When it comes to research, academic medical centers are second to none. But when it comes to interoperability, there is often room for improvement, and the University of Arkansas for Medical Sciences is no exception. As incoming CIO Dave Miller tries to position the organization for Meaningful Use, he is faced with a host of challenges, including EMR systems that don’t speak to each other, systems that enable clinicians only to view records, and — like many academic systems — funding that exists in silos. In this interview, Miller discusses how he plans to use his experience, both in the clinical and vendor worlds, to transition the organization from a best-of-breed shop to an enterprise system, what it will take to become an accountable care organization, and the importance of being able to put on the salesperson’s hat.
Chapter 3
- Working toward MU while (possibly) changing application horses mid-stream
- Reflecting on the ACO NPRM
- MU, ACO & ICD-10 “are all means towards the same end — population management”
- The state of state HIEs
- ICD-10 — “If you’ve got homegrown apps, it’s just going to be a nightmare”
- How much can healthcare organizations afford?
- CIOs must “keep their fingers on the pulse of the organization”
- Why having a clinical background has been key
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Bold Statements
We’re in the process of preparing for attestation with both of our EMRs. And I’m not really sure I’ve fully figured out all of the ramifications of changing horses and what that means. Do we do these things in parallel and attest with our existing EMRs, and then do we have to re-attest once we get to a new platform?
We just have to figure out a way to get everybody to connect to the pipe. And that’s really the easier piece. I think the infrastructure piece is a tougher nut to crack, and I think we’re well on our way to having figured that out.
I think most organizations are kind of behind the planning curve—we certainly are here, at some level. But that, actually, is going to be one of my driving factors to move to a single platform, because I think that will make ICD-10 remediation so much easier for the organization. It will save us a lot of money.
With the tumultuous environment that we’re in today, keeping your finger on the pulse of the organization is vital to what we have to do. I would encourage all IT leaders to take that as a mantra.
Guerra: How do you plan for Meaningful Use in terms of the certification requirements if you are going to be pushing for a possible change in your application environment? How do you work toward Meaningful Use and handle certification? You almost wish they happened sequentially rather than at the same time.
Miller: That’s a great question and probably one of the bigger questions on my plate right now, frankly, because we’re in the process of preparing for attestation with both of our EMRs. And I’m not really sure I’ve fully figured out all of the ramifications of changing horses and what that means. Do we do these things in parallel and attest with our existing EMRs, and then do we have to re-attest once we get to a new platform? I think we probably will. And what does that mean from a reimbursement perspective?
It’s such a changing platform, this whole Meaningful Use thing. We’re still waiting for some things to come down. We don’t know yet what all of the Stage 2 requirements are going to be; those aren’t coming out until later this year. It’s a great question, and one that we’re kind of wrestling with right now. I don’t have an answer to that frankly, but it’s something that we’re going to have to figure out, and we’re going to have to get some direction from our folks in terms of what they think that’s going to mean, and whether or not we’re going to have to re-attest, which is fine if we have to do that. But we’re still kind of noodling through. I mean, it’s kind of a unique situation. I don’t think anybody really thought about, what if we have an EMR that’s certified, but we switch EMRs. What happens then? I don’t think there’s been a lot of discussion around that. And like I said, we may unfortunately be a leader in that area and have to figure that out.
Guerra: Right. So, you’ve mentioned ACOs a few times, and they’ve come out with the NPRM information about ACOs. CHIME just put out a statement; they took issue with a number of things, including the provision that patients can opt out, but still have to be considered part of the ACO. They can still see the physicians, but they can opt out of data sharing and meaningful use—the dovetailing of meaningful use. I believe 50 percent of the PCPs have to be Meaningful Users by the start of the second year, I believe. And then there a number of other areas—quality reporting requirements, health information exchange. CHIME took issue with a number of things. I just wanted your thoughts on what’s been put out so far about ACOs, and maybe how the organization stands in reference to those?
Miller: I think that fortunately for us, we’re somewhat unique. We already have a statewide footprint; besides our main campus here in Little Rock, we have eight area health extension centers across the state and are building. Through the use of the tobacco settlement money that all the states got, Arkansas made the choice to put in broadband across the state, which we’re in the process of doing. So I think we’re actually better positioned than most organizations, but I certainly understand the position that CHIME is taking. When I look at ACOs, Meaningful Use, and information exchange—I’ve just recently been appointed to the state HIE council here in Arkansas—to me, they’re all means to the same end, which is population management for healthcare. They’re all very connected. And frankly I think I’m a little more of a better place than most health organizations because, number one, I’ve already got a head start on the infrastructure. I’ve already got a statewide presence here, and then extending that statewide presence—it’s kind of like building a broadband and then you’ve got to get the sort of final leg. I don’t really want to use this analogy, but it’s probably a good one. It’s like how the state runs the sewer line up close to your house, but you have to pay to connect basically.
And so frankly, I’ll be the state sewer line. We just have to figure out a way to get everybody to connect to the pipe. And that’s really the easier piece. I think the infrastructure piece is a tougher nut to crack, and I think we’re well on our way to having figured that out.
I mean, there is no infrastructure for most states to do this kind of stuff. We haven’t figured out the sustainability model for an HIE in most states. Coming from Illinois, it’s a disaster there. They chose to divide the state into 17 what they call medical trading areas and give HIE planning grants to each one of those. It’s just crazy, the approach they’re taking. How they’re going to cobble all that together, I have no clue, but that’s an issue. Fortunately for me here and now, that’s much less of a concern, again, because of my footprint across the state already.
Guerra: And then we have ICD-10 which really the work-intensive third leg of the ACO, Meaningful Use, and ICD-10 stool. What are thoughts around that, and how are you doing in terms of that? What kind of work is it going to take? There are a lot of things happening at once.
