John Stanley is no rookie when it comes to health IT. The senior VP and CIO at Riverside Health System, a 5-hospital network based in Newport News, Va., has been deploying technologies for 35 years. What has his experience taught him? To position his organization ahead of the curve when it comes to initiatives like Meaningful Use, and to have a ‘bullish’ attitude about meeting requirements. In this interview, Stanley talks about his organization’s long-standing relationship with Siemens, how he and his team are working to create an environment of interoperability, and why sometimes you need to bring in help to deal with the complexities of order sets.
- CMS and Meaningful Use clarifications
- Judging the MU bar: “I didn’t have compassion for the whining that was going on”
- From attestation to electronic reporting
- The importance of proper context for quality reporting
- How to “properly” implement HIT
With the attestation website, I had some real concerns with how it was going to play out and how we were going to do that. So maybe they’ve exceeded my expectations on that. However, the way the regulations are written, there are several areas that are open to interpretation.
When I would read about how people thought this program isn’t fair and how organizations aren’t going to be able to take advantage of the incentives, I just kept thinking, this is an incentive program, at least for the first four years or so. It’s incentive; it’s not meant to pay everybody. It’s meant to encourage the adoption of electronic technology.
We have more issues with how things might be measured than with results. That’s usually the case when somebody grabs some state data or Medicare information and decides to publish it.
We were using the physician advisory group, of which we had physician representation from all our hospitals, so that when a tough issue came up, that group would deal with it and possibly send it back to the drawing board for more consensus, or try to move on.
Guerra: You mentioned that CMS is clarifying a lot of the Meaningful Use regulations with FAQs, follow-up FAQs and Webinars, things like that. Do you think they’ve done a good job clarifying the fuzzy areas of Meaningful Use?
Stanley: Relative to my expectations two years ago, I would say they’ve done a pretty good job of that. With the attestation website, I had some real concerns with how it was going to play out and how we were going to do that. So maybe they’ve exceeded my expectations on that. However, the way the regulations are written, there are several areas that are open to interpretation, and maybe that was purposely done. Maybe it was just a learning experience. At different times I found it helpful that we’d submit some questions, and generally, I didn’t get a nailed-down response. They would point back to a certain page, and I know they were being careful on that.
There were some other interpretations, however. We were very slow coming out. We were using Siemens, and we were saying to anybody, ‘What do you think of this?’ and ‘Do you have an interpretation on what can be used?’ As a matter of fact, as recent as 10 days ago, I was understanding that for exchanging data with another institution, CDs and thumb drives were out; our interpretation now is that’s not the right way of doing it. I haven’t confirmed that yet, that’s just what I hear. It didn’t matter for us because we didn’t use those to exchange data, but I understand there’s still probably interpretation going on.
Guerra: I guess that’s not a big deal unless there is an area that’s open to a lot of interpretation and you come down ultimately on the wrong side of that interpretation. Then I could see that being very irritating—that it wasn’t clear and now they tell you, ‘You’re wrong.’
Stanley: Yes. The bottom line is that we’re trying to do what’s right for the patient and in a safe environment too, so that if we have to make a call, it would be very clear. But generally it’s been there and gotten clarified, through either FAQs or webinars, or just diligence. I’ve got the regs—they’ve never left my desk. The first thing I did was make a whole bunch of notes with references to the pages so I can go back and find it if I need to in a very short period of time, and understand right away that this is how you count or that the numerator and denominator is supposed to be counted this way.
Guerra: Are there any other areas that come to mind now that you still have a lot of questions about that you think are pretty important?
Stanley: My focus is shifting in two ways, so it’s not so much as phase 1—although we are completing the other hospital. It’s more focused on October 1. And we’re not doing this for 90 days; we’re doing it for everyday of the year. And we’ve built it and approached it that way from the get-go, so that’s not even a big concern for me. It’s really Stage 2 and the proposed regs that are out there. I’ve looked at them and I’m using that same word that I used with our board—I’m feeling really bullish on what I’ve seen out there. They’re certainly not final, but I don’t see anything that’s going to keep me up at night with what’s being proposed, and basically it’s been part of our IT plan for years, whether it’s patient portals or some of these indicators being a higher percent, or bar code and medication administration, which we’ve been doing that for years. As a matter of fact, while were waiting for CPOE, we put that into place, so I’m happy to see that in phase 2. I’m surprised that it wasn’t in phase 1. That’s a huge technology for improving patient safety, and we were ready with the bar code medication administration. I was surprised that it got booted out of phase 1 into phase 2, because I think that should be a no-brainer, and everybody should be doing that.
Guerra: Your organization is pretty advanced, going on Soarian in 2004. A lot of hospitals are still on paper today, and certainly weren’t even thinking of doing much in 2004. This program was supposed to be for the entire country, not just for the advanced organizations. What are your thoughts around that in terms of where they’ve set the bar, being that it’s not just for the organizations that were well along? Do you think they’ve set it too high, or do you think they’ve set it out at good point?
Stanley: I would say that if you want change to occur, you need to set the bar high enough to encourage that. Early on when I would read about how people thought this program isn’t fair and how organizations aren’t going to be able to take advantage of the incentives, I just kept thinking, this is an incentive program, at least for the first four years or so. It’s incentive; it’s not meant to pay everybody. It’s meant to encourage the adoption of electronic technology. So I didn’t have any compassion for the whining that was going on. Now granted we were in pretty good shape, but it’s because we’re doing the right things. We’re trying to take care of our patients and using technology to do so. Our CEO would always remind me that this isn’t new incentive money; this is just recognition of the investments we’ve made to get to here. So for those organizations that haven’t made those investments, there is monetary incentive to encourage you to make those investments, and to get going if you’re behind the curve on deploying some of the technologies.
