As a CIO, having all hospitals within a health system on the same EMR is the ideal scenario. But as Todd Richardson knows, it isn’t always a reality, particularly when physicians are minority owners. In this interview, Richardson, who serves as CIO of the six-hospital Deaconess Health System, gives his honest take of how having physician owners can impact IT decision making, and why organizations need to accommodate the growing need among patients to access their data. He also talks about the flaws with statewide HIEs, the challenges of managing the different needs of device users, the IT rounding program his team implemented, and the importance of viewing technology as an enabler.
- About Deaconess
- Running an Epic Systems shop
- Joint ventures and enterprise applications
- Selling the system internally
- Patient migration to “My Chart” practices
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As you start pushing that out across the network, the devices are very particular. We push Epic out to Citrix so that would have to run back to our Citrix farm. So if they come on board, it will be a huge change for us as a system from an IT perspective, simply because of that level of integration.
While this is our facility, in today’s world, you simply can’t take the hard line of ‘This is my shop. This is how it is.’ Those are our partners. We need to work together with them very collaboratively—even more so as we’re going through health care reform and the payment model is going to change.
From a joint venture perspective, we’re investing as well. So they’re going to be able to drive a lot nicer, more complex, more highly developed system than they could afford to drive on their own. If they were just going to pick something on their own, they clearly wouldn’t pick Epic because of the cost.
The ones coming out of medical school now are all on their smart phones. It’s a bell curve. You have the folks that come here and go, ‘I can’t believe we aren’t on electronics,’ and the other people that say, ‘I don’t ever want to be on it.’
As patients take more and more ownership and control over their care, they’re going to make decisions based on data and based on the technology and the access that’s provided to them. And so we’re seeing a shift of having to be more conscientious of the data and health record and the continuity of care for the patients.
Guerra: Good morning, Todd. Thanks for joining me to talk about your work at Deaconess Health System in Indiana. I appreciate you joining me.
Richardson: No problem.
Guerra: Well, we will get into your Stage 7 recognition in a bit, but why don’t you start by telling the readers and listeners a little bit about the health system and all of the moving parts.
Richardson: We’re located in Evansville, Ind., throughout the southern tip of Indiana. We’re a six-hospital system and we have about 17 independent or affiliated physicians within the health system. We have a couple joint ventures. We have two main acute care hospitals, behavioral health, Women’s Hospital, which is a joint venture with the OB physicians, and Heart hospital, which is a joint venture with cardiologists. We have a venture with Health South for a rehab hospital and again, 17 physicians. We have a multispecialty clinic. With our EMR, we’re pushing that out to affiliated independent physicians in the community—they’re using Epic, so we have one patient-one chart within the health system. We service an area of about 2.5 million in the area of southern Indiana, northern Kentucky, and the western part of Illinois, so it’s quite an area that we draw from. The outlying communities that we will send out to would be Louisville up to Indianapolis primarily, and we act as a tertiary care center for a lot of the smaller critical access hospitals around Owensboro, which is about 40 miles away, down to Owensboro, Ky., and Good Samaritan Hospital up in St. Vincennes, and a number of other facilities. As Indiana goes, Indianapolis is obviously the center, but there’s no real good way to get there from here. They do have an interstate that they’re trying to get through, but it takes three to three-and-a-half hours to get up there. So we do a fair share of transporting the patients up there for critical things; Riley Children’s Hospital is up there. So that kind of gives you a sense of our health system down here.
Guerra: If you combine the two main hospitals, how many beds are we talking about?
Richardson: A little over 450 beds total.
Guerra: Okay. Do you have a lot of owned practices and affiliated practices?
Richardson: That’s correct. We have 17 clinics that are owned, representing about 125 physicians—multispecialty and family practices, as well as specialty clinics and affiliated physicians that are on the medical staff.
Guerra: And you said you’re an Epic shop?
Richardson: We are. We are a fully deployed Epic EMR across all of the facilities, with the exception of Women’s Hospital. Because of the joint venture, they’re working with their physicians now trying to figure out what they want to do on their EMR side. They’ve done some site visits with Epic. They’re looking probably to move to Epic—it makes sense for us as a health system. But again, having that joint venture, they really will make the call, and we’ll do what we can to support that effort.
Guerra: When did you sign the Epic deal?
Richardson: I’m not sure of the exact signing date.
Guerra: In what year?
Richardson: I believe that was about 2007-2008.
Guerra: And you’ve been there about two years almost?
Richardson: I’ve been here about a year and a half.
Guerra: So it preceded you. And at what stage was the implementation when you first took a look at the organization considered coming on? Was it all finished or where there still things being rolled out?
