It was going to take a lot to draw Tim Moore back into the workforce. That’s because Moore had been there, done that. He’d found success in all his career endeavors, made some money and bought some houses (a few in sunny Mexico). But one day Moore got an offer even he couldn’t refuse. That offer came from Hoag Memorial Hospital Presbyterian, and Moore couldn’t refuse it because, in it, he saw a unique opportunity to improve the healthcare of an entire community, an opportunity that “very, very, very few other places” could offer. To learn more about Moore’s work, along with the laws he’s developed along the way, healthsystemCIO.com editor Anthony Guerra caught up with the California-based CIO.
Chapter 2
Moving away from Stark, “redirecting” the subsidy to HIE
A three-phased implementation rollout
Working with the ambulatory vendors — Allscripts, eClinicalWorks, NextGen
Syncing up data in a multi-EHR community
Privacy and security in the cloud
HIE sustainability and illusive financial models
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…it was my recommendation that we stop and think about that a little bit before we go forward and answer some questions, such as, ‘What is our bigger vision? Is it a vision to do the subsidy for the stand-alones, or is it a vision to connect our community?
Ultimately, the holy grail of all of this, within the data exchange, is the illusive continuity of care document.
So they have the complete picture and they don’t feel disconnected, which is, by the way, a huge complaint for primary care physicians. Often times, they feel that they lose control of their patients when they refer them because they don’t know what’s happening to them.
Guerra: Talk about what happened after you got the contract settled with Medicity.
Moore: Sure. So we worked through the contract, got that done; and as I mentioned earlier, we had been running a subsidy program here for a couple of years. When the economy bottomed out, was that 2007 or 2008?
Guerra: I think it happens every 10 or so years.
Moore: Right. But it got so bad here a couple of years ago that all of our stock portfolios went into the tubes. And with Hoag being very prudent—I mean, even though they have a very, very solid balance sheet, they are prudent—they froze any additional subsidies and said, ‘Wait a minute. We have to see what the economy is going to do before we fund that any further.’ And when I came on board, which was in the very beginning of August 2009, they had actually made the decision to reinitiate the subsidy.
And it was my recommendation that we stop and think about that a little bit before we go forward and answer some questions, such as, ‘What is our bigger vision? Is it a vision to do the subsidy for the stand-alones, or is it a vision to connect our community?’ And we had already gathered a significant amount of information. So we knew at the time that of around 1,100 physicians, approximately 350 of them already had their own systems in place, and we knew that of those, there were approximately 50 different flavors out there.
Guerra: Yeah.
Moore: And so I recommended that we consider not reestablishing, but redirecting it. We actually had a discussion that went all the way to our board, and we unanimously agreed to redirect those funds and essentially double it and put it towards the HIE. So that’s kind of filling in a gap that I think might be important. But going forward, we laid down very carefully how we would work with Medicity. This isn’t ours and it isn’t theirs; it’s both of us working together, so we laid out a three-phased approach. And each phase has a planning, implementation, and ongoing enrollment and rollout phase. The first phase is essentially their electronic drop box, with the thought being, let’s add some stickiness, if you will. Let’s start feeding the community members—our physicians—information they could get near-immediate value from. Let’s start with all of the things we’re sending via fax and courier and mail—and I’m not sure we don’t messenger pigeon. Let’s use an electronic drop box and let’s get that to them. And that’s just the start. Nobody believes it’s the end-all, be-all of anything.
And then with that, ultimately, let’s bring on a physician portal and a clinical viewer so they can start having a very lite view of some of the enriched functionalities. And although we keep rolling out the drop box—and I think currently we’re somewhere north of 300 of those that are out there—that’s not that focus. Nobody believes that’s an HIE. And we’re very clear when we’re out educating the community; we make sure they don’t think that’s any part of an HIE. That’s simply to get things started and get on the same infrastructure.
So where we’re at today is phase two, which is much more about the bidirectional exchange and order entry. This is where you start to have the promise of an HIE; where we start being able to exchange information from the doctor’s office, out of their health record, and into the community, managed through the Medicity exchange.
Ultimately, the holy grail of all of this, within the data exchange, is the illusive continuity of care document. We are just now doing some pilot work around that and meeting with some of the EHR vendors; the larger ones. Recently we met with NextGen, and they have committed to work with us to get that working a little sooner than our original timeline.
