Like many organizations located near New Orleans, East Jefferson General Hospital faced an enormous test five years ago when Hurricane Katrina ripped through the area. Thanks to a dedicated staff, the 450-bed hospital was able to remain open throughout the ordeal, so it made sense that Jim Burton’s first priority as CIO was to ensure that in the event of another disaster, patient records would always be available. Now, Burton is taking it a step further and working to create an environment in which data isn’t just available; it’s robust and useful for clinicians.
- East Jefferson’s ambulatory strategy, featuring Stark
- Cerner’s Healthe Hub
- Measuring up to Meaningful Use
- Fostering CPOE — “Nine months ago, it would have been an impossibility”
- Wireless power, tablets, going Beta with Apple devices
- Thoughts on the MU bar
The biggest thing that physicians are learning is trying to figure out what the 44,000 dollars mean. And even with the subsidy, you try to educate them on the fact that this is money that they can invest back in. It was never meant for putting in the bank; it really was meant for re-investing in their organization.
We were customizing the system to some degree. Cerner wasn’t thought of as a partner, and they didn’t think of us as a partner. It was just a supplier relationship, and so what happened is this brought us together. They had skin in the game now.
They were very non-enthused about IT, because there were so many things that were wrong. The wireless infrastructure wasn’t working. There were a lot of basics—a lot of blocking and tackling that they couldn’t do. So they couldn’t envision the world in which they could actually enter orders when the COWs moving on the floors we’re getting disconnected.
In Stage 3 and beyond, there is not going to be a lot of mercy. They expect at that point that they’ve given you the money, they’ve given you the time, and they’ve given you the process. That becomes a penalty phase where you really start seeing the teeth.
Guerra: Let’s talk about your ambulatory strategy. You have the independents out there and you have Stark, where you can underwrite. Are you taking advantage of that?
Burton: Absolutely, we are subsidizing physicians who go with what we consider our enterprise product.
Burton: Absolutely. It’s all tied together—sort of a cradle to grave type of approach with software.
Guerra: So if they don’t want to go with Cerner, they’re on their own?
Guerra: Alright. And if they do, they get the full 85 percent?
Burton: We have a blend. We created clinical integration groups, so if they’re part of that, there is a subsidy, and if they’re not, there’s a different subsidy. And it is drawing people in. I think the biggest thing that physicians are learning is trying to figure out what the 44,000 dollars mean. And even with the subsidy, you try to educate them on the fact that this is money that they can invest back in. It was never meant for putting in the bank; it really was meant for re-investing in their organization.
Guerra: So of the 650 independence in the area, approximately—and I’m not looking for specific numbers—how many do you think have an EMR?
Burton: I think about 10 percent.
Guerra: And that is probably a mix of all different products.
Burton: Absolutely, from the one you can buy off the shelf to Allscripts to NextGen. I think Cerner is a relatively new entry into this area, but I think West Jefferson and East Jefferson both have a strategy with Cerner.
Guerra: So what is your strategy for getting some connectivity with that 10 percent—that mix of everything under the sun.
Burton: Under our policy, anyone can attach to us. It’s just that the Cerner product has a lot of features that the other ones do not. And we have something called Healthe Hub from Cerner, which means that not only from ambulatory but over time, other hospitals can tie into that hub. And it won’t be our hub; it will be sort of like a RHIO where everyone’s able to get an encounter for a patient all the way through and share that information, so that if a person goes from one hospital to the other, they don’t have to transport a record with them.
Guerra: Where are you with the Cerner implementation?
Burton: On the ambulatory?
Guerra: On the inpatient side.
Burton: We already had Cerner, so we’re already there on that.
Guerra: Okay, just straighten me out here—I thought you said you had Phoenix.
Burton: No, we had Phoenix as an outsourcer, not for software. It was always Cerner Millennium software.
Guerra: Oh, okay.
Burton: What happened is we decided to match the outsourcer with the product. That’s what we did.
Guerra: So it was always Cerner software, and you went from the outsourcer being Phoenix to Cerner.