Richardson: When I came on board, we were in the middle of it—a lot of it had already gone live. We’ve had several go-lives since I got here. I don’t know what stage the organization was at before the Epic contract. It was a pretty quick install—less than 18 months from contract signing to go live. We went live in May of 2009 in the ambulatory environment with those physicians in their clinics, and then in November 2009 we went live in the hospital in the acute care setting. We did a big bang—CPOE came on in February.
I came in April and then since I’ve come on board, we’ve brought live the op time in the ORs, and we just brought anesthesia on in September. Things like MyChart we’ve rolled out for the patient portal, and we’ve done two major upgrades. So we are currently on version 9 of Epic and we are in the midst of our next install to go to version 10 probably sometime next fall.
Guerra: You mentioned that one of the many joint ventures you have is with the Women’s Hospital. That is the only entity in your health system that is not on Epic, correct?
Richardson: The Health South facility is a joint venture. We’re a secondary owner. They’re not on anything. They will probably be going with Cerner—that’s the Health South model.
Guerra: So that’s another entity not on Epic.
Richardson: Correct. And we don’t provide support for them on the IT side while it’s a joint venture. They really have their own systems.
Guerra: Okay, so it’s not that big of an effect on you. Although there are integration issues there if you want to link things up, right?
Guerra: And the Women Hospital is your responsibility?
Richardson: They have a separate IS staff over there—a very small staff of about five folks. When they come on board with Epic, we’ll be working with them to try to figure out what that looks like. They don’t have the staff to bring on Epic and support that. They will certainly rely on us. We’ve played with the thought of rolling Epic out to the affiliated hospitals—some of the smaller critical access hospitals that don’t have EMRs or are in need of one—in a model much like with the independent physicians. So we’re kind of playing right now and coming up with the total cost of ownership for them and seeing how that will roll out.
Being a Women’s Hospital, they have all the OB work there. So the Stork product, which is Epic’s product for the OB area, we don’t have within the health system because all of the babies are at the Women’s Hospital.
So as they come live with that, they would certainly have ownership of that. But as you get into these EMRs, you can’t really flip switches and touch things in any of the modules because they have that ripple effect throughout the system. So as we look at registration scheduling, we already have that up. That would all flow through us, so we’re putting together the model now to say, what staff would be required to bring on to support that? Those would be my staff at this facility. And we own their IT department, but their systems from an Epic perspective really would be controlled by us, even to the extent that as you start pushing that out across the network, the devices are very particular as it relates to printing and setup. We push Epic out to Citrix so that would have to run back to our Citrix farm. So if they come on board, it will be a huge change for us as a system from an IT perspective, simply because of that level of integration.
Guerra: Does Deaconess have majority ownership of that Women’s Hospital?
Richardson: We do.
Guerra: Okay, so you’re not doing to dictate, but you pretty much run the show at that hospital. It’s not like you’re a minority owner and you have to go with what they say. How does that work from a point of view of, you might say, ‘Listen, the best thing is to go on Epic,’ but they want to go in another direction. If Deaconess has majority ownership, Deaconess makes the call.
Richardson: Well, when you have the majority ownership but the minority ownership are the physicians, one would call in to question who really has the minority or majority ownership.
Guerra: Excellent point.
Richardson: Within our health system, it really is a partnership. Clearly we work to support the physicians. We have a number of independent physicians around that bring their services and provide care at our facilities. While this is our facility, in today’s world, you simply can’t take the hard line of ‘This is my shop. This is how it is.’ Those are our partners. We need to work together with them very collaboratively—even more so as we’re going through health care reform and the payment model is going to change. We’ve got all be in this thing together. We are not an organization that tries to dictate. We would be better served to come into the table and say, ‘Okay, what makes sense?’ Clearly, it makes sense when we’ve got a huge investment in Epic if it’s one of our co-owned facilities to have Epic in there simply because of the continuity of data and the continuity of care from a patient’s perspective.
I sit back and look at it from a patient’s side. If I work within the Deaconess Health System for my care and I go off and get married and have a child, and I have my child at Deaconess facility, why would it make sense for that part of my record to be in another system that really doesn’t flow back into my record for my primary care physician who I’m working with on a daily basis to see? Conversely, in having the child, doesn’t it make sense that all of the data that’s in my record is accessible? While those physicians would have access to Epic, they would be bouncing back and forth between the two systems and we’d lose that continuity. I think that as we laid that out, it makes sense to them but you just can’t go into this with the mindset that we’re the majority owner and this is the way it’s going to be. It just doesn’t work that way.
Guerra: It’s fascinating. The dynamic is fascinating to me. You make a huge investment in Epic, and one of the benefits and one of the goals is to get everybody on the same system, but when you’re involved in these joint ventures, even when you’re majority owner, as you said, you can’t ram it down their throat, so you have to really sell. But at the end of the day, could you live with them picking another system?
