When it comes to running a 23-hospital health system, Michael Warden believes too many decision-makers can spoil the broth. So when his organization merged with another to form Banner Health, Warden was fully on board with the goal of implementing a centralized governance model. However, he knew that this meant getting separate departments to communicate more effectively, and finding a way to combine budgets. In this interview, he talks about what it was like to walk into a merger, why it’s critical for CIOs to take control of the budget, the system Banner has for evaluating new ideas, how the organization is working to facilitate data exchange with physicians, and his clinical application strategy.
- HIE/ACO work in Arizona
- “It’s a huge undertaking”
- Security challenges
- The patient identifier problem
- Managing mobile devices — BYOD
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We haven’t had any grant money whatsoever thus far, and we can sustain the organization into the future without any grant money. Although, like all new and getting-off-the-ground organizations, we hope to have a little bit of the state and federal grant funds allocated to us to do certain things that benefit the state beyond basic exchange.
There’s a huge infrastructure that has to be built. So for Banner, that means recruiting and contracting with a large number of non-employed physicians, and bringing systems to those participants so that they can contribute data that can then be aggregated and processed and made available to them so that they can practice medicine in a more efficient and more reliable way.
If you misidentify somebody and you send data about the wrong person to somebody, you’re liable to be sued, and you’re not even held harmless if the mistake is made in good faith — those kinds of nonsense things where the government is demanding that we do things but not providing the tools.
We are held accountable for security even if we’re doing the best job using the best tools available to us in the industry. If someone still breaks in, we’re criminally liable. That’s sort of like holding the bank responsible for a bank robber.
Rarely are the decisions judged today; they’re always judged three to five years from now as far as whether you’re headed in the right direction or not. So you really have to look out a little ways to be sure you’re doing the right thing.
Guerra: Let’s talk a little bit about your work with the Arizona Health-e Connection. You’ve got two concepts. You’ve got to integrate everything within each hospital, and then you’ve got everything running off the same system so all your hospitals are able to pull up information. So that’s the internal piece, and then you’ve got external integration. I would imagine that’s where Arizona Health-e Connection comes in. And you’re on their board as a non-permanent member — I don’t know if you still are but you were. Tell me about your work with them and how that’s going to help move the organization forward.
Warden: Well, there are two organizations here in Arizona that operate in this similar space. Arizona Health-e Connection was the original organization that came about because of work that Governor Jan Brewer did when she was governor of Arizona. She wanted to start fostering the use of technology in healthcare in Arizona and so she and her staff worked pretty hard to put together this idea of a group, an organization—the Arizona Health-e Connection—that would work to foster the development of deployment of health information in healthcare. So I am on the board and have been on the board since its inception, and that organization does a lot today to educate the consumers and to educate healthcare providers. They’re also participating in the regional extension program to help physicians acquire and implement technology to meet Meaningful Use. But they haven’t really been directly responsible for health information exchange. There’s a separate organization in Arizona called the Health Information Network of Arizona (HINAz). HINAz is the health information exchange, and I sit on the board of directors and the executive committee of that organization. That organization is trying very hard to actually operate a robust health information exchange where Banner is one of the early participants in that process. Currently we are sending data to HINAz, which is running the Axolotl health information exchange engine, along with some other participants, and getting ready to fully operationalize that exchange.
Today, if you think about Banner, because we have so many hospitals here in Arizona, we’re about probably 25 percent of the inpatient volume in Arizona or something pretty close to that. We are already operating, in Banner, the largest health information exchange in the state, because we exchange all our data with all our facilities. As we move into HINAz with Banner Health, Carondelet Health Network, Tucson Medical Center, and Maricopa Independent Health System and a couple of others as early participants, we’ll have over 50 percent of the state of Arizona pushing data through the Arizona Health Information Exchange very shortly here within the next two or three months.
Guerra: We continue to see the sustainability concern about HIEs, is that a concern of yours with the entity you’re talking about?
Warden: It’s always a concern, but when we started putting this organization together a couple of years ago, we started off with the understanding that sustainability has been probably the biggest challenge for health information exchanges. So we have a model that we put together that has funding by participants, hospitals, healthcare providers, physicians, and health plans, all participating and all funding their fair share of the organization. It’s a self-sustaining organization. We haven’t had any grant money whatsoever thus far, and we can sustain the organization into the future without any grant money. Although, like all new and getting-off-the-ground organizations, we hope to have a little bit of the state and federal grant funds allocated to us to do certain things that benefit the state beyond basic exchange.
