As a veteran of healthcare IT, Alan Abramson knows one of the biggest hurdles to adoption is in convincing providers that implementing IT systems won’t disrupt workflow. At HealthPartners, an organization in which clinicians are leveraging electronic data to close the gaps in disease management, the merits of IT are well understood. In this interview, Abramson talks about the advantages of having employed physicians, the importance of having a deep understanding of the clinical practice, and how he benefited from being on the ground floor during early IT implementations. He also discusses HealthPartner’s Epic everywhere journey, the opportunities and challenges presented by HIEs, and the role that EMRs can play in mergers and acquisitions.
- HealthPartners’ Epic everywhere journey
- Considering the EMR factor in hospital M&A
- HIE opportunities and challenges
- The occasional disconnect between policy and reality
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In a couple of cases, it started more as an affiliated relationship and then became a joint-ownership position, partly due to the need for capital funding for the acquisition of the electronic record, and partly because it became clear that scale economies really do work in healthcare.
Physicians in the hospital environment and specialists said that for the benefit of the patient care and the benefit of the historical database, a single integrated product is our preference over a best-of-breed subsystem solution that might be better in meeting the needs of a particular specialty. And that just blew me away.
There really are no IT projects; there are business projects that have dramatic impact on daily business practice, and therefore they need to be business-led decisions. And IT — we haul the water, we do the work, we do the integration, but we’re directed by committees that have the interest of the business at heart.
There are advocates in Minnesota legislature that are proposing even more stringent controls, including the concept — and I think this is ill-informed — that a patient must give consent for every individual transmission of data; even, it appears, within IDNs.
When lobbyists get together and provide strong voices in subcommittee meetings, there’s a tendency for elected officials to give more credit to those vocal individuals that show up at hearings and less credit to professionals in an industry.
Guerra: You’ve got four hospitals, the largest one at 454 beds, one at 97, and two at 25. I was looking on your website, and I see they were built up through acquisition and fairly recently over the last 10-15 years, it looked like. I understand you’re an Epic shop. Are you Epic everywhere in your organization? When did you go on Epic and how did you handle acquisitions? We’re assuming that some of these acquired hospitals were either on nothing or on a different vendor, and I’m also going to assume that you have put in Epic everywhere. Can tell me about that journey?
Abramson: Yes we have. Most recently the last two hospitals came up in February of this year. We’re on Epic, as I said, from the development of their ambulatory system, so 2004 in the clinics, 2006 in Regions Hospital, and as these new organizations joined us, we put in plans to move them forward with our standardized systems. It’s a model that’s used more than just in our organization — in Minnesota, most IDNs have this approach. And I would not really call these acquisitions; I would call them mergers from the standpoint that these individual community hospitals looked pretty critically at how they were going to get to the electronic medical record and then invited organizations like ours to talk with them about potential partnership.
In a couple of cases, it started more as an affiliated relationship and then became a joint-ownership position, partly due to the need for capital funding for the acquisition of the electronic record, and partly because it became clear that scale economies really do work in healthcare. And with common population coverage and the need for referrals in tertiary specialty care, these community hospital organizations and their affiliated provider groups — some owned, some not owned — found it to be the best model to pursue to partner up with a larger organization like ours. So that’s how this other hospital groups joined us. We’ve got a couple more affiliate discussions underway, and in so doing, they were able to get the benefit of the installation of the Epic record, which did require modifications for their community hospital focus. There’s a little bit of the sense of too much organization and too much complexity in a large tertiary care center. So interestingly, as we did these last hospitals in February, we actually led with the billing system in the community hospital and came back and replaced the non-ready ICD-10 billing system in Regions Hospital with the ICD-10-ready system from Epic, and so that’s an interesting case where we started more simply in the community environment and then moved to the more complex billing system at the larger hospital.
The clinic systems did not go that way. They were developed obviously in our larger environment, and then we looked at workflow processes and where we need to either simplify them slightly or modify them for the rules in Wisconsin, because two of those hospitals are across the St. Croix River in Wisconsin as opposed to Minnesota, and they had some slightly different rules. But by and large, the single footprint, single common electronic record database, single record for me as a patient, regardless of which organization I go to, is all preserved in these installations and it is Epic everywhere, you’re right. With the exception of some lab systems and some pharmacy subsystems here and there and some of these other vocations, which probably ultimately will evolve to a completely Epic-centric environment.
Guerra: Could you picture a merger or acquisition of a hospital by your organization that wasn’t on Epic and going on Epic was not part of the agreement, so you would have an outlier?
