When Eric Raffin took on the role of CIO at San Mateo County Health System in 2013, he knew it would be a challenge, and not just because he’d be the first to hold the positon. The organization needed someone who could help create a sense of unification — not an easy task in a best-of-breed environment where there was little communication between departments. But nearly two decades with the Department of Veterans Affairs helped prepare Raffin to take on the challenge, and four years later, SMCHS is making great strides.
In this interview, he talks about his approach to being the new CIO (which involved “a lot of listening” and learning), how he worked to incorporate change management strategies into the IT governance framework, and the question his team asks to help prioritize projects. Raffin also discusses how they’re laying the groundwork to facilitate data sharing and improve outcomes, why his EHR 2.0 strategy involves much more than just the EHR, and what it’s really like to work in a public health setting.
- About San Mateo County HS
- Community outreach with street medicine
- Best-of-breed environment for 20 years
- Reimplementing multiple systems — “It’s tons of organizational change in one big bite.”
- A “new, united EHR footprint” with EHR 2.0
- “There’s a lot of spaghetti connecting systems together.”
- EMPI’s Master Person Index
LISTEN NOW USING THE PLAYER BELOW OR CLICK HERE TO SUBSCRIBE TO OUR iTUNES PODCAST FEED
It’s really about strategically managing the information and making sure all the right information is available at the right place, at the right time, for the right provider. That’s very challenging, but we’re making a lot of excellent progress in being able to present information on demand.
That affords us the great opportunity to deal with most important thing: where is the information, and is it getting to where it needs to go? We’re taking a novel approach to being able to deal with some of the information needs first, and then dealing with the tremendous change management task of implementing a new unified EHR footprint.
We realized that our organization has never taken a bite out of that apple, and so we found the apple and we took a big bite out of it, and have been dealing up until this point with planning for what we ultimately call our EHR 2.0 program.
It struck us that if we have this Master Person Index in place, it’s not terribly challenging to implement an internal health information exchange.
Gamble: Thank you Eric, for taking some time to speak with HealthsystemCIO.com today.
Raffin: It’s my pleasure.
Gamble: I think the best place to start is to get some information about San Mateo County Health System in terms of size, where you’re located, things like that.
Eric: San Mateo County Health System is based and serves the county of San Mateo, which is in the San Francisco Bay Area, nestled between San Francisco and the rest of Silicon Valley to our south. The health system is one of 16 public health systems in the state of California. When you combine those with the five University of California healthcare organizations, it makes up California’s healthcare safety net. We are a direct delivery organization in the safety net, which means we have a hospital: a medical center, and a clinic system. It also means we operate a complete behavioral health and recovery services program, which stems from mild to moderate to severe mental illness, as well as the alcohol and other drug recovery programs that a lot of people hear about, but don’t know that they’re often managed by your county behavioral health office.
In addition to that, we provide healthcare services to our county jail system. We also have social services functions under our umbrella, which is sometimes a little unique in the public health safety net. Our Family Health Services and Aging and Adult Services divisions provide services to disabled children and pregnant mothers, as well as looking out for seniors by supporting the In-Home Support Services (IHSS) program. We also have a whole host of other activities that aren’t normally ascribed to healthcare because they really touch more on the social determinants of health than direct healthcare services.
Finally, we have our public health functions, which includes operating the public health lab and a lot of street medicine and community outreach. The health policy planning for the county is also performed here, along with environmental health. In that case, we’re not seeing clients or patients, but we’re working with all of the businesses as a regulator in the county to make sure the water and food and the maintenance of hazardous work sites and hazardous materials are safe and we’re keeping the county out of danger.
Gamble: And when you say street medicine, what exactly does that refer to?
Raffin: I see mobile teams go out every day. We’ve got a lot of community outreach where we’re going out and holding essentially clinics dealing with communicable disease maintenance and testing for clients who may not normally find their way to another healthcare organization. We do have people that are out on foot who are working to help the homeless population in this county. I’m always asked, what kind of a homeless situation do you have in San Mateo County? It’s a prosperous county. It’s a very affluent country. But at the end of the day, when you look at the number of people that are being provided services here in our health system, close to 10 percent of this county receives services from us, so it’s a lot larger than most people would think.
Gamble: I’m sure when people hear you’re in San Francisco area or Silicon Valley, there’s a certain image that comes up.
Raffin: There sure is. I’ve spent my whole career in safety net settings, so it wasn’t too much of a surprise for me. Although this is the county of my childhood; I grew up here; and so I never saw the things that I see now in my professional life. I’m just lucky to be able to help support the organizations that are reaching out and dealing with our most vulnerable populations.
Gamble: I imagine being part of the public health system comes with some different territory. As you already alluded to, you’re treating patients who are uninsured, underinsured and dual eligible, for starters.
Raffin: That’s right. We have a good solid relationship with our health plan. Most of the folks that we provide services to are covered by Medicaid — in California, that’s the Medi-Cal program. But there are folks who are not otherwise eligible, and so we have a program that we call ACE (Access to Care for Everyone), and that covers our uninsured clients. And so we’re trying to make sure that everyone has access to healthcare services.