Guerra: Did you wind up becoming a pioneer ACO?
Warden: We are.
Guerra: And what does that entail?
Warden: There are a number of specific requirements to meet ACO funding, but it turns out there’s a huge infrastructure that has to be built. So for Banner, that means recruiting and contracting with a large number of non-Banner employed physicians, and bringing systems to those participants so that they can contribute data and contribute information that can then be aggregated and processed and made available to them so that they can practice medicine in a more efficient and more reliable way. So it takes building the administrative part of the organization, building a set of analysts and scientists to think about how to use the data properly, contracting with lots of doctors and also with health plans and members, and getting the whole thing off the ground — it’s a huge undertaking.
Guerra: I only had one or two more questions. Is there anything else you want to talk about; any things you’re doing or thoughts on anything in the industry?
Warden: No, the biggest worry of course for us today or one of the biggest worries — I guess there are a lot of them — is security. We’re being challenged to do a number of things, but we don’t have the tools today to do some of them. For example, we’re being challenged to exchange health information widely and reliably, across not only a city but a state, and maybe even a region or maybe even the United States, and yet we don’t have a national patient identifier. It makes it very challenging. So on one hand, the government is telling us to exchange data, and on the other hand, it is saying, but I won’t help you identify anybody. And in fact, if you misidentify somebody and you send data about the wrong person to somebody, you’re liable to be sued, and you’re not even held harmless if the mistake is made in good faith — those kinds of nonsense things where the government is demanding that we do things but not providing the tools.
Secondly, the government is not providing any standards for some of this exchange and some of this information. So again, they’re asking us to invent these processes, but if we make mistakes then we’re accountable for those mistakes.
Thirdly, security; we are held accountable for security even if we’re doing the best job using the best tools available to us in the industry. If someone still breaks in, we’re criminally liable. That’s sort of like holding the bank responsible for a bank robber to come in and rob the bank instead of holding the bank robber hostage. That puts a huge worrisome cloud over healthcare today.
Guerra: And it takes a lot of investment that could be going elsewhere.
Warden: It takes a lot of the time and a lot of the investment that could be going elsewhere, and introduces us to a large amount of risk.
Guerra: Right, it goes contrary to giving you the desire to go out and exchange ever more information with more and more partners.
Warden: Yeah, it makes it much tougher and more expensive. Now one of the challenges for healthcare is that we can be held at least slightly harmless if we can encrypt all of our data at rest. But I can tell you today, we have about 14 or 15 terabytes of patient data in our Cerner database, and we’re not sure how to encrypt all that today and still be able to process the that volume of data.
So these are big challenges that we’re facing. And then lastly, there’s the whole mobile device challenge. Everybody has got their own devices. They all want to use them at work, and yet they are very insecure devices as far as we’re concerned. We’re not in full control of those yet. So we have activities underway to try to gain control of mobile devices in such a way that they can be used, but they can only be used under a controlled situation.
Guerra: As a final question, you’ve been in the industry a long time certainly; you’re what I would call a veteran. For some of your younger colleagues that are maybe getting a little bit overwhelmed by some of the stuff, do you have any advice on how they can keep their heads above water?
Warden: I always thought the younger folks didn’t get overwhelmed. This may be the new normal for me, but for them it’s just the way it is. My only advice to people is whenever you’re making a decision about anything, move yourself forward in time about three to five years, and turn around and look back and ask yourself, ‘did I do the right thing when I made that decision?’ Because rarely are the decisions judged today; they’re always judged three to five years from now as far as whether you’re headed in the right direction or not. So you really have to look out a little ways to be sure you’re doing the right thing.
Guerra: Great. Well that was all I had for you today. I have to point out that you didn’t think we’d be on the phone 45 minutes and it’s been 53.
Warden: You were right and I was wrong, as usual.
Guerra: Thank you so much, Mike. This was a real pleasure and like I said I hope we get to work together again soon.
Warden: You bet. It was nice talking to you. Thanks for letting me ramble.
Guerra: Have a great day.