Five years ago, Chris Belmont was called upon to help Ochsner Health System recover from one of the worst natural disasters the United States has seen in decades. Not only was the organization able to get back on track, but it acquired several facilities, forcing leadership to begin the process of replacing the homegrown record system with an EMR that could more effectively serve its growing patient population. Belmont was looking for a partner — not just a supplier, and that’s exactly what he got with Epic, a company that uses unconventional methods to achieve results. In this interview, he talks about why Ochsner called on third-parties to assist with the enterprise EMR rollout, why integration always trumps individual preferences, and how to get the right mix of talent in the C-suite.
- About Ochsner
- Update on the Epic implementation
- “The integration, really, is what sold it”
- Epic’s secret sauce
- “If they tell you to do something, just go ahead and do it”
- “They manage variance very well”
- Integration will trump preferences
- Pushback points: looking at order sets & specialties
- “You can’t muscle the technology into the operations”
It started out as just basically a database to store patient information, and morphed into a full-blown EHR. And we looked at it and said, ‘Okay, does this scale? Does the architecture work? Would it service the organization as a health system now?
When I was talking to other colleagues that have worked with Epic and have gone through these implementations, the theme was, if they tell you to do something, just go ahead and do it. And we’ve followed that, all the way from hiring.
It feels like every Epic project probably runs very similar. In the projects I’ve done in the past, you allow variance. ‘This person is not performing well, so let’s just stick with it.’ And they’ll just say, ‘No, it’s time to make a replacement here.’ They do everything for the better of the project.
One of the mantras that we adopted was, ‘Integration will tramp preferences.’ That’s the common theme. So when someone says, ‘I don’t want to do it that way. I want to do it my way.’ We sit them down and say, ‘Can you live with the integrated version of this?’ And it’s tough, but at the end of the day, it works.
You don’t want to say, ‘It’s Epic or nothing,’ because there are operational concerns that you absolutely have to consider. The ability to capture a lot of the information from the cardiology equipment and the cardiology rooms, for example, is missing in Epic, and that would have been a major setback.
Guerra: Good morning, Chris. Thanks for being with me today. I look forward to chatting with you about your work at Ochsner Health System. Why don’t you give me a little bit of an overview. You have, I think, eight hospitals and 38 health centers—are there any other details you want the listeners to know to give them some context.
Belmont: Sure. We’re located in Southeast Louisiana, and you’re right about the size and the number of facilities. I guess the best way of framing Ochsner is that we’re a large physician practice that happens to own some assets—those assets being hospitals. We have about 800 physicians employed; that’s the way Ochsner was started years ago. And following Katrina is when we became a health system. Prior to Katrina, we were basically one main hospital and a large physician practice with a lot of clinics. Following Katrina, we purchased four facilities from Tenet Health and an additional facility in Baton Rouge, and we’re continuing to grow. We purchased yet another facility from Tenet last year and combined them into a larger health system. We’re still based on Southeast Louisiana, mostly in the New Orleans market, with just one facility and a small group of clinics in the Baton Rouge area. So our coverage area is within about a hundred mile radius.
Guerra: You mentioned 800 employed docs—are the independent community physicians credentialed to admit to those hospitals?
Belmont: That’s correct, and that’s part of our cultural challenge. We were more or less a closed system—Ochsner doctors practiced at the Ochsner facility. Now, we’re embracing the community physicians. It’s a little bit of a culture shift and it’s been quite a bit of a challenge, but it’s working out well. Now we can incorporate community physicians now into our organizations.
Guerra: Yeah, and we’ll get into that. It’s a whole different dynamic. As a CIO, it’s one thing rolling out those EHRs in owned practices, but it’s a whole different dynamic with those independent businessmen, right?
Belmont: Absolutely. It is a whole different dynamic.
Guerra: Okay, so I think a good place to start is an update on the EPIC implementation. That’s probably the number one thing sitting on your place, right?