Miller: From my perspective, that’s one of the rationales that I will use to drive toward an enterprise system. I’ve had a number of conversations. When you look at the amount of dollars that are going to be required to remediate ICD-10 for most healthcare organizations—if you look at the IT component, the medical records component, the training component of that, for providers in particular—most healthcare organizations are going to spend probably in the 15 to 20 million range to remediate ICD-10. For academic medical centers it’s at least up in the 25 million range from all reports that I’ve seen, and for academics who are best-of-breed shots like we are, I would say it’s probably 50 percent over that 25 percent, at least.
So to move to a common platform, why spend that kind of money in a best-of-breed environment where we also have a lot of custom application development which, if you’ve got home grown apps and you’re trying to remediate ICD-10, that’s just going to be a nightmare. So it’s huge. I think most organizations are kind of behind the planning curve—we certainly are here, at some level. But that, actually, is going to be one of my driving factors to move to a single platform, because I think that will make ICD-10 remediation so much easier for the organization. It will save us a lot of money. And, in fact, that money should be part of the return on investment for moving into an integrated platform here. And that’s going to be clearly one of the arguments.
So it’s big. And I don’t think most of the organizations realize that it’s not an IT thing or a medical records thing. This is a huge change in a way that physicians are going to have to document the level of documentation that’s going to be required. When you change the number of codes by tenfold to get reimbursed, which is basically what they’ve done, that’s a huge, huge change. And the physician piece and the provider reeducation and training are just as big, if not bigger, than the IT piece.
Guerra: When you talk about the expenses that come with running a healthcare organization now—Meaningful Use, ICD-10, and ACOs—everything is in the tens of millions of dollars to run a healthcare organization of the future. You’re at an academic medical center, which I assume does well, but what about the small community hospitals? We always hear about the thin margins of hospitals. What do you see happening? Do you see some class of hospitals just not being able to stay in the black after doing all the things or in the process—all of the things that are going to be required?
Miller: I don’t see how the smaller community hospitals or the critical access hospitals are going to be able to meet Meaningful Use requirements. When I lived in Illinois, I lived in a small town a couple of hours south of Chicago that had 5,000 people, and the smallest critical access hospital in the state of Illinois. There’s no way they have the dollars to get to Meaningful Use, and yet they are probably the ones most reliant upon government funding of healthcare, whether it’s Medicare and Medicaid.
I think that eventually they’re going to have to be carved out in some way or given more time to conform, or there’s just going to have to be some additional funding from the government. And it’s not just the smaller hospitals, its one and two-doctor practices—getting them to Meaningful Use and to be part of accountable care and be able to play in the accountable care space. There’s going to have be some carving out of that. And I think that if it’s not clear yet, it’s going to become clearer as we get closer to the deadlines for conforming to the new law.
They’re going to have to have some additional help that the rest of us don’t need. We’re a state organization here, so we have some of that. But we only get about seven or eight percent of our funding from the state, so it’s not quite the issue for us here. But those smaller organizations that don’t have the money to pony up for something are going to need help from the government and a longer time to conform.
Guerra: Before I ask you my final question, is there anything else you wanted to touch on in terms of projects you’re working on or thoughts you have?
Miller: Well, I’ve got a lot of things on my plate even though I’ve only been here a little over a month, and there’s a lot of new direction that needs to be laid. And in some ways it’s a long-term proposition, but in some ways it has to be a short-term proposition and has to be done quickly. I think that building trust across the organization is something that IT leaders are really going to have to focus on more and more. I make a point of having monthly meetings with just about every major stakeholder that I have, one-on-one; sitting down, finding out what their pain points are, finding what their needs are, and just spending time with them. I make rounds across the organization—in clinical areas, academic areas, wherever it might be—to listen to end users.
It’s not necessarily a skillset that most IT leaders might have, but it’s an absolute necessity to be able to do that. And especially with the tumultuous environment that we’re in today, keeping your finger on the pulse of the organization is vital to what we have to do. I would encourage all IT leaders to take that as a mantra.
Guerra: Now for my favorite final question. I interview a lot of CIOs, and before you, the most interesting degree I had seen was Randy McCleese from St. Clare’s Regional Medical Center, who had a degree in geology. But if your LinkedIn profile is correct, you have BA in Zoology. Is that correct?
Miller: Yeah. I have a BA in Zoology and Chemistry. Actually, that goes to my initial foray into healthcare of medical technology. You pick that academic space to specialize in if you are going to go to medical technology. And I will say that having spent time in the clinical space has been probably one of the most valuable experiences that I’ve had for my healthcare career, because I can relate to the clinical side. When you’ve spent time with clinicians and you’ve assisted with autopsies, there’s probably not any area of the clinical empire that you’re afraid to venture into, whether it’s the surgical suite or whatever might be. So it’s served me well.
Just as an aside, my favorite undergraduate background is that of a good friend who I worked with in my consulting days who became CIO and now is back out in the vendor space. His name is David Finn; he’s now the Health IT Officer with Symantec, and his undergraduate degree was in theater. That’s my favorite one. In fact, I just saw him a couple of weeks ago at a conference where we were both speaking, and I followed him and made known the fact that he has a theater background. And he was a CIO at one point as well. So that’s my favorite one.
Guerra: Well, I’m sure I don’t want to talk—my undergraduate was anthropology.
Miller: There you go. See?
Guerra: It takes all kinds.
Miller: That’s right.
Guerra: All right, Dave, that’s all I have for you today. Thank you so much for a wonderful interview.
Miller: Thank you, Anthony. I look forward talking with you again soon.
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