Burton: At that time, we were two or three releases behind. We were customizing the system to some degree. Cerner wasn’t thought of as a partner, and they didn’t think of us as a partner. It was just a supplier relationship, and so what happened is this brought us together. They had skin in the game now.
Guerra: So you just didn’t need that extra layer between you and Cerner?
Burton: No. And the challenge that happed was that the knowledge of the product is very tough to come by around here, so a tapping into Cerner gave us that ability. The good news is a lot of the people who were here had the capability of moving to the other outsourcer, Cerner, because there were talented people, and Cerner really wanted to keep them. So that was good news. The good news with that is they’re getting the training they weren’t getting before. Cerner is investing in them; they had some trainers in some other day. I’m excited about that, because it’s all about the people. The idea when you outsource isn’t to cast to people to the wind, because I still care about the people. It’s to make sure they have the tools to be successful.
Guerra: Right. And what version of Cerner are you on inpatient?
Burton: We are on 2010.07.
Guerra: So is that the version that going to be certified or do you need to take an upgrade?
Burton: Nope. We did the upgrade in December.
Guerra: How did that go?
Burton: It was excellent, actually. There were very few bumps. I would say that the work that was done before Cerner in the outsourcing and Cerner stepping in really brought it through it with minimal disruptions.
Guerra: And where are you standing with your usage of advanced clinicals in terms of CPOE and electronic documentation?
Burton: We’re a Level Four EMR.
Guerra: How does that line you up for meaningful use?
Burton: We got CPOE in the ED, I’d say we’re lined up to make meaningful use that will be in 2012, not 2011. I believe we’re in a strong position for Stage 1 and 2; Stage 3 is sort of a crapshoot because we don’t really know it all yet. I’d say we’re looking for March 2012 for full CPOE and MD doctors.
Guerra: And how are they taking to it? I mean, the independents can be the toughest ones because they’re not your employees; they kind of want to be in and out, so how have you brought them around to entering their own orders?
Burton: Well, there a couple of things. One is I would say that nine months ago would have been impossible. They were very non-enthused about IT, because there were so many things that were wrong. The wireless infrastructure wasn’t working. There were a lot of basics—a lot of blocking and tackling that they couldn’t do. So they couldn’t envision the world in which they could actually enter orders when the COWs moving on the floors we’re getting disconnected. But what we did is we won them over little by little.
The first thing I did was I tore all the wireless out and put in new wireless. So now they can actually see they can get access. The other thing is we’re migrating towards tablets, which let them know that there will be tools they can use.
The third thing is, to make sure they’re totally focused, we’ve got a subset of doctors flying to Kansas City three times to really go through the process of helping us with the CPOE. So they’re going to be there in some cases three to five days in that period of time.
Guerra: You mention wireless. Tell me a little bit more how important it is to empower the physician in a wireless point of view. And you mentioned tablets; do you have any plans to allow them to use Apple devices—iPads, iPad touches and all these type of things?
Burton: Actually we do. We have a few doctors who are battering it for us because there’s a lot of complexity to it. For instance with Cerner, if you use Millennium, we have to work around the fact that they don’t have a right click. So we’re trying to work that through. They don’t have Adobe because they don’t want to use it for just for one thing; they want to use it for their total hospital usage, so we really have to work it through.
There was a story in the Boston Globe that talked about how Children’s Hospital Boston, Beth Israel Deaconess Medical Center, and other places that are actually bringing the information to the patient at the bedside with the tablet, and that’s our goal as well. Our goal is that if the physician comes in with their tablet, they’ll be able to go through the network and bring up the information and be able to sit with the patient so that the COWs won’t become obsolete—they’ll become just another tool.
Guerra: And you picture these devices as being the personal device of the physician, like the iPad that they own?
Burton: Yes, we’ll have a variation, meaning that for the ones who are employed, we’ll provide them with the tools. And for the ones who aren’t, we may have a few that are available depending on need, but the idea is to encourage them to really have an iPad, or anything—it could even be BlackBerry.
Guerra: Right, but it will be their own device; I would think that’s what they would want.
