They’re the words every CIO dreams of hearing: “Thank goodness we had an EMR.” When a new building sustained fire damage a few years ago, it could’ve been devastating. But because Franklin Community Health Network’s last clinic had just gone live, not a single record was lost, and CIO Ralph Johnson was given an opportunity to assess the organization’s disaster recovery plan and to revisit his device management strategy. In this interview, Johnson talks about leveraging partnerships with large health systems while remaining a standalone, why a CIO’s best strategy is to make a recommendation — and then step back, the risk small organizations take on with ACOs, his work with the ConnectME Authority, and why he has no regrets.
Chapter 1
- About Franklin
- A standalone partnering with large systems
- Meditech in the hospital, eClinicalWorks in the practices
- Recovering after a fire: “It was a good test”
- Managing device preferences
- Workflow & governance challenges
- Letting docs make decisions — “I abstained from voting”
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Bold Statements
All the practices in that building actually had to move and relocate during that process. It was probably the only time I’ve heard a doctor say, ‘thank goodness we had an electronic medical record.’
The tablet computers really didn’t work the way they thought they were going to. So when we rebuilt those practices, it gave us a chance to replace that technology with something that suited their workflow better.
We could have three primary care practices with probably a complement of nine physicians all chart a flow sheet for PT/INRs differently — and they each wanted to bring their own methodology forward.
I abstained from voting; it was 10 physicians who chose the system. I offered input into what would work and what wouldn’t work or what the consequences were, but I really wanted the decision of what EMR we chose to be their decision, not mine.
My role is to say, ‘You need to decide but here are the consequences of that decision.’ For example, ‘I will be able to flow lab results from one system to the other,’ or ‘I will not be able to flow a medication list.’ Be very upfront and explain those things.
Gamble: Hi Ralph. Thank you so much for taking the time to join us today.
Johnson: Thank you for inviting me.
Gamble: Why don’t you start off by giving us some background about the organization, just in terms of bed size and what you have in the way of ambulatory services?
Johnson: Sure. Franklin Memorial Hospital is a sole community provider. We’re currently staffed for 45 beds and we’re located in Farmington, Maine. We’re the only hospital in Franklin County. Geographically, Franklin County is about the size of Rhode Island, but it only has a population of 44,000 so it’s a small, rural area. We are not part of any of the health systems here in Maine, so we will partner with the Eastern Maine Health System or MaineHealth or even Central Maine Healthcare, but we’re still independent. I’m not sure how much longer that will last given the changes in accountable care, but right now, that’s where we stand.
We also have a number of satellite facilities. We employ about 85 percent of the physicians in the community. We operate 11 physician practices to serve the area, and we also have the ambulant service for the county.
Gamble: When you talk about the partnerships with Eastern Maine and MaineHealth, what does that mostly entail?
Johnson: Usually it’s to bring specialties to the area where we don’t have enough volume to actually support that specialty. We operate a cardiology clinic where MaineHealth has a cardiologist who comes up here two days a week. We also operate an oncology program, where we have an oncologist who’s here, I believe, three days a week. We do some other programs, like pulmonology — just the areas, as I said, where we don’t have enough volume to justify offering that service ourselves.
Gamble: What area of the state are you in?
Johnson: We’re in the western mountains. We’re right near the three large ski resorts in Maine, so it gives us a good orthopedic business in the winter.
Gamble: Yeah, I imagine. What is the nearest city?
Johnson: Lewiston-Auburn is about 45 minutes from here, and Portland is about an hour and a half.
Gamble: Okay, let’s talk a little bit about the clinical application environment.
Johnson: Well, the hospital has actually been on Meditech’s clinical system since I would say the 90s long before I got here. The practices were paper-based, and then in 2009 we selected eClinicalWorks, and we brought them forward into an electronic medical record. It was actually kind of ironic that we went live with the last practice in December of 2009, and in January of 2010, our new medical arts center actually had a fire. All the practices in that building actually had to move and relocate during that process. It was probably the only time I’ve heard a doctor say, ‘thank goodness we had an electronic medical record.’