Phase three for us is coming up this fall, and that’s where you start getting the true value for the community members—not the Hoag physicians, but the true community physicians—and that’s where you start with the personal health record, the population health management tools, the disease registry type tools, those types of things.
So far, we have a team of seven full-time people who are dedicated 100 percent, and then we have a matrix team of probably another 10 folks that come in behind that and do pieces and parts. It’s executing very well, and it is such a pleasure to bump in to a physician. One of the first things they often want to tell you is, ‘You’ve got that Medicity integrated into my Allscripts, and I so much appreciate that. It’s fabulous. It’s never been so good.’
So that’s stickiness. That’s not foundation stickiness, but that’s stickiness.
Guerra: Let me give you a scenario and you can sort of take me through how this might work. You have Eclipsys in the hospital, and the office-based providers have any numbers of systems. So let’s say for example I’m a patient with a chronic condition and I go to Hoag and maybe there’s a competitor hospital that I also go to at some point. Now I have an EMR at Hoag and an EMR at the other hospital. I see five specialists in my primary, and everybody has an EMR.
Now I understand that between one or more of those physicians and Hoag, you communicate through the HIE; information can go back and forth. You said you had bi-directional exchange; do we get to a point where there are really five or six EMRs within the community of the patient, and that they’re never really completely synched up if that patient is seeing multiple providers? Take me through how that works.
Moore: Here’s the analogy I use. Today, too frequently, even in our community—because we haven’t rolled this out completely by any means—a consumer, Mrs. Smith, can go to her primary care physician. And her primary care physician can say, ‘Hmm, I don’t like the way this looks. I want to send this all over and have an orthopedic specialist take a look at this.’
So Mrs. Smith gets there, and she is essentially, for the most part, a brand new patient. They don’t know her. They don’t know anything about her. If she’s had an extensive history with the primary care physician, she may have brought over three or four inches worth of records.
So they establish or re-establish a relationship. An orthopedic specialist looks at it and says, ‘I don’t like this at all. I need you to go over to Hoag and get these tests done. I want you to get an MRI and I want you to have some blood drawn.’ And when they show up at Hoag, unfortunately, too frequently it’s a brand new interaction, so she has to establish an interaction with us.
Now they get the results and it all goes back to the orthopedist who ordered it. So we will courier it over or fax it over. But that’s who gets the information, and they get that limited view. That doctor could be one of the finest doctors in the world, but that’s all that has that information and that’s all they have.
With the primary care physician, unfortunately, there’s too frequently a disconnect. The primary care physician never gets that same knowledge. And they had no way of having that intimacy. We have a tagline here which is, ‘We know you.’ And that’s not meant in a negative way, but in a very positive way. You’re in our community and we know you.
Guerra: Not in a Big Brother kind of way.
Moore: Right, not in a Big Brother kind of way. And so in the HIE world, when it’s fully functioning within the Medicity vision and our shared vision and it’s populated, we will have the physicians in our community connected, and they’ll be able to—and quite frankly it’s expected they will—publish key data off of that primary care visit.
Now when you show up over at the doctor’s office, they have the ability to schedule for you through enterprise scheduling, which is another component of things that we’re doing here at Hoag. It’s not there yet, but it’s in process. You’ll also be able to send some notes, and you’ll be able to send standard data as well. That if it’s a coordinated event.
Let’s be honest, there are patients—and I’m certainly one of them time to time—who don’t follow all the rules. So if I just decide I’m going to a primary care doctor, and they say, ‘Go home. It’s just a sore knee,’ I might decide I’m going to see an orthopedic anyhow, because I’m kind of a nervous Nelly.
Well if I show up in that office, I can go right to the clinical data repository of Medicity and I can see if you had been seen anywhere in our community—if you’re a member, if your physicians are members. And all throughout, it’s a very secure exchange, and there is appropriate logging of information; security logging and episode logging that is robustly monitored.
I can break the glass, so to speak, and I can see if Mrs. Smith has been seen. ‘Oh, you’ve been seen by the primary care physician and he’s already done the same blood work that I would have done, what do you say we wait two weeks like he suggested. Let me take a look at it.’ But I have that information available to me.