Burton: Most organizations that do this have the physicians own their own device for number of reasons. One is that they leave them on the table and they disappear, and we don’t want to be accountable for that. And iPads are pretty constrained, so we don’t have to worry as much about viruses, even though we’ll have virus protection, so we feel pretty comfortable. And we also created separate networks so that when people are entering things into the iPad, they’re not going it to the core system. They’re getting access, but not direct access.
Guerra: So you found a way to let them use their own devices and still be able to manage the security of the data that comes up on those devices?
Guerra: Okay. Is there an overall philosophy here that you really have to let the physician’s work the way they want to work, if they want to use their devices, you have to figure out a way to let them?
Burton: Let’s say, yes and no. that’s kind of a trick question.
Guerra: I didn’t mean it to be.
Burton: Within boundaries, we want them to be able to get the information, but we’re always going to have security restrictions and things like that because there is HIPAA and a lot of other regulations that we need to comply with. For instance, if they get information sent to them, in some cases we may force encryption, because it’s critical. How many stories have we heard about companies like IBM and others where data is leaked? I know personally because I worked at IBM at one point and was getting free credit checks for two years because they lost the tape that had my information on it.
How many times in health care have we heard stories of things like that? I wouldn’t say we’re paranoid, but we’re regulars about making sure that we’re protecting the information.
Guerra: Right. So what are your thoughts on Meaningful Use—do you think you’ve done a good job correcting Stage 1 and preliminarily, what they put up for Stage 2?
Burton: Yeah. I’d say Stage 1 is sort of like, ‘Come on, you can do it,’ like the chubby kid who is running a race for the first time. They’re not looking for you to win, but looking for you to get across the line.
In Stage 2, it’s like “A Few Good Men” where there’s a mentality of, ‘You’re not man enough,’ really forcing you to shape up and prove you can actually deliver what you say. But I think in Stage 3 and beyond, there is not going to be a lot of mercy. They expect at that point that they’ve given you the money, they’ve given you the time, and they’ve given you the process. That becomes a penalty phase where you really start seeing the teeth.
Guerra: But overall, the requirements they put into place make sense to you.
Burton: Absolutely. Well the thing is, in a lot of organizations around the country there’s variations. I mean as these affiliations come closer and closer—way back when, there was capitation. Well guess what come back around then a lot ways? Capitation, for improving quality measures and things like that, and I think that’s what we’re doing. The idea is to drive quality and sharing; to have measurements and comparisons, so the clinical integration group is a first to step towards that. But a lot of cities like Boston, New York, and Chicago are way ahead in some ways because Partners and CareGroup and places like that are already there in a lot of ways. So I think there’s been sort of a passage going on that has hit all parts of the country. Some areas are going to have more pain than others in hitting the criteria.
Guerra: Are there any other specific steps you’re taking to prepare yourself to be in ACO?
Burton: No, because clinical integration step, which is getting physicians where they will actually share information—not financial information, but clinical information. And then what happens over time is the metrics and reporting become more rigorous, and that’s what ACOs are about. And then if you go further along, it gets into payment schemes where they start dictating payments based on quality. I’d say that there are three stages of ACOs. I think were in stage one which is let’s be nice and share.
I’d say Stage 2 becomes more much rigorous with the integration, and Stage 3 is capitation—and I don’t think we’re near capitation.
Guerra: Do you think it all dovetails pretty well—the meaningful use work, the HIE stuff that’s included in that, and the ACO stuff?
Burton: Absolutely. I think that it’s just stepping stones. I think the idea is how do you improve quality and drive cost down. For instance when I was in New York at Montefiore Medical Center, which was part of a RHIO in the Bronx, the insurance companies actually wanted to sponsor the RHIO, because they want to be able to jump and make sure that duplication of tests and all that stuff wasn’t happening if a person went from hospital to hospital.
So the idea is the same thing. The other part is quality, where a person can transport their record anywhere, and that gets into personal health records. During Katrina, the one organization were people were always able to be treated and their records were readily available was the VA system. As people dispersed around the country, their care continued. So it was a wake-up call.