Gamble: Looking into the clinical application environment, it’s not an integrated EHR across the board, right?
Raffin: That’s right. We are living in what has often been called best of breed where different clinical and ancillary applications were acquired, in this case, over about 20 years. The health system had actually started on its journey to electronic health records not too long after the turn of the century. We’re at a point now where we have a lot of these systems that are not terribly interoperable — I always call it the ‘I’ word. I see it as one of my strategic goals to help steer the organization toward unification. Not so much with applications — we have to have them, but for me, it’s really about strategically managing the information and make sure all the right information is available at the right place, at the right time, for the right provider. That’s very challenging, but we’re making a lot of excellent progress to being able to, even with a best-of-breed environment, present information basically at hand.
Gamble: Would you say that it’s not realistic to think that in the next two years or so you’re going to move to a system — that it’s more like, okay, let’s make the most of what we have?
Raffin: That’s one way to say it. What’s challenging is that when you already have all the systems, you don’t feel like you’re paying as much as you are; but we’re certainly paying plenty to have these different information systems in place. But the one thing the organization has never experienced from a change perspective is re-implementing all of them at once. So many other healthcare organizations have gone through it — you might call it a big bang, but either way, it’s really tons of organizational change sort of in one big bite. And that big bite could last a year, it could last two years, it can last three years. But we’ve never experienced that here, because we did everything in much smaller bites over a much longer period of time. It’s not something where you say, in 24 months we’ll be done. It’s a much longer journey for us.
However, that affords us the great opportunity to deal with what, in my opinion, is the most important thing, which is where is the information, and is it getting to where it needs to go? We’re taking sort of a novel approach to being able to deal with some of the information needs first, and then dealing with the tremendous change management task of implementing a new unified EHR footprint.
Gamble: Can you walk us through how you’re doing that as far as dealing with the information needs first?
Raffin: Sure. It started when I got here a little over four years ago and I realized that the organization itself didn’t have that big binder on the shelf that said, ‘this is the strategic plan of the health system.’ And I think the reason for that is that the strategic plan of the health system is really all over the map, because we provide lots of different services that don’t necessarily come into contact with one another terribly often. But we are often serving the same individuals in our county.
And so it struck me that we needed to start talking about the strategic management of information. I took a step back and said we need to have some governance, so we’ve implemented a governance program for all of the health information technology and programs that we offer here. With that came what I call the big deal with big data or BD2. That was sort of my mini manifesto that said, look, we need to be very focused on all of this information that we keep collecting. Just like anywhere else in this country, we have what are essentially really highly paid clerks at this point, where everyone is entering information into systems, and the value you get or the return on the information you get out of them is really poor.
That’s changing, but of course it means now you have to invest in another system to get the information out to analyze it. At the end of the day, there’s a lot of spaghetti back there. There’s a lot of spaghetti connecting your transactional systems together, and there’s a lot of spaghetti when you’re talking about all the different places your data lives, what the data looks like, its structure, is it standardized, and is there an information governance function in the organization to deal with taxonomy and standards. And we realized that our organization has never taken a bite out of that apple, and so we found the apple and we took a big bite out of it, and have been dealing up until this point with planning for what we ultimately call our EHR 2.0 program — which certainly involves a unified EHR solution, but also involves other components.
Those components include ensuring that we do identity management, and so the first task that we undertook a couple of years ago was to implement a Master Person Index. A lot of people say master patient index, but we call it a Master Person Index because we provide services to lots of different clients who are not always considered patients.
And then we realized that all these different EHR applications have modernized to a point where they can, in a standards-based way, ingest information from other sources. The real issue is that we had never said, if I have five systems, I don’t want to have to set up communications for five different systems and monitor interfaces, integrations, or just all that traffic all day long. It struck us that if we have this Master Person Index in place, it’s not a cakewalk, but it’s not terribly challenging to implement an internal health information exchange which then we can connect to the rest of the world, and that’s the work we’re doing right now.
There are several reasons why that’s important to us. The primary reason is that even with all of these different disparate EHR platforms, we’re going to use the modern capabilities that they now have to be able to have sort of a mini Carequality framework or a mini CommonWell Health framework, just within our organization for starters. That’s information known about a child who perhaps was seen in our medical therapy unit in family health services but also had a pediatrician in one of our ambulatory care clinics — we’re actually going to be able to move that information around and let the providers in both arenas consume information that they need to know, and be able to do it in a really modern way. It’s the same way you might choose to read, trust, and import information in any of the big EHR systems that we would buy today.
By doing that, we set the stage for what providers need to change when they start getting information from other sources. And in many ways, I feel that it’s more important than the user interface the person has with the software. We have to deal with the information part first, and that’s what we’re going to deal with.
This internal HIE will serve that purpose, and of course we’re going to be connecting that to the rest of the world as well, subscribing to the Carequality framework and being able to get the information that we would want to see and query about our clients. And also, we operate the county psychiatric emergency services program and we operate a very busy emergency department. I’m sure there are folks seen in many of the other organizations in the Bay Area that have been seen here, and folks would want to consume that information. So we’re looking forward to being able to share that to improve all of those folks’ healthcare outcomes.