When it comes to research, academic medical centers are second to none. But when it comes to interoperability, there is often room for improvement, and the University of Arkansas for Medical Sciences is no exception. As incoming CIO Dave Miller tries to position the organization for Meaningful Use, he is faced with a host of challenges, including EMR systems that don’t speak to each other, systems that enable clinicians only to view records, and — like many academic systems — funding that exists in silos. In this interview, Miller discusses how he plans to use his experience, both in the clinical and vendor worlds, to transition the organization from a best-of-breed shop to an enterprise system, what it will take to become an accountable care organization, and the importance of being able to put on the salesperson’s hat.
Chapter 2
- Having the confidence to push for massive investment
- Are we moving toward a two-tier healthcare system?
- “If you have the money, you should go with the product that positions you best”
- Specialty practices and primary care EMRs
- The clinical/research chasm
- The price of data silos
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I think they’re going to be vital, especially to interoperability and the exchange of information. But the fact of the matter is, to run the business at the granular level, those standards are not going to do what I need internally to help us become an organization that can handle bundled payments and can handle accountable care.
There are trade-offs to taking any centers of excellence, and at some level, making them kind of bend to the larger wheel of the organization in terms of their need to be sustainable. That will be painful for some of the specialty areas, and we will do our best to accommodate them.
Frankly, there are no products out there that, from a research perspective, can handle both the clinical care piece and the research piece very well. They just don’t exist. And so we’ll have to do some custom programming.
We’re going to have to manage patient populations across our own enterprise as well as externally, and we’re going to share in the payment for the patient and their disease state. And you’re not going to be able to do that as well with a one-off type of approach as you would if they were all part of the larger picture.
Guerra: You can’t convincingly ask people to spend tens of millions of dollars unless you’re confident of what you’re telling them. And you can’t be confident unless you got the kind of experience that you bring to the table. So I want to talk about a little bit about that confidence, in terms of how you’re sure this is the right direction. And by that, I mean that there is no plug-and-play that’s going to come down the pike in the next couple of years that will make all of your systems talk to each other. There is nothing the HIT standards committee can do or put out; there is no CCD. The world that will make your current application environment work doesn’t exist and won’t for foreseeable future. Is that right?
Miller: That’s exactly my position. And I don’t see anything on the horizon; I don’t see anything from the technology perspective that’s going to be able to solve my problem at that level with my current application footprint. We talk about standards, and I’m all for them. And I think they’re going to be vital, especially to interoperability and the exchange of information. But the fact of the matter is, to run the business at the granular level, those standards are not going to do what I need internally to help us become an organization that can handle bundled payments and can handle accountable care—these types of things. We might be making progress on that, but it’s just not going to help me make me a sustainable organization for the future.
Guerra: But basically the stakes to play—the tools required to run a health care enterprise changed over the last five years with these new programs. And what they require, you cannot produce with the current setup. So this is what we need going forward.
Miller: Right. Like I said, I think the organization is realizing that this is true. And it’s somewhat advantageous that I happened to be in the right place at the right time, where the pain was great enough to make the organization move off the dime and spend tens of millions. I mean, it’s probably going to be something in the rough order of 60 million dollars to sweep the decks and start over. That’s a big number for any organization. And when you’re a state organization, those kinds of numbers get wide distribution—quickly. It’s a little bit different animal here that I’ve ever had to deal with before. But you learn that you have to be careful about what you say and where, and make sure your message is consistent wherever it might be. And I think that in my first brief period here, I’ve been pretty successful doing that.
Guerra: Do you think we’re going to see a bifurcation in the industry between the organizations that are able to make the investment you talk about and get on the kind of electronic environment that will allow them to comply with the new world that is being created, and those who can’t figure out how to make that investment? Do you think we’ll see a division in terms of both the quality and the ability to qualify for reimbursement?
Miller: I think the bifurcation will be on the quality side. I don’t think we have choices, frankly, of whether we do this or not. It has to be done. I think the issue is going to be around the quality of the end product that we find ourselves in. If you have the money, you can do it in a more robust fashion. There’s always the Meditechs of the world—and I’m not denigrating them in any way; it’s a good product for their space. If you have to, you can go the open source route with a Vista or something like that.
But if you have the money to do it, you should go with the product that’s going to position you best. And I do think there will be bifurcation there. I think you’ll have organizations with really robust system to handle what’s on the horizon, and you’ll have a group of those who will have just enough to get by. So I absolutely think you’re right.
Guerra: Let’s talk briefly about specialty practices. You said you’ve worked with this particular vendor in a number of cases. Do you see specialists pushing back on sort of the primary care-centric EMRs that are being rolled out enterprise-wide around the country? Some specialists say that they need and deserve any EMR that was designed for them. And obviously with an enterprise rollout, you don’t want that because you’re going to have silos of information and you’re not really going to get the benefits that you’d hope to get.
Miller: Well, you’re absolutely right. We’re going to get some push back here, I have no doubt. In academic medicine in particular, you often have centers of excellence around a particular disease states. We are one of the top organizations in the planet for multiple myeloma, for example. Oncology in particular is a very complex clinical area, and a primary care approach to their EMRs is not going to cut it. Whether it’s oncology, cardiology, neurosurgery, or whatever it might be, you’re going to get pushback. Interestingly here, since they’ve had an EMR for so long, they were actually doing GE Logician in the late 90s for the campus. They’ve done a lot of development work around kind of customizing electronic records for very specific areas. And there’s going to be some pushback.
