’s not going to do it on its own. We all know you can implement the best technology and screw it up. The easiest thing to do is screw up a great system if you’re not careful, and the organization must have bought into the plan and understand its responsibility in an IT transformation for it to work.
And so the thing that encourages me is that at NYU, this is not an IT project, this a medical center project being driven by the senior leaders of this place, and I’m just providing service to that. And that’s a huge difference that I don’t know is happening all over the place.
GUERRA: What if it’s determined, five years from now, that we’ve reduced medical errors by 20 percent, but somebody can also prove that we’ve reduced hospital revenues and physician income by 20 percent? Would that formula be sustainable?
CONOCENTI: I think that there are going to be winners and losers, and, at the aggregate, healthcare will be improved and cost will go down, but when you look at all of the pieces of the pie, some are going to be making more and some are going to be making less, and that cuts to the core of transforming the compensation model associated with healthcare. The transformation of that model has to happen because you can’t transform the industry without adjusting and retooling the compensation model associated with it. And so, in fact, the compensation model is probably one of the biggest disablers of the HITECH plan, and this pay for performance is nice, but it’s just one small thing that has to happen. The industry is still struggling with getting paid for online consults. It just has to change. Who’s going to bear the burden of this change is going to be a very interesting dialogue, but unless we look at all the players and all of the components of healthcare and adjust that, then you will have lots of articles, you’ll have tons of studies that say that this stimulus bill and this whole transformation did not meet its objectives. But I think if you look at the aggregate and you adjust the compensation, I think it’ll be better for everyone. The fact is, that’s where it’s going, healthcare is too expensive, and it’s too expensive because we’re dealing with paper, we’re dealing with inefficiencies in the system; we’re dealing with inequalities around the compensation, and the payment structures of healthcare.
Look at research, research loses money all the time because it lives off of the back of the hospital. But without good research, who’s going to come to a medical center which is dealing with tertiary and quaternary care; and the primary care is out in the community? You’re going come to a place like NYU because it’s got great research. You want to talk about personalized medicine, how does that interact with this? Who’s paying for that? There’s no compensation for research. You would want to be able to take your data, and have it living so that the greatest research that happens can impact your life, and there’s a cost to be able to do that, and that could protect a lot of lives, that could really save a lot of money.
We’ve got grants and we’ve got a lot of these other parts of the stimulation and the CTSA, which is a very good initiative. Payers – what’s their role in this? You’ve got the government putting their finger in it but what’s happening to the Oxfords and the Aetnas and all these guys? Are they just hoping it all happens and it’s going to reduce all of their costs because they’re going be living off of the back of the government? They’re the ones making lots of money; what about the pharmacy industry? So we’ve got to look at the whole thing, but you’ve got to start somewhere.
So right now I think that the benefit of the compensation with HITECH, and the $44,000 being offered, has really stimulated things.
GUERRA: Do you have any advice for colleagues who may not have the same level of resources at your disposal?
CONOCENTI: For the smaller organizations, if they even have a CIO and they’re struggling with cost constraints, I think that there is a lot of research around the benefits of an information technology system. I think they have to start with where is the most pain? So, if they’re a community hospital and they’re still on paper, from an ordering point of view, I think they can make a very compelling case that they need to be able to get a CPOE system. There are monies available, hospitals get some of the stimulus as well, and they should work with whoever it is in the organization that handles business planning and the CFO-type person who understands the reimbursement model, because the reimbursement model is driving even hospitals to get electronic. If they’re on paper, actually, in many ways, it’s easier for them than if they’ve got a lot of hybrid stuff.
I would also suggest they look at some ASP models, because they can’t really do it all themselves, and I would also say that they should partner up with some of the bigger guys.
GUERRA: Partner with vendors or hospitals?
CONOCENTI: Hospitals. So, for every region there’s always a couple of big guys out there. If you have an affiliation agreement, which most community hospitals have with someone, you should be asking that larger partner. ‘How much would it cost if you extended your IT system to us? We’ll pay for what we get, pay for it by the glass, I can’t buy the whole bottle, but I can pay by the glass. Right now, I can afford a glass, and you’ve already worked out all of the best practices and all the alerts and all the workflows because you’ve been doing it for years, so I don’t really need to reinvent that. Can we work something out?’
Some places will say, ‘Get out of here, I’ve got my own worries,’ but others might actually think, ‘Well, that’s not a bad idea,’ and so I would try a number of those things, but I think doing nothing is not an option. And if the CEO and/or the president and/or the COO doesn’t get it at this stage of the game, with all of the stuff going on, unfortunately my advice would be to find another place to go.