An organization’s name can be very telling. Doctor’s Hospital at Renaissance, which includes a 506-bed hospital and five freestanding imaging centers, was founded in 1997 by a group of physicians. Fourteen years later, it is one of the largest physician-owned facilities in the country and, as the organization has undergone a major IT renaissance, the focus has remained on physicians. In this interview, CIO Les Clonch talks about how he was able to lead an aggressive rollout of EMR and CPOE while still being mindful of the many doctors who still haven’t fully embraced IT, and how choosing the right products and getting the right help have been instrumental in positioning his organization for growth.
- About Doctors’ Hospital
- For-profit versus not-for-profit
- The role of ROI in clinical IT investments
- Integrating with the independents
One of the unique things is the dynamic between the investor community that is non-clinical and the investor community that is clinical, and the ability to establish governance that addresses the concerns, needs, and interests of both.
Making money is very important in the context that we want to have funds to address additional growth and additional mission issues with respect to services, and be able to bring additional specialties down here. And also to position ourselves from an infrastructure and technology point of view that allows us to coordinate care more effectively.
Doing the right thing is important. But I also think you have to make sure that doing the right thing is something you can afford to do, and it’s something that has been thought through before you do it.
We still have the issue of some physicians who just are not comfortable with information technology at all. They’ve been burned. They feel like this is an investment that they just don’t understand. They’re very uncomfortable with it, and they know ultimately they’ll have to do it, but they’re not sure what to do.
Guerra: Good morning, Les. Thanks for joining me to talk about your work at Doctors Hospital at Renaissance.
Clonch: Good morning, Anthony. It’s great to be here. I appreciate the opportunity to chat with you.
Guerra: You have a unique hospital—or maybe not unique, but certainly different than a typical organization. Your hospital is physician-owned, for-profit and I wanted to have you provide us with an overview of the organization, maybe with an eye toward what might make your work as CIO at this type of facility different than that of your colleagues, if that’s the case.
Clonch: Sure, I’d be happy to. Doctors Hospital at Renaissance is a delivery system representing about 500-plus beds. It consists of all different specialties and other services, from cardiac to neurosurgery to orthopedics to women’s and children’s, care. It’s located in the Rio Grande Valley, about an hour north of Brownsville, about an hour and a half west of Corpus Christi, and about four hours south of San Antonio. We’re about 10 minutes from the border with our friends in Mexico.
It’s a delivery system that’s relatively young. It’s been here a little over 10 years, and in that 10-year-period, it started as really an ambulatory surgery center and has grown into the large delivery system that is today. It was the idea of several physicians who, as I understood it, banded together after having a little difficulty getting the capabilities, technologies, services, and support from one of the larger for-profit delivery systems in the United States, and decided to go on their own. And they partnered with some non-clinical investors and ultimately created this organization, which has done very well for itself in the last 10 years.
As for some of the differences you might find as a CIO, in a for-profit world, there’s a very strong sense of entrepreneurism. It’s time-to-market pace; there are multiple concurrent things going on at the same time, which obviously my colleagues are familiar with, and very similar issues. One of the unique things is the dynamic between the investor community that is non-clinical and the investor community that is clinical, and the ability to establish governance that addresses the concerns, needs, and interests of both. Some of the common threads between the two parties would be that we’re all here to focus on the patient; that was what drove the development of this organization in the first place.
There’s a very strong sense of community and doing what’s best for the community. The physicians are very focused on quality care. They’re very much focused on being effective at delivering that care, and the non-investors are very focused as well on making sure that everyone here in the Valley gets the best that they can provide without having to go to more major metropolitan areas such as Houston or Dallas or places like that. So it’s been very successful, and it has the capability and infrastructure and certainly the focus on being very successful going forward.
Guerra: What are your thoughts are on for-profit versus not-for-profit? Some people think that just because an organization is not-for-profit, it acts in a more altruistic sense, but that’s certainly not the case. And it’s certainly not the case that because you’re a for-profit, you would be more motivated to increase revenues and these types of things. Does that make sense; that it doesn’t necessarily break along those lines, and that it has more to do with the values of the organization?
Clonch: Absolutely. That’s very true statement, Anthony. The focus of the organization—of every organization—is to have margin. And margin that is reinvested in the organization to produce additional capabilities, technologies, services and support, and deliver the primary mission, which is to care for people. With for-profit organizations in my experience, and not-for-profit organizations—multi-hospital, academic, community-based, and not-for-profits—the common threads among them are focused on the quality and the compassion aspect of care. Making money is very important in the context that we want to have funds to address additional growth and additional mission issues with respect to services, and be able to bring additional specialties down here. And also to position ourselves from an infrastructure and technology point of view that allows us to coordinate care more effectively and allows us to share services with others in a community.
We have multiple other providers, both in the hospital and physicians, who both practice in other places as well as the HR. So getting the changes in health care from a reimbursement point of view, from a delivery point of view—all of those things play to us investing the money that’s made here into making sure those things are provided and that we’re in a position to coordinate care going forward. So I wouldn’t say there’s really any huge difference between a for-profit and not-for-profit with respect to money. The emphasis on margin was just as strong in the not-for-profit world when I was working as CIO there as, it is in the for-profit world. I find very little difference in that focus and that emphasis.