Abramson: I suppose that’s feasible. I think it would be unlikely. The circumstances would have to be other than our current business model, I think. They would have to be forced, probably through healthcare reform or some other kind of model that would change our basic focus. Now I think it’s a small probability, but for example, a merger with an organization similar to ours in a completely different state that was needed because of the continual advantage of economy of scale — they might be totally integrated around a Cerner product or something else, which would then in the longer run force a discussion about which system would ultimately prevail. And I say it with that example because that’s the discussion that took place at Allina over the years as that organization grew, and we had that discussion many times. But after a few years, the answer is usually a single integrated IT department and a single common footprint with very few exceptions in particular cases.
Guerra: And I would imagine in those discussions, one of the things that CIO needs to bring to the table is what exactly the challenges will be or what will be given up or what investments will have to be made in interfacing in order to bring the organization back to the level of data fluidity and integration it had before the acquisition. Does that make sense?
Abramson: That’s exactly the discussion, and what happened with these mergers I referred to earlier back in the 1990s at what became Allina. What I thought was really interesting and it was a change-point in my career was in the 2004-2005 discussion with Regions Hospital as to whether they would look for either a separate product or a best-of-breed solution. Physicians in the hospital environment and specialists said that for the benefit of the patient care and the benefit of the historical database, a single integrated product is our preference over a best-of-breed subsystem solution that might be better in meeting the needs of a particular specialty and the workflow or the demands of a particular subspecialty. And that just blew me away that physicians working together would see the big picture and uphold the advantages of that integrated approach. Usually that’s the IT people trying to bring that discussion from their perspective of a little bit more abstraction than actual day-to-day workflow. In this case the physicians led the discussion and it was an easy decision after that, and we’ve never looked back. And when we have new physicians in the discussion, we bring him over and talk with those physicians that were there when they made that decision and they talk about why they did it and why there’s an advantage.
Guerra: I guess the main thing you don’t want is to remain silent for whatever reason and then have everyone making the decision expect that you can just plug the two systems into each other with no problem.
Abramson: No you can’t do that, and we never let it be an IT discussion or an IT decision. We learned long ago there really are no IT projects; there are business projects that have dramatic impact on daily business practice, and therefore they need to be business-led decisions. And IT — we haul the water, we do the work, we do the integration, but we’re directed by committees that have the interest of the business at heart and that’s all the way through our organization, from the enterprise steering committee and its investment decisions for the long term, all the way down to the subspecialty practice that’s optimizing the latest release of the product.
Guerra: Let’s talk a little bit about HIE work. I see you’re the chair of the Board of Directors at the Minnesota HIE, and as we said, you’re responsible for the health plan and provider parts of your business. Tell me about your organization’s HIE journey in terms of going beyond your organization and its component parts and even those independent physicians that are referring in — beyond that, what kind of HIE work are you looking at?
Abramson: There’s a lot of good news there, but it’s been a mixed solution in the long run with a lot of ups and downs. Because of Minnesota’s early investment in the electronic record, we had integration within IDNs to a pretty high level fairly early on. When it came to exchanging data between HIPAA entities — and I’ll use that term because in Minnesota, these IDNs are usually structured as a single HIPAA OCR, which I think is the acronym for an organization-wide HIPAA construct — the exchange of data between them is really what HIE turns out to be in Minnesota. So at one point, we did some innovative work before other states and exchanged a little data back and forth — this was an era of the development of some of the early HIEs like the Wisconsin Health Information Network. There wasn’t much of an economic model supporting it so that fell by the wayside.
Then along came initiatives at the Federal level, and ultimately the state of Minnesota level, and Minnesota legislature adopted a mandate that all providers have an interoperable electronic record by 2015, which put in motion some state-wide activities. CEOs of the major providers met and agreed with CEOs of the major health plans and said this is a good thing to do. They set up a health exchange shell organization which was a not-for-profit, put several million dollars into it, and stood up a health exchange called the Minnesota HIE, which had about I think about three million of Minnesota’s five million patients in the master index with a record-locating service and the ability to find medication histories, which was used daily in emergency rooms for patients that hadn’t been seen previously for which they did not have longitudinal record at hand. And it was useful but pretty narrowly defined.
