They say everything is bigger in Texas. But Memorial Hermann Healthcare—a system that certainly qualifies as ‘big’ with 11 hospitals and a large network of affiliated physicians and specialty programs—is trying to make healthcare better. One way the organization looks to change the game is by offering different organizational models for physicians and letting them choose the option that best meets their needs. In this interview, David Bradshaw talks about the challenges he faces in establishing connectivity between the hospitals and the various groups of physicians who work with Memorial Hermann, managing an application environment that includes multiple vendors, working with fiercely independent physicians, wearing different management hats, and competing with big oil for IT talent.
- About Memorial Hermann
- The application environment: Cerner Millennium, GE Centricity, (Allscripts, eClinicalWorks)
- The Memorial Herman Information Exchange
- Enterprise vs best of breed — Can you ever really get away from integration?
- Working with independent-minded docs in Texas
We’ve had a rather aggressive effort to standardize across all of our facilities, and we have accomplished that.
Even though we have Cerner for the employed physicians, I’m still dealing with the 900 physicians at UT who are on Allscripts, and I’m dealing with the independent physicians that have chosen their own EMR platform. So I’m thrust into the interconnectivity business. We made a decision for our employed physician that we think is best for them.
There’s no way that in Houston, Texas—considering the dynamics of the independent entrepreneurial spirit of our doctors—we’re going to employ 2,500 doctors and have them on one common platform that is the same platform in our hospitals. It’s just not a market reality for us.
We’ve chosen to accelerate our implementations. We’re on CPOE. We’re driving rules and alerts. We’re working on advanced, innovative functions on our platforms. We’re not back doing the basics.
With healthcare reform, with the indigent load in Houston that we have, and with the economic pressures, contract negotiations with the insurance companies and those independent doctors are becoming rather one-sided, and I think doctors are seeking refuge in some collective and group bargaining.
Guerra: Good morning, David. I look forward to chatting with you today about your work at Memorial Hermann Healthcare System. So first off, thank you for joining me.
Bradshaw: No problem, Anthony.
Guerra: Well, let’s start where I usually like to start. Memorial Hermann is definitely a big health system with 11 hospitals, but give us the lay of the land so that some of the listeners who aren’t quite as familiar can understand what’s under your purview over there.
Bradshaw: We operate in Houston, Texas—which is the fourth largest city in the United States—down in the Gulf Coast. The primary industries here are petrochemical and big oil companies. The medical field is centered with the Texas Medical Center. And that is quite a dense population of hospitals and physicians—two medical schools and 6,900 beds in the Texas Medical Center. We operate both in the med center as well as out in the community suburban hospitals, of which they are 11, as you said. In addition to that, we operate a network of 28 imaging centers and 26 sports medicine therapy and rehab centers.
We have a very active diagnostic lab business. We employ physicians; we have a very large IPA of about 3,000 physicians. We partner with the University of Texas Health Science Center, one of the med schools here in Houston, and we employ through our own 501A series of physicians. And we also have an insurance company. So we’re putting all the pieces of an accountable care organization together as this industry evolves.
Guerra: Tell me about your clinical application environment on the acute side. You have 11 hospitals—do you have the same EMR in all of them?
Bradshaw: Yes. On the inpatient side, we actually started with Cerner out of a Kansas City around 2002. We’ve had a rather aggressive effort to standardize across all of our facilities, and we have accomplished that. We range from surgery to pharmacy to ED to radiology to scheduling. And then of course, out on the units, we have CPOE at the majority of our hospitals for full clinical documentation and positive patient identification. We have a whole informatics team around clinical decision support and clinical alerts.
We’ve started our Meaningful Use stage 1 reporting period across all of our hospitals. I think two or three of our hospitals have reached HIMSS Stage 6, and we’re actually doing the paperwork for two of them to be recognized as HIMSS Stage 7.
And then on the ambulatory side, the 900 physicians that are part of the University of Texas operate on an Allscripts platform. That’s not directly in our set of controls—that’s under the University of Texas. But we have quite a bit of dataflow back and forth between and Allscripts and our Cerner system in the inpatient setting.
The IPA, known as MHMD—the Memorial Hermann Physician Network—four years ago started an effort where they offered eClinicalWorks to their physicians through a subsidy program where the doctors actually pay the IPA every month for the right to use eClinicalWorks. And the IPA has kind of outsourced that work to our IT department. We have a team—at the end of June, I think we had 484 physicians that were signed on to eClinicalWorks, with just over 300 of those live and paying their bill, and a backlog of about 184, and we’re working hard to try to get that backlog down. So we have ended with a series of EMRs in various clinic settings that we are integrating into our Cerner Platform.
Guerra: Do you have any integration going on between eClinicalWorks and Cerner?
Bradshaw: Yes, both. I also need to describe that in our own employed group, we actually are using GE Centricity. And in addition to those three larger aggregations of physicians, at Memorial Hermann we work with quite a few independent practices as well. In those independent practices, some have chosen other EMRs, from Sage to Allscripts to NextGen. And so 18 months ago, we launched an effort inside of the organization—funded by the organization—to devise, build, and go live with what we refer to as MHIE, which stands for the Memorial Hermann Information Exchange. And MHIE is actual software, people and services that provide an interconnectivity service between the hospitals and the independent physicians, as well as our highly aligned partners at UT, our own employed group, and the clinically integrated physicians of our IPA.