Guerra: Some of your colleagues talk about making investments because they’re the right thing to do. I never kind of bought into that reasoning. I just don’t think it’s enough to make an investment, these multi-million dollar investments, and your colleague in Texas, Lynn Vogel at MD Anderson, has said that it’s not enough. It’s got to be more to studying these investments and you have a responsibility to come up with some sort of ROI even for the softer patient safety and these type investments. What are your thoughts about that? Is there a greater responsibility for you at a for-profit entity to come up with ROI on some of these investments, or do you think some of them are just the right thing to do and you have to put that to the side?
Clonch: I think there’s a balance between the two. And I look at it in this context—there is a very strong emphasis to understand costs. We look at a five-year total cost to ownership focus for every major investment we do. We also look at return on investment. Return on investment, both empirically and from the non-empirical perspective, is one of the studies we do. And we look at it in the context of, from an empirical point of view, not only is there a margin with respect for the service—sometimes you need to put the service in because the community needs it, and that’s the right thing to do—but there’s also emphasis on making sure that the investment has the potential to reduce cost through the concept of cost-avoidance, and through the concept of reducing the operating dollars associated with current operations.
One of the things that we do is we look at how our workflows will change any investment we make so that we have the ability to understand what those costs are going to look like. Are there efficiencies with respect to human resources that we can reallocate or that we can make more effective by investing these tools. So I would tell you that, in my experience here this far, the emphasis on return on investment is strong; but it’s strong in the context of let’s make sure we invest in things that makes sense for the community that carry on our mission of caring for people. And let’s make sure that those investments are things that we can afford to do and that we have ways of trying to further improve and be effective stewards of the resources that we have.
I think that’s a key focus; at least in my conversations with my colleagues, that has always been an emphasis. And so, again, return of investment is just not about empirical. I think there has to be a balance in both, and I think doing the right thing is important. But I also think you have to make sure that doing the right thing is something you can afford to do, and it’s something that has been thought through before you do it from a variety of different perspectives.
Guerra: In terms of the physician mix at the organization—are they all employees or are they all investors? How does that work?
Clonch: None of the physicians are employees of the hospital from an investor point of view. With all of the employees that we have, it’s about 2,600 total FTEs and then when you add PRM/per diems and temporary employees and other categories, you’re probably looking a little over 3,200-3,300 people. But from a physician point of view, they have an equity relationship with the organization but they are not employees of the organization. Many of our investors who are physicians have privileges elsewhere. And obviously, patient choice drives where these patients are sent based on their conversations with the doctors and what they together believe is the best path of care for them.
Guerra: Are there independent physicians that can refer in who don’t have any sort of financial association with the organization?
Clonch: Absolutely. In fact, we have many different physicians in the community, both locally within the McAllen-Edinburg-Mission area as well as outside the area, that do have privileges to admit here who are not investors. To be an investor in the organization is purely a choice. It’s not by any stretch of the imagination a requirement. And many physicians who practice here or refer patients here for care are not investors in the organization.
Guerra: So you do have that typical community hospital dynamic where you as CIO have to integrate, if you can, a whole bunch of independent physician offices that could be on paper or any number of ambulatory products.
Clonch: We do. We run into that all the time. We still have the issue of some physicians who just are not comfortable with information technology at all. They’ve been burned. They feel like this is an investment that they just don’t understand. They’re very uncomfortable with it, and they know ultimately they’ll have to do it, but they’re not sure what to do. So we do have a great dynamic of those who don’t have anything, those who have an information system that is primarily just to manage the administrative aspects of their office, and those that are focused on the clinical and financial aspects. And those have been very successful.
In supporting them we deal with a variety of different vendors. There’s the mom-and-pop type, which is small and very risky, in my opinion, with respect to being able to position that system and that software and that physician for the changes that are coming in health care—those that we’re seeing now and those that are to come. And so we encourage physicians to invest in IT, but to do it in a very thoughtful way. And as we can help them within the constraints of the law and what we’re allowed to do, we do. I will talk to them and say, ‘Here’s what I’m seeing and what I’m hearing from my colleagues. Here are companies that I’ve talked to. Talk to them; they sounded like they had a good tool.’
But in terms of dynamics of the different vendors, there are just so many different ones out here. We have over 600 physicians that are on our medical staff, credential to practice here. There probably are 10 common systems among them and that represents 60 to 70 percent of our doctors, and 30 percent have a smattering of systems, some of which I’m not familiar with.
Guerra: That has to be interesting when they call you or when it comes to your attention that they’re using a system you’ve never heard off.
Clonch: Yeah, that’s when I have the Internet ready, so I can look at them and have somewhat of an intelligent conversation with them. But there’s a strong, growing interest in having the right tools in place. They see it coming. It’s not something they relish, but they understand that they have to make these changes, and rightly so. They are doing the best thing they can do by reaching out and asking for assistance and help in understanding what information technology types of things they can do to position themselves to be successful. Those are good conversations. I really, really enjoy working with the doctors. In every organization I’ve been with, it’s just been a great experience. One of the things that keeps me in health care is the opportunity to work with them and help them be successful in all aspects of the profession.
Guerra: Have you ever not even been able to find a website a company that some of them were using?
Clonch: You know, there was one information system a doctor said he was using. It was something called Triple D and I was like, I don’t even know what that is, and I still haven’t found it on the Internet. So if any of the colleagues listening to this have ever heard of it, please call me. It’s one of the many failures in my career. But I’m tenacious; I’m not giving up.
Guerra: Right. Well, we’ll see if we can find that organization, Triple D.
Clonch: It would be helpful.