Now, I do think there are products out there that give you the opportunity to better target some specialties. Oncology is an area that some of the major vendors have started to realize they need to focus on; cardiology is another area. So I do think there is some opportunity there. But we will get push-back. There’s no question about it. There are trade-offs to taking any centers of excellence, and at some level, making them kind of bend to the larger wheel of the organization in terms of their need to be sustainable. That will be painful for some of the specialty areas, and we will do our best to accommodate them.
But you get it. With primary care to specialty, there is this sort of a natural tension between those two. You get the same thing if you look at the tensions between surgery and medicine and medicine in general. I’ve gotten comments that my EMR is medicine-centric and not friendly to surgery, so there are trade-offs that you’re going to have to make. And you want to be as accommodating as you can to the specialty areas—especially in academic medicine, because frankly, specialties are more of our focus than primary care. Most academic medical centers do primary care sort of as necessary evil, for lack of a better term, really to feed the specialty areas of the organization which is what academic medicine specializes in; what they’re best at.
Guerra: Are you able or are you interested in having a discussion with them where you say, ‘Listen, here’s the tool.’ And you tell them that there are some things you can do to customize this tool. But you said that GE Logician was customized. Would you do the same thing with whatever product you select? Would you tell them, ‘There are some things that I can do to help you here. But you’re not going to get what you had.’
Miller: I think you have to have to have that conversation with them. There are some good products out there; I have implemented from the specialty modules of the vendor whose name we shall not speak, and they’re actually pretty good. And they’re getting, better especially around oncology. Their oncology module is very, very robust. And I think I could do a lot with that to meet the needs of my multiple myeloma friends.
But that is absolutely a conversation you have to have. And it’s tough because the other piece for me is building something that also flows relatively easily into the research area and back and forth. And frankly, there are no products out there that, from a research perspective, handle both the clinical care piece and the research piece very well. They just don’t exist. And so we’ll have to do some custom programming around whatever we do to make that transition smoother. It’s just not a market that anybody is putting their money into or probably will in the foreseeable future.
Guerra: So when we talk about modules—and tell me if I’m wrong—some vendors have specialty-specific modules that are truly part of their integrated suite. They have them for some specialties to what degree they equal a truly best of bridge EMR in that area, probably with varying degrees. And sometimes they may not have any modules at all for a specialty that you are trying to address. Is that correct?
Miller: That’s correct.
Guerra: So it depends. With some specialists, you’re going to be able to hear something from the vendor and then maybe we can do a little something further with this. And sometimes you’re going to have to say, ‘They don’t have anything for you. Here’s the vanilla primary care EMR, and maybe we can do a little something with this.’
Miller: I’m not averse to that, even in those cases where you would have situations where you’ve got a very successful specialty group doing a one off. But I’d like to keep that to a minimum. The other thing I’ve found is that when you look at the big vendors that come to the table and you have a relationship with them that’s a true partnership, you begin to learn overtime and share with them and find out for those unique specialty areas—if it’s not a place where they have a product—who their preferred partners are in that area. And if they have a preferred partner, it’s somebody that their customers are pushing for a tighter integration with.
So even if it’s not a space that your primary vendor partners is in, they have other vendors that they’ve began to kind of create that partnership space with, and so you figure out who that is. It’s a trade-off between functionality, obviously, and integration. And if you can get a level of integration that works, then go with the one off, but it’s not as common as you might think.
Guerra: And that’s not something you want to keep in your back pocket and make it sort of a last resort, right?
Miller: Right, absolutely. The perfect world is a single platform, single database, single user interface type of approach. But you don’t always get to achieve that.
Guerra: I would imagine that when you have these discussions, you want to also educate these physicians about what they would lose if they insist on having a best-of-breed one-off—in terms of integration, the sort of data exchange they might lose.
Miller: Yeah and that’s a tough conversation with them, because for physicians, it’s about the patient. Taking care of the patient is job number one for them, and having conversations around the importance of being linked to the larger strategy of the organization—for example, accountable care. We’re going to have to manage patient populations across our own enterprise as well as externally, and we’re going to share in the payment for the patient and their disease state. And you’re not going to be able to do that as well with a one-off type of approach as you would if they were all part of the larger picture.
So I really don’t think there’s going to be a lot of options. I remember being at CHIME about a year ago, sitting at a focus group with a vendor whose primary focus was around the ED. I asked the question, ‘How are you going to survive in the world to come, where everything has to be tightly linked?’ And frankly, they didn’t have an answer. If I was in that space of the specialty kind of areas, whether it’s ED or whatever it might be, I would be very worried. I think we’re going to begin to see those guys drop off the face of the earth, because they can’t play in that new world. It’s going to be tough for them.
Guerra: And the problem is that I don’t even know how attractive they are for acquisition because we all know the problems that don’t go away. If you’re simply acquired and become part of a parent company, it doesn’t mean the product is any more integrated than it was before.
Miller: Exactly. You really don’t gain anything. If you’re a vendor who’s merged with someone else, short of a pretty drastic rewrite of your systems to a common platform, you’re not going to get the level of integration that you need to play in an accountable care kind of approach for healthcare organizations. It’s going to be very, very tough. For these organizations out there that have primarily grown by acquisition, short of a total rewrite of their systems, I just don’t see it happening.
Guerra: And then what did you pay for?
Miller: Yeah, exactly.
Guerra: Might as well build it.
Miller: Right, so you maybe got some pretty robust functionality around it, but again, without the integration that’s going to be required, you’re going to be in a world of hurt.
Chapter 3 Coming Soon
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