Guerra: You went with Cerner in 2002, you said?
Bradshaw: Yes, for the inpatient Millennium application. Correct.
Guerra: So with the employed physicians, I would imagine that one of the benefits of getting a product like Cerner is that they have the inpatient and an ambulatory product so you get that sort of integration there. But you don’t have that. So did GE precede the Cerner buy, and it was sort of there?
Bradshaw: It actually all happened around the same time. Our employed physician group is a relatively new growth strategy for us. However, it is based off of the family practice residency that has been in our system for two decades. And our lead physician at the family practice residency was one of the beta Logician customers, even prior to GE’s acquisition of Logician. And so yes, that decision for GE Centricity preceded our Cerner decision, and just recently we’ve reaffirmed that we want to grow our employed medical group on that platform for various strategic reasons.
Guerra: So as CIO, when you look at the landscape, does it kind of bug you that you don’t have Cerner in the employed physicians?
Bradshaw: Well, even though we have Cerner for the employed physicians, I’m still dealing with the 900 physicians at UT who are on Allscripts, and I’m dealing with the independent physicians that have chosen their own EMR platform. So I’m thrust into the interconnectivity business. We made a decision for our employed physician that we think is best for them. And so what we’re doing now is building the interconnectivity between all of those physician practices and the health system.
Guerra: What you say makes a lot of sense. What I’m confused by are organizations that we see throwing out everything and spending tens of millions of dollars to go with an enterprise vendor that they think is going to get them complete integration in their inpatient and in the practices they own. But you make a good point. There’s always going to be at least independent physicians outside that you want to integrate into the system, so you’re going to need some sort of HIE solution regardless. You don’t ever get away from that, do you?
Bradshaw: Well, first of all, it’s not tens of millions, Anthony. It’s typically hundreds of millions.
Bradshaw: And if the world was perfect, and I employed all the physicians that we needed to serve the equivalency of our market share in Houston—and by the way, we have approximately 25 percent of the Houston healthcare market—I think our numbers would say that would be like 2,500 physicians if we were a closed-staff model. There’s no way that in Houston, Texas—considering the dynamics of the independent entrepreneurial spirit of our doctors—we’re going to employ 2,500 doctors and have them on one common platform that is the same platform in our hospitals. It’s just not a market reality for us. So we have an IT strategy that is following the reality of the business strategy in our market.
Guerra: Do you think it does make sense in some cases, in some closed systems?
Bradshaw: Well, if they’ve got the hundreds of millions and if they’ve got the time to go back and do that, then yes, I think it would make sense. However, where we are, we’ve chosen to accelerate our implementations. We’re on CPOE. We’re driving rules and alerts. We’re working on advanced, innovative functions on our platforms. We’re not back doing the basics. So I think the thing that our industry is missing is the opportunity costs for time also.
Guerra: Right. Now I’ve interviewed Ed Marx and Ferdinand Velasco at Texas Health Resources, and they’ve also mentioned that independent streak—we get in a lot of places, but I imagine it’s even stronger down in Texas with the physicians. Do you think so?
Bradshaw: Do you remember the Marlboro Man commercial? Riding on his horse with his backpack and his rough beard—that’s the typical DNA of a physician in Texas.
Bradshaw: Yes, fiercely independent.
Guerra: Even the physicians there are independent and rugged.
Bradshaw: Yes. Some of them carry guns, Anthony.
Guerra: That’s right.
Bradshaw: Now, let me come back on that point, because there may be some of my physician colleagues that hear this and tease me and I don’t want to do that. Houston’s average practice size is 1.8 doctors per practice. We are starting to see the aggregation of groups and clinics. We at Memorial Hermann are causing some of that in the market place, and the market is starting to move around that with some of the other systems. I think the reality of being an independent doctor in a 1.8-doctor practice is a hard row to hoe going forward.
With healthcare reform, with the indigent load in Houston that we have, and with the economic pressures, contract negotiations with the insurance companies and those independent doctors are becoming rather one-sided, and I think doctors are seeking refuge in some collective and group bargaining. So we at Memorial Hermann afford them one of three options. You can come as a physician that has an academic interest in joining the University of Texas, our partner. We’ve recruited numerous neurosurgeons and trauma surgeons and a renowned orthopedic sports medicine physician into the University of Texas with our partner. Number two, you can become an employee of our healthcare system. You can sell your practice to us and you can become an employee and get a paycheck and operate in our multisite, multispecialty clinic model. Or if you are independent and you want to remain independent, you can join our clinically integrated group of physicians that stand for reporting quality, stand for holding each other accountable, and, through some recent Federal Trade Commission rulings, can collectively negotiate. And so that’s where we have approximately 2,000 physicians that are operating in our clinically integrated model that are going to the market as a whole.
So a very pluralistic strategy right now in Houston afforded from our system to basically conform to what our doctors want to do. They’re not all the same, and they choose different models.
Guerra: So you try to offer something for everyone?