Richardson: Well as a physician, you have to see our side—we are a health system. And the investment that we have is as a health system. On the other side, you have a bunch of physicians whose personal pocket book is in the investment of that, so they are owners. They are owners in that hospital differently than I am an owner in Deaconess Health System. While I work here, is not my financial wherewithal that’s funding that side of the partnership.
So when you’re talking about money, when you’re talking about Meaningful Use, when you’re talking about getting there, they’re talking about their investment as individuals—they’re businessmen and they’re physicians. And so I think the data is there and they’ll make a good business decision that’s going to be cost-effective in their minds. Epic is a very large, very complex, very expensive system. And their investment in that will be tremendous. That being said, it will be basically a 50 percent investment because we will be investing the other part of it.
So, we have to keep it from a joint venture perspective, we’re investing as well. So they’re going to be able to drive a lot nicer, more complex, more highly developed system than they could afford to drive on their own. If they were just going to go and pick something on their own, they clearly wouldn’t pick Epic because of the cost. If they’re getting subsidized at a 50 percent rate because we’re the other 50 percent owner—and I say 50 but it’s actually 51-49—you can drive a lot nicer car for half the price, but in the end it’s got to make sense for them. And I think it probably will.
Guerra: So let me just make sure I have it straight. In the scenario you’re describing, the physicians are owners of the hospital—that’s the 49 percent.
Guerra: Okay, so it’s a physician-owned hospital.
Richardson: Yes. The members of the physician OB group are the other owners, so every one of them is a partial owner.
Guerra: Okay, so that’s even more interesting.
Richardson: Much like the Heart Hospital. The cardiologists are the owners. So they are part owners, and they’re business people.
Guerra: So they may be looking at another system and saying, ‘Hey we can get this at a lower price.’ I totally understand the dynamic. I get it. It’s just really interesting, right? There are so many people with different stakes and different points of view and there’s a lot of money at stake and people’s careers and everyone’s health—it’s a lot going on.
Richardson: And some of them, to be honest, are at the end of their careers and they’re looking at retiring, and they’ve done things on paper forever. Why would they want to change? Why would they want to change and invest their money in an electronic system if they’re going to be out in a couple of years? The ones that are newer in their careers that are going to be there for a while see the trends. The ones coming out of medical school now are all on their smart phones. It’s a bell curve. You have the folks that come here and go, ‘I can’t believe we aren’t on electronics,’ and the other people that say, ‘I don’t ever want to be on it.’ And then they’re scattered across the curve.
Guerra: The physicians at this particular hospital—are there some of them who travel around the health system more than others and therefore they might have more of a vested interest and being on a system where they can pull up the data in any facility?
Richardson: Well again, they’re OB-GYN physicians, and the work that they do is primarily within their office practice and then at the Women’s Hospital.
Richardson: We’re not doing labor and delivery out in the main campuses. Some of them will come out if one of their patients comes over, but they don’t, for the most part, get into the systems and play with it, other than logging in to take a look at the information because one of their patients was in the primary care or internal medicine practice and now they’re pregnant and they’re moving to the OB-GYN for the labor-delivery component. They might login to Epic and look at the record because that record exists and they have privileges within the health system, but the data doesn’t exist within their system so they’re going to log in and look at it. So there’s some interaction, but it’s not like they travel around the health system like a primary care physician or a neurosurgeon that’s in the hospital rounding on patients. They’re not.
Guerra: So it’s a little bit of a tougher sell.
Richardson: It is, because they kind of see themselves, I would think, as this little island that sits out there, and they’re really just worried about the data and the information as they see patients within their practice and then within the hospital.
Guerra: So there has to be a concerted sales effort on the part of the Deaconess administration—not just yourself, but you’re definitely a big part of that—to convince this hospital to come along on the Epic ride.
Richardson: Yeah, I would say so. But we certainly don’t want to approach it as a car salesman and try to be a car salesman—not offense if there are any out there listening. It’s just data. What is it we want, and what is in the best interest of our patients? I think you need to continue to drive that mantra—what’s in the best interest of the patients. And I think that’s a big change that we’re going through as an industry—patients are beginning to take more and more control over their health and over their care and are making choices. We have physicians across our health system that use and are pushing out the portal MyChart so the patients can access their medical record online. Some of them aren’t embracing it as well as others. And I know we’ve got employees within the health system that are changing physicians to move to one that is more supportive and will allow them access to their charts.
We’re seeing migration of patients because of the rollout of MyChart and access to their records. So as patients take more and more ownership and control over their care, they’re going to make decisions based on data and based on the technology and the access that’s provided to them. And so we’re seeing a shift of having to be more conscientious of the data and health record and the continuity of care for the patients.