I don’t see this as like government program as much as organizations using technology to render better patient care. And so coming back full circle, I think they watered down the regulations between the proposed and final versions, and they lowered a lot of the percentages tremendously. When you’re trying to do CPOE, the actual metric is that you must do at least one medication. That’s relatively easy, unless you have CPOE deployed in one single unit in the hospital. I think 99% of our patients have at least one medication order by CPOE, and that was early on when not all our specialties were even up—partially because the hospital’s program touched so many patients.
Guerra: You mentioned the glitch in the attestation website, but attestation is a totally different situation then electronic reporting when we get into Stage 2 and 3. Is the idea of doing electronic reporting directly out of your systems to CMS a little scary?
Stanley: From a technology stand point, our partner in this case is Siemens. And I’m not saying the ball just gets thrown totally in their court, but to be certified, we’re heavily dependent upon those transactions. Right now those transactions are feeding reports that produce numerators and denominators that we validate and look at and are attesting to, so I don’t think it’s scary as far as our ability to get there and to do that. What might be scary for other folks is the amount of information that is being fed to all sorts of agencies to gather information. And if it’s done in context, that’s fine. But if it’s taken out of context, whether its mortality rates or publishing physicians’ C-Section rates, if it’s not done properly, then that would be a concern that this data will be available to all sorts of agencies.
Guerra: Do you mean that it might make your organization look like it does poorly in a certain area when that’s not really fair?
Stanley: Well, it certainly brings transparency. We have more issues with how things might be measured than with results. That’s usually the case when somebody grabs some state data or Medicare information and decides to publish it. It’s just a matter of understanding numerators and denominators—what’s in there and what’s not, are these types of patients excluded, and are we truly being fair in comparing apples to apples. It’s sort of an unknown, so that would be my only concern—how all of this data gets bundled up and either reported out, or whatever the future is of reimbursement, in terms of Medicare, Medicaid, ACOs, etc. But overall, transparency is a good thing.
Guerra: Right. I’m going to read you a quote I found online from a press release in which you were quoted in. It says, ‘We believe there is transformative power behind properly implemented health IT systems, with the direct benefit on the quality of care we deliver to patients.’ I wanted to focus on the phrase ‘properly implemented.’ What does that mean to you, and can you give me a scenario where there is an improperly implemented system?
Stanley: First off, ‘properly implemented’ involves a process that you are either trying to improve on or automate, and realistically matching it with software to allow you to take advantage of technology. And that might mean going back and redoing a process, and not doing it like you were used to doing before. In other words, not just taking paper and turning it into electronic documents—that would be improperly installing systems; but taking advantage of the technology to rethink some of the processes. Now timelines don’t always allow us—and I’m being brutally honest—to take every process and totally do a perfect design, but if you put some proper planning into it and have realistic expectations of what you’re trying to accomplish, you can go about putting in CPOE or putting in a safer environment to deliver medication, assessments, or nurse documentation.
One of the things we’ve done very successfully is lowered our infection rate. We’ve been able to take some of the automation that we have—in this case, using Soarian—to take a look at patients that might be more susceptible. And we’d get this information through our nursing documentation—doing a lot of assessments and providing alerts to infection control departments to much earlier intervene. And we’ve seen a lowering of our infection rate. And I didn’t even know we were doing this until about a couple of months ago, but one thing we’re doing is that for patients who are in isolation, we are notifying the environmental services department so that depending on the infection, they can use different cleaning agents that are more effective. We’re using our work list in Soarian to notify the folks down the basement so they can do a better job of cleaning and keeping the infection isolated. It’s all part of just another variable that we’re able to put in place. And we’re thrilled to see those reductions anytime we can improve the care. And if I can point it toward the technology and we’ll take credit for it.
Guerra: I would imagine that CIOs approach physicians with a certain technology and the physician might say, ‘No, this is how I work. Why don’t you give me something that helps me work this way, but better.’ But you’re saying it doesn’t work that way. You have to also look at changing the workflows, and that’s really where we get the tension with clinicians, correct?
Stanley: You’ve hit the nail. That is the key with clinicians—particularly physicians, and we certainly have had and will probably continue to have physicians who have different techniques. Some of them are probably evidenced-base and some of them are not. What we’ve found to be helpful is we formed a physician advisory counsel (PAC) and we made it multi-hospital, so that we had representation from all the hospitals. And that’s sort of our bubbling up group, particularly when it comes to the evidence-based and the order sets, and now we’re using them even to help us do some priorities of next frontier, CPOE, and things we can even improve on better. But we did use that group as sort of a sounding body. So it wasn’t IT saying, ‘This is how you must do it.’ It was more that we were using the physician advisory group, of which we had physician representation from all our hospitals, so that when a tough issue came up, that group would deal with it and possibly send it back to the drawing board for more consensus, or try to move on. And beyond that, the chief medical officer of each hospital may need to sit down with the physician and review if there really was a reluctance of ‘I’m not going to use this system,’ or ‘I came from a place where they did it this way, and I’d like to change everything to that.’