Also if you did interact with the hospital, we would have pushed those results out to all of the appropriate places. We would push the results to your primary care doctors, who got the results at the same time as your orthopedic physician.
So they have the complete picture and they don’t feel disconnected, which is, by the way, a huge complaint for primary care physicians. Often times, they feel that they lose control of their patients when they refer them because they don’t know what’s happening to them.
Guerra: But the primary would want not just the raw results, but also the interpretation of those results by the specialist, right?
Moore: And that’s the publishing that would occur out of the specialist’s office—in this case, the orthopedist—back into the clinical data repository. And then in this case, because it was a referral, it would actually push directly to that physician.
Guerra: So the clinical data repository, can we think of that as the cloud sitting in the middle?
Moore: Yeah, I think that’s a fair way to think of it.
Guerra: And then, any provider in this community who’s part of this, who sort of opted into this program—they can first record the results of an encounter in their EHR, and then they have the choice of whether or not to publish those results out to the cloud.
Moore: That is correct.
Guerra: And are there any parameters or any decision points at which they could say, ‘Well, I’m not going to publish. I am going to publish this,’ and do you put on any best practice in terms of, ‘Hey, this cloud is here now, so therefore, we expect you to publish certain information.’ Do you ever choose around psychiatric care, where maybe they’re not going to publish the same type of things?
Moore: Those are very serious, important questions. At Hoag, we are an inclusive, transparent organization. We actually have a governance group, the Health Information Exchange Governance group, which meets on a monthly basis, and it includes physicians from the community that rarely come to the hospital, and physicians that do a lot of work in the hospital; for example, pathologists.
And that even includes community member that deal with issues like, ‘What are going to be the guidelines? What are going to be the rules on opt-in and opt-out? Let’s review these policies and make sure they stand for what we think the community is looking for us to do.”
And to your question is, there’s been much discussion around making sure—and Medicity understands this in their business model—that you have the dynamic ability to call out what you will and won’t share. This is very important, and one of the most sensitive areas, as you touched on, is psychiatric.
Guerra: So, obviously, the funding for this is coming from the hospital?
Moore: Yes, it is.
Guerra: Now, I definitely see the financial case in this, in terms of the hospital putting up funding to, in some ways, interact more closely with physicians. So we have Stark and we’ve redirected that to an HIE model, so it totally makes sense to me from a business sense as well as in terms of patient safety. Where we get into a hospital-to-hospital type or health system-to-health system HIE, those business models break down. Does that make sense to you?
Moore: They definitely can break down for sure.
Guerra: Do you see a business model for a health system-to-health system HIE in terms of who’s going to fund that beyond the government?
Moore: Yeah. I’ve got a presentation that I’ve given about 30, 40 or 50 times within our organization. I have three main bullets I always start out with, and they’re short and simple. Number one, ‘Hoag’s HIE is not a reaction to health care reform.’ In other words, it was here before and it will be here should reform go away. Number two bullet is, ‘The beneficiaries of the HIE are the communities we exist to serve.’ And the third one is, ‘Hoag’s HIE program is currently underway, it’s not just a vision.’
So one of the reasons I say that is because we really do believe that this is for the communities we exist to serve, the people in our communities. And we think we’re a fabulous health care organization, but the reality of it is that even our community members go to places other than Hoag. And we know that at the full vision of our development, that we will have patients who may go to Memorial Healthcare down in Long Beach, which is about 20 miles away. They’re going there for something, and we need to do our part in exchange with them. So our secondary strategy is, in fact, to connect with regional HIEs to the extent that it helps our communities. And that’s kind of where we at this point.
Now, we also may have to participate at the state level and at the national level, but that will never be part of our base strategy. There are people that do travel statewide and they do travel nationally, but that will not be our primary goal.
And that’s pretty consistent with our communities have told us they want. They’re not really interested in the off chance that they are in Nome, Alaska.
Guerra: It’s diminishing returns on those investments, right?
Moore: Exactly. So I do think there is a model where it works, and I think it’s a shared expense model. Maybe in the future at some point, if it becomes slick and concierge-like, maybe we’ll see a business model for this.
In the meantime, we just think it’s just good healthcare, and that’s what we’re about.
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