Belmont: Absolutely. We have a home-grown EHR that Lynn Witherspoon has built over probably 20 years. It started out as just basically a database to store patient information, and morphed into a full-blown EHR. It’s CCHIT-certified—not currently CCHIT-certified on the new standards, but we achieved certification of home-grown EHR a few years back. And we looked at it and said, ‘Okay, does this scale? Does the architecture work? Would it service the organization as a health system now? Would it service the community physicians? Could we grow? Should we double in size? Could we handle that if we decide to go international or even outside of Louisiana? Could this structure support it?’ And we realized that we pushed it about as far as we could.
I guess the best way to say it is that our prototype made it in the production and it worked really well for us; it services 800 physicians well. They’ve adopted it, and it served us well during Katrina. Actually it was somewhat of a life-saver because the city was closed and the file room clerks had all departed, and we were able to get to patient records online. It was a real life-saver, literally, during Katrina.
But we pushed it far as we could. So we started on a journey to replace it about a year ago, and we came to the conclusion that Epic was the best solution for us; given our ambulatory, our physician practice, and other issues. The integration really is what solved it. So we signed a contract in September of last year and we’ve been working very hard. Our first site will go live in December of this year—we’re going up big bang by region. So we’re bringing up the North Shore region at the end of 2011, we’ll bring up the main campus and the majority of our facilities in 2012, and then we’ll finish with the Baton Rouge region in the first half of 2013. So it’s a fairly aggressive timeline. We’ve added 80 FTEs since September. They’re all getting Epic-certified, and it’s working out quite well. We’re pleased with where we are right now.
Guerra: One of the things that we hear about Epic is that they have a good methodology, and thus, they have high success rates. They pre-qualified their partners, they proactively select the people they’re going to work with based on their chances to success, and they’ve good methodology. Have you seen that so far? Have you felt that? Have they said, ‘You need to get 80 FTEs,’ and do you get that feeling that they’re not going to let you fail?
Belmont: Yeah, I do. During the research phase, when I was talking to other colleagues that have worked with Epic and have gone through these implementations, the theme was, if they tell you to do something, just go ahead and do it. And we’ve followed that, all the way from hiring. So the 60 FTEs new hires and the additional 20 FTEs from the inside the organization that were transferred over to the project, we actually ran them through the Epic C test. During the hiring phase, Epic graded them and said, ‘These are keepers, these are borderline, and we would stay from this group.’ And so we stayed with the keepers and it’s worked out quite well. We’ve had less than a handful of people not passing the Epic test and getting certified, and it’s panned out well.
The other thing is a lot of the non-technical methodologies that they bring are very helpful when it comes to change management. The one that really got us launched was the decision day process. So we started out by bringing a group of our executives together and going through decisions, and it’s really high-level to see. For example, are you going to do CPOE? It’s an obvious answer, but when those 40 executives walked out of their room, we all were in an agreement; we all voted. Everybody had a red, yellow, and green card in front of them. And when it was time to vote, they held up their green card if they were in favor of it, the yellow card if they wanted to discuss it more, and the red card if they were against it. But the reality is when you walked out the room, you had put your card up and we tallied that score. So everybody was on board.
And then we ran through about six days down at the workflow level of decision days, and that worked out well. We had a lot of stakeholders down in the trenches come to a central location and go through the same process. Would this workflow work for you? Everybody voted on it, and it went down, extremely down into the detail level. It gained consensus, it gained alignment, it got people bought into the system, and now we’re heavily into the build side of things. So yeah, the methodology is outstanding.
Guerra: You’ve been in the business for a while, and in different roles. You’ve probably seen just about everything there is to see out there. Is this pretty unique, the way this vendor works?
Belmont: The best way of saying it is they’re doing what I’ve always wanted to do in my implementations. They actually have accomplished it. All of these decision-day processes work. It’s just that they have it well documented and they stick to it. So, yes.
Guerra: So what they do—and this is what I imagine every vendor should try to do—is extract learning from each implementation, and continually get better and refine the methodology.
Belmont: Right, and they manage variance. So I would assume that it feels like every Epic project probably runs very similar. In the projects I’ve done in the