If the recent trend in hospital consolidation is providing CIOs an education in change management, then Jonathan Goldberg is on his way to a master’s degree. Two years ago, three organizations — including St. Peter’s Health Care Services, where Goldberg served as CIO — merged to form a $1.2 billion IDN. But, as he quickly learned, “change doesn’t move fast,” particularly when the organizations that are joining together run different EHR platforms. In this interview, he talks about the need to focus on “the people aspect of integration,” why it pays to give physician practices some autonomy, and his organization’s data exchange efforts. Goldberg also talks about improving patient flow, his real motivation for seeking CHCIO certification, and why CIOs need to keep an open mind.
- HIEs in upstate NY
- “We’ll always have multiple systems. That’s a reality.”
- Frustration with portals — “I’m not sure the patients know what they want.”
- CareLogistics for patient flow
- A “major transformation” in clinical care
- IT rounding
- Avoiding the “flavor-of-the-day” mentally
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Even if we integrate clinical systems, one system will not cover the specialty-type organizations that we have, and so we’ll always have multiple clinical systems in existence. That’s a reality. So the question is, how do we connect those.
People leave our meetings all frustrated because there are so many different opinions. We seem to be stymied by the fact that there’s so many different ways we can approach this, and each one has its own sort of idiosyncrasy in terms of some of the benefits and the negatives.
Putting yourself back on this side of the fence, you try to anticipate what the patients want, and I’m not so sure we’re doing such a great job with that because I’m not sure the patients know what they want.
The goal is to create awareness of who’s on the floor, what state they’re in, and when we expect them to be out of the hospital. We’re trying to create full visibility and transparency of information to allow the caregivers to really understand how best to take care of their patients.
We were warned early on as we implemented this model that this is not the flavor of the day. It cost us so much money that we had no choice once we signed on the dotted line that we had to make this stick; we had to make this work.
Gamble: So you have the pretty sizeable initiative of trying to get all of this data exchanged within the organization and then, of course, there’s data exchange outside of the organization. What type of HIE involvement do you have at this point?
Goldberg: Well, there are two things I can speak to. First, in New York State, we’re pretty fortunate in that the state made some significant investments with grants years ago to help fund regional exchanges. The exchange here that we have, which is called HIXNY (Health Information Exchange New York) has been very successful. It’s been a long ride. From its infancy, which I was involved in, to today, it’s really matured significantly. It’s a large exchange, governed by providers, payers, physician groups, and even community organizations. It has a solid technology behind it and it’s being used significantly. There have been recent announcements that they’re going to start connecting to the other upstate exchanges that exist in upstate New York, across east to west.
And so we’re really creating that platform — a very mature platform, at this point — of health information exchange, and New York State is continuing to evolve its thinking and wanting to create a state exchange. There are different opinions of how that should happen and how we’re going to make that happen, but certainly we’re pretty far along in the lifecycle of the HIE here in the region, and that’s from the public standpoint.
As we look internally at ourselves, St. Peter’s Health Partners has 170 locations throughout the region, and we have a lot of different systems that cover acute and non-acute care. Even if we integrate clinical systems, one system will not cover the specialty-type organizations that we have, and so we’ll always have multiple clinical systems in existence. That’s a reality. So the question is, how do we connect those, and how do we connect them in such a way that we can actually get data from them and look at our patients at a St. Peter’s Health Partners level and aggregate information looking at that clinical lifecycle.
So as we look internally, we do have a strategy to try to create a private exchange, and that’s more for internal use of being able to do the analytics and do the modeling of data and support that population health model, at least within our world. Obviously with the public exchange you don’t have access to analytics, so we can’t leverage that platform. So you’re seeing a need for both, and because of the breadth of the organization, we do need to figure out how to get data aggregated in some way.
Gamble: Right. I can just imagine the challenges in focusing on how to exchange all of this data internally and then take the next step and do everything you need to do with that data before really focusing on the external exchange.
Goldberg: It’s interesting because it gets highlighted when you start looking at the patient portal strategy. When we talk about patient portals, people leave our meetings all frustrated because there are so many different opinions. We seem to be stymied by the fact that there’s so many different ways we can approach this, and each one has its own sort of idiosyncrasy in terms of some of the benefits and the negatives. And as we try to figure the solution, because we’re talking about multiple systems, we can certainly leverage the public HIE. We may develop our own patient portal strategy, or we could do niche patient portals through the legacy vendors. And again, each one of them has a reason to move forward with that, and hence, there’s always a downside. It’s interesting dialogue because it’s just a moving target, and we certainly don’t want to make an investment that becomes out of date before we even go live with it.
Gamble: Right, and that’s such an interesting topic, because even if you do decide on this is the portal that we’re dealing with — this is our strategy, then you have to get patients to actually use it. That’s another one that we’ve found really has a lot of CIOs just scratching their heads.
