If you want to drive real change, you’re going to have to get personal. It’s one of many lessons Randy McCleese has learned during his career, both as CIO at St. Claire Regional Medical Center, and as a member of CHIME’s Policy Steering Committee. Rather than just present Congressional leaders with facts and figures, McCleese describes the challenges that his and other rural organizations face in meeting complex regulatory requirements, and it’s made a difference. In this interview, he talks about the work his team has done during the past few years, and what they hope to accomplish in the future. McCleese also touches on the difficulties facing vendors, the value in partnering with outside organizations, and why CIOs need to be more strategic.
- Winning CHIME’s Federal Public Policy Award — “It’s a group effort.”
- Challenges of small & rural providers
- “Physicians want to practice medicine.”
- MACRA/MU concerns: “We have to make sure the workflows we’re designing can provide quality measures.”
- The “cumbersome” job of getting EHRs to talk
- Innovation on hold
- St. Claire’s postponed EHR update
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Over the past 12 to 15 years, what we’ve noticed is that the physicians want to practice medicine. They don’t want to be in this business where they’re having to deal with regulations and making sure they’re getting all the reporting and everything done.
As we move from MU into MACRA and all the things that are happening there, we’re finding that we have to go to them and get them more involved to make sure that as we change workflows, the workflows that we’re designing can provide us the quality measures that we have to be able to report.
Each physician, group of specialists, and clinic has developed workflows over time that they are extremely reluctant to give up on. And because we are moving to electronic records and we’re trying to standardize how practice is done, how the patients are taken care of, it’s difficult for them to give that up. So it’s a cultural change.
How do we push our vendors to make sure that what’s coming out of Washington is better for them because it allows us to do a better job of taking care of the patient, instead of looking at it just as we’ve got to meet the regulations and the regulatory requirements?
Gamble: First off, I want to congratulate you on winning the CHIME’s Federal Public Policy Award. That’s a great honor.
McCleese: Thank you. As I told one of the folks on policy steering committee, it’s been a group effort, especially, thanks to the CHIME staff in Washington I’ve worked with over the years: Sharon Canner, Jeff Smith, Leslie Kriegstein, and Mari Savickis. They’re wonderful people to work with; that’s what keeps me going.
Gamble: I want get into some of the work being done, but I think a good way to start is to talk about some of the challenges that providers in small and rural communities are facing when it comes to meeting the regulatory requirements and even staying afloat.
McCleese: We are a regional medical center, and over the past 12 to 15 years, what we’ve noticed is that the physicians want to practice medicine. They don’t want to be in this business where they’re having to deal with regulations and making sure they’re getting all the reporting and everything done that’s required. In our community, there were two major groups outside the hospital — they were associated with the hospital because they did work here. One of them came to us in 2004 and the other one came in 2011, and they wanted to merge with the hospital. And their main reason was too many regulations coming at them. It was just too cumbersome and burdensome for them to have to get out there and take care of the regulation requirements that were there. So they wanted to kind of push that off to the hospital and let them practice medicine, which is what they wanted to do.
That in itself is one of the issues I’ve seen, because those providers are trying to get away from what are some of those requirements they have to do in order to meet the quality measures. And of course, as we move from Meaningful Use into MACRA and all the things that are happening there, we’re finding that we have to go to them and get them more involved to make sure that as we change workflows, the workflows that we’re designing can provide us the quality measures that we have to be able to report.
Couple that with the fact that we’re on multiple electronic medical record systems. It’s just what’s happened over the years — whether it’s good or bad, that’s not part of the story. We have move toward the point where we’ve got one patient record and we have that continuum care associated with that patient record, because we don’t see many patients moving in and out of our care system. Once they come in, they get pretty much all of their care here, and then it continues like that. We do have to refer to the Lexington-Kentucky market, which is about an hour away, for some of the very high levels of care. But most of it is done here. So we try to take care of those patients, but trying to get those systems to talk to each other over the years has just been cumbersome.