Ultimately the economic model supporting that became something that was not sustainable, and despite the mandate for 2015 interoperability, that organization could not crest the hill to ultimate sustainability. And with the federal funding on the 3013 program that’s putting, in Minnesota’s case, about $4.5 million of federal stimulus money into the operation of HIEs, the rules that evolved in Minnesota were that we needed to have a Minnesota-based, not-for-profit 501c3, which the Minnesota HIE was not structured as for a number of technical reasons, one of which was Minnesota law did not permit that structure at that point. But the legislature changed that and changed the rule, and so now that’s evolving through kind of a merger concept to a single Minnesota base 501c3, which in some ways are going back and starting over with some of the development work on the record locator service. So it’s not functioning at the level of the previous one yet, but it intends to very shortly. That’s one whole story and that’s a story about state-initiated efforts with a lot of state governance and heavy external control from a governance and management standpoint with kind of a review committee that’s not unlike a public utilities commission for a utility corporation. That’s one effort.
Concomitant with this was the individual vendors like Epic bringing forward fairly simple exchange using the direct protocol. And so the providers of Minnesota that have Epic have begun to exchange pretty frequently with the use of Epic’s Care Everywhere model. That was put into place among those providers in the last year or two, and pretty much for the same purpose, emergency departments looking for record data or a new patient registered in a hospital from another provider. It’s fairly simple and it works remarkably well with appropriate consent in place for providers to be able to get access to that record from another provider for that same patient. So that’s the status today. I think it’s in a transition phase, and ultimately and certainly by 2015, we’ll have a more integrated model in Minnesota. But right now, it’s fairly fragmented.
Guerra: Many organizations cross state lines with the patient population. You’re right on the border with Wisconsin or pretty close to Wisconsin, and Iowa is a bit away. But have you found it challenging dealing with state initiatives when you’ve got to deal with Minnesota initiatives and Wisconsin initiatives? Are they pretty lined up or is it sometimes difficult to navigate the two states in putting together an HIE?
Abramson: We’re fairly collaborative in this part of the country, and that is true for government as well. Having said that, Wisconsin has some of the most liberal laws about the exchange of patient data with consent — although there may be some changes coming about now — and Minnesota has one of the tightest. There are advocates in Minnesota legislature this session that are proposing even more stringent controls, including the concept — and I think this is ill-informed but there is an idea among some legislators — that a patient must give consent for every individual transmission of data; even, it appears, within IDNs, although that’s debatable at this point. But there are advocates for contacting that patient every time information is to be exchanged.
So we have very strong laws. The two states, Minnesota and Wisconsin, have been talking about a common consent program. It’s actually a prototype that’s been drafted and is being discussed. It’s based around the notion of opt-out as opposed to opt-in, which actually is in the Minnesota record locator service statute, so on that point, Wisconsin and Minnesota are somewhat compatible. But the idea would be that a patient has a responsibility and the right to opt out of these systems and to block the transmission of data, and they can do that at a record-locating service or at the HIE level. And even though they have said ‘yes’ in terms of transmitting data to each of their individual physicians, anywhere either in this state or multiple states, they can also reverse that by opting out and blocking all those transmissions of data at the exchange level.
So it’s a fairly complicated process being developed here that would involve keeping the equivalent of ‘do not call’ lists that we think about for telephone solicitation. And those organizations that are licensed to operate as HIEs would have to maintain these ‘do not transmit’ lists until the patient reverses their decision. This of course involves proper education for the patients and the realization at the patient level that in an emergency, although there are some break-the-glass rules, they might be in a situation of having their record information blocked because of their decision to opt out of these systems.
Guerra: I think you used the term ‘ill-informed’ referring to some of the things under consideration. Do you find that a lot of times the policy makers or policy influencers — or, to use a word I really don’t care for — stakeholders sometimes don’t pay as much attention as they should to whether or not some of the things they’re talking about or promoting can be actually operationalized?
Abramson: That’s very true, even more so because there are they’re politicians, they’re very sensitive to voices. And when the lobbyists get together and provide strong voices in subcommittee meetings, there’s a tendency for elected officials to give more credit to those vocal individuals that show up at hearings and less credit to professionals in an industry because of the assumption that industry always works to benefit the industry against the individual consumer. And so what we found is vocal minorities that present themselves as having the voice of the consumer, when you talk to a wider variety of people — for example, we have our own patient focus groups and we ask them the same questions that are being asked at the legislature — we find that these patient groups are much less likely to voice the opinions that are being voiced by their advocates supposedly down at the legislature. So it’s difficult to be a politician and have to know all the details about how an industry operates in order to pass the rules for that industry. And it’s difficult to be in a situation of having such vocal interest groups always available for every individual kind of hearing.
Guerra: Right, so true. They’re always there. They always have someone to show up because that’s their full time, job influencing policy, whereas the rest of us have day jobs, right?