Goldberg: It’s interesting. I was thinking about this topic in the last day or so. I’m the CIO of a health system, but I’m also a patient — luckily not an active patient, because I’m fairly healthy. If I wanted to participate in a patient portal in my community, what would it be? And if I take the St. Peter’s Health Partners hat off, I’m not so sure I would know where’d I go. I know one of my physician practices has a portal that I could access. I found it complicated the last time they gave me directions, so I didn’t bother. The Health Information Exchange is about to announce their portal; maybe that’s where I’d go. Although as a consumer, I’ve read articles about the big blue button initiative. I’d probably try that, and then I’d realize none of the providers up here are connected to it. There was a story in the newspaper about New York State pursuing a patient portal for the state, but they’re just in the design phase.
So thinking about that as a patient, I’d probably just do nothing at this point and I’d wait until something hit me in the face to say, ‘Yeah, that’s it.’ So now putting yourself back on this side of the fence, you try to anticipate what the patients want, and I’m not so sure we’re doing such a great job with that because I’m not sure the patients know what they want. I think trying to find that middle ground to understand what they want and then reacting to that will be the secret sauce. And I think, as least in this region, we’re not there.
Gamble: So just thinking about that, you’re the CIO and you aren’t even saying okay, obviously this is the portal that I want to join. So patients who don’t have as much understanding of that are definitely not going to know which one to use. I think it’s the same in a lot of areas — if there isn’t one particular way that patients should go, then we’ve really got a lot of work to do.
Goldberg: Absolutely. If New York State came out with a patient portal and everybody was connected to it, or if you have a public exchange in the area, those are probably the most compelling portals to go after from a patient standpoint, because they should capture information from multiple providers. The problem is that as a patient, if you utilize St. Peter’s Health Partners, for example, you could have more engagement. You could do online scheduling or online bill pay, or maybe you could communicate with providers via secure messaging. You’re not going to have that in the public portal realm — at least I don’t see that coming so quickly.
So if we want to create that connection with our patient, there’s always going to have to be that private portal, so to speak. At least that’s the way we see it. And I guess in some respects it’s no different than what you’re seeing in the commercial market. You don’t log into one portal and do all your banking; many people have accounts in different places, or they trade stocks in one place and maybe their 401 is one place. But you can’t log into one portal and do everything that has to do with financials in one place, unless you decided to have everything within one bank. So that’s the way I see it. I guess there will always be a world of multiple portals, but I’d love to think that there would be a better way.
Gamble: Right. Okay, so we’ve talked about a lot going on that’s on your plate, but are there some other major things that you’re looking at for the next year or so, just as far as some of the priorities for the organization from an IT standpoint?
Goldberg: Certainly we have the normal regulatory stuff in terms of Meaningful Use, ICD-10, etc. We certainly have some interesting initiatives going on in our acute care hospitals, where we’re implementing a system that really targets patient flow and reducing length of stay, hence delivering a better patient stay. That tool involves process improvement using lean methodology in terms of how we cut white space out of the clinical process, and then there’s the technology piece. We have a logistics center, which is really a hub where a lot of our patient flow gets taken care of — transfers into the facility, as well as transportation, nutrition services, and external transfers. Basically there’s a center with a lot of technology in there that helps get patients in the right place at the right time, and it connects to our clinical systems so it prioritizes orders. So when medical imaging orders are given, they are prioritized based on the person’s estimated discharge date. Our ultimate goal is to get patients through the system efficiently and as expeditiously as possible, and hence, get them out of the organization and into the right place.
On each of the nursing units there are large boards that actually have patient information in terms of the room, and it also shows what their estimated discharge date and time is. The goal is to create awareness of who’s on the floor, what state they’re in, and hence, when we expect them to be out of the hospital. We’re trying to create full visibility and transparency of information to allow the caregivers to really understand how best to take care of their patients. And there are role changes that are involved with that based on different types of roles within the organization. We’ve done really a major transformation of clinical care within the hospital. We’re fully live in one hospital, and there are two other hospitals that are in the midst of going through the process of implementing this system. It’s interesting. It’s been an interesting and very different approach to things that I’ve ever encountered, so it’s been pretty exciting.
Gamble: It seems like it combines a lot of the things you’re talking about, like process improvement and patient flow and just looking at the length of stay and things like that. It’s tackling a lot of things at once that need to be looked at.
Goldberg: That’s exactly what it’s done. It’s made the organization become very introspective of how it operated and how it worked, and be very open to change. We were warned early on as we implemented this model that this is not the flavor of the day. It cost us so much money that we had no choice once we signed on the dotted line that we had to make this stick; we had to make this work, for many reasons. Certainly you didn’t want to see that money being wasted.
It also encompasses leadership rounding. I commit four hours every Wednesday morning to round in the organizations. I do two out of the four hospitals — we’ve split up the duties. It’s been phenomenal for me. I get so much out of it. Even though I’m representing the senior leadership team, I have learned more and understood more in getting into that level of detail than I’ve ever been able to before. There are so many levels of benefit that this has created, but certainly it takes the commitment of time.
Gamble: Is there a company you’re working with on this?
Goldberg: The company that handles the technology and the processes is called CareLogistics, and they’re based outside of Atlanta. They were brought to us through our parent company and we’ve worked with them on developing the program for our own use and taking their methodology and their technology and marrying it with some of the uniqueness we have and it’s been a very interesting journey.