Gamble: Oh my gosh. I imagine that threw things for a loop.
Johnson: A little bit, yes, but we recovered quickly from it. It was pretty quick because everything was electronic. The fire was on a Saturday morning, and we had staff in on Sunday in our computer training room actually bringing up the patient schedules. We had already identified where we were relocating the practices and staff, so we were recalling those patients and directing them to the new practice. I think we only had one practice — the one that was immediately impacted — that was closed for four days. All the other practices picked right back up. It was a good disaster test.
Gamble: Yeah, exactly. That’s something you just don’t anticipate, especially with that timing.
Johnson: Right.
Gamble: How long did it take the practices to be able to set back up in those buildings?
Johnson: It took a while, actually. Only one side of the building had smoke damage, and so we had those practices back in action within two weeks. The other two practices had water damage and everything else, so we had to replace sheet rock. I would say it was by that fall that they were back — about seven or eight months later.
Gamble: As far as the response to this, were you following a disaster plan that you had in place, or was it a lot of improvising?
Johnson: A little bit of both. The computer room itself was not damaged, so our traditional disaster recovery plan didn’t really kick in. What we did do is use the hospital incident command center approach that most hospitals apply for disaster or emergency preparedness. Our COO took over as the incident commander during the process. We took teams and went out and did just as I described and rebuilt how we were going to get the practices up and running.
Gamble: I’m sure there were a few takeaways you had from going through an actual situation.
Johnson: Yes. One of them was it was certainly an opportunity to revisit some of the technology decisions we made. Our physicians thought that they wanted to use tablets before we went live and when we were building the system and getting everything ready. And then what they found was the tablet computers really didn’t work the way they thought they were going to when they were taking care of the patients. So when we rebuilt those practices, it gave us a chance to replace that technology with something that suited their workflow better.
Gamble: What did you find that they liked to use?
Johnson: It’s a mixture. We have some who would prefer to have a laptop with a larger screen than the tablets offered, and some of the providers actually prefer having a stationary computer in the exam rooms so that they could go room to room and just pull up the records there. That’s actually proven to be a secondary benefit for patient education depending on the practice we’re in, because we could pull up PACS images in the orthopedic practices. The physician can bring that image right there to the patient to show them as they’re talking.
Gamble: As far as the practices going electronic, it’s a big leap going from paper to electronic. Did you find that there were challenges like in terms of change management, and if so, how did you through those?
Johnson: Not so much in change management — it was more around workflow and governance. We discovered early on that a number of these practices are primary care. We could have three primary care practices with probably a complement of nine physicians across those practices all chart a flow sheet for PT/INRs differently — and they each wanted to bring their own methodology forward. Well, if you’re going to have a single database to be able to follow that patient regardless of which practice they’re in, we need to standardize that.
Getting the physicians to agree on standardizing those flow sheets, for example, was probably one of the bigger challenges. So what we did was set up a governance process were the practices were all represented in large decisions like a standardized flow sheet or what indicators for PQRS we’re going to follow. That committee, staffed by those physicians, made the decisions, and so there was more buy-in.
Gamble: Did you find that by having those representatives, the physicians didn’t feel like this was something that was being forced on them, but instead that they were able to have enough input?
Johnson: Exactly, and that was the whole reason behind it. It’s very similar to the whole RFP process and the selection process. In the end, I abstained from voting; it was 10 physicians who chose the system. I offered input into what would work and what wouldn’t work or what the consequences were, but I really wanted the decision of what EMR we chose to be their decision, not mine.
Gamble: Do you think it’s the decision that you would have made?
Johnson: I don’t know. It’s hard to say. We’ve always got the dilemma of best-of-breed versus a single integrated database. There are challenges either way and functionality loss either way. So in the end, I think my role is to say, ‘You need to decide but here are the consequences of that decision.’ For example, ‘I will be able to flow lab results from one system to the other,’ or ‘I will not be able to flow a medication list.’ Be very upfront and explain those things. And then a year later, remind them of the conversation when they’ve conveniently forgotten.
Gamble: Exactly.
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