This is a part of what I’ve tried to work in as we’ve done some of the work in Washington through CHIME. The regulatory environment is more idealistic inasmuch as, you just put in a system and everything works. Well, it’s not like that. First of all, the systems are not there yet. Even though we put it in a system, workflow doesn’t match. And I’m speaking just from our standpoint, but I see this across the country too as I talked to other CIOs. Because each physician and each group of specialists, and maybe even each clinic, has developed workflows over time that they are extremely reluctant to give up on. And because we are moving to electronic records and we’re trying to standardize how practice is done, how the patients are taken care of, it’s difficult for them to give that up, because they’re part of a larger organization. So it’s a cultural change.
The other part about the systems — and this is one of the things I’ve noticed, especially in the last 3 or 4 years — is that the vendors as a whole are not being able to develop the software as fast as the regulations are changing, and wanting that software to respond to the regulations. Part of it is that some of our bigger EMR vendors have gotten so big that when they go in to start making changes in response to regulations, then it takes a long time for them. Because if they make one little change, it affects so many different parts of the software system itself — the EMR — so they’re trying to make sure that every area that it touches, they know what it does in each of those area. It takes time for them to develop that and then after they get it to us to put in our system, then it takes us time to test it and make sure that it works correctly.
I’ll give you one example. We had what should’ve been a routine update to our system in November of 2015 and we found rather quickly that the workflow changes to get some of the quality measures just were not working correctly. We were scheduled to go live in March of 2016. So before we went live, we realized, we can’t do this, so we put it off. The vendor went in and did some more work on that and we took the same release again in June of 2016, and we just went live with that software. So in this particular case, what should’ve been a routine update took us 10 months, and the regulations are wanting us to change. I can just feel that the regulations want us to change much faster than that, and that’s difficult, because as those regulations change, we have to change workflows.
Gamble: That’s really interesting. All of this really highlights the importance of speaking to policymakers, educating them, and giving real feedback. How important is it that CIOs and other executives take out the time to do this when they can?
McCleese: To me, it’s extremely important, especially as we move forward. Because to me, a lot of what we’re doing and a lot of what we’ve done over the past five or six years has been driven by regulations. I’ve heard vendor representatives say that they really don’t have time to innovate because they’re just trying to respond to regulations. And we feel that.
As we, from the time standpoint, are talking with the folks in Washington, specifically about how do we get these things working correctly, we also want some innovation into that. Because how can we do a better job — and I don’t mean it negatively — but how do we push our vendors to make sure that what’s coming out of Washington is better for them because it allows us to do a better job of taking care of the patient, instead of looking at it just as we’ve got to meet the regulations and the regulatory requirements? The end result has to be that we provide a better environment of care and a better method to make sure that we are providing a higher level of care.
I think we’re just now starting to see some of that in our environment because we’re more rural here. Like I said, we’re 60 miles from some of the major hospitals and some of the higher levels of care, so it’s a little more imperative on us that we have good systems in place to take care of those patients that come here and have to get transferred. We’re starting to see some results of the electronic communication through Health Information Exchange, and making sure that it’s getting to the appropriate places it need to be. And over time, I think we’re going to see more cost savings associated with that. There has been some, but I’m not sure that we’re seeing as much as we can see yet.
Gamble: Right. Every once in a while, a survey will come out that shows how deep into integration hospitals are with the EHRs and it’s really interesting because the large systems that are on Epic or Cerner throughout, that’s maybe more the exception than the rule. There really is a long way to go for a lot of organizations, it seems.
McCleese: Oh yeah. We had a visit from a critical access hospital yesterday looking at one of our products that we have here. I was talking to the director of IT and he said that in this critical access hospital and the associated clinics, he is working with six EMRs. This is a critical access hospital, and trying to get six EMRs — and I’ve said this in some of the circles I’ve been in Washington — it’s like trying to get six kids playing in the sandbox with the same rules. They all interpret the rules differently.
Gamble: Oh yeah.
McCleese: That gets difficult, but you’re right, the exception is the organizations that have been able to put in an Epic or Cerner, specifically Epic because it’s so comprehensive, with primary care all the way through acute care, and in our case, we’re getting into the home care part of it as well, whether that’s hospice, palliative care or home nursing. Because we have that full continuum of care — we want to make sure that we could take care of that patient and see their records across that continuum of care. And that from the rural standpoint, I think it’s probably one of the things that we have that’s a little more unique than you see in some of the larger environments, because they can break those down into different areas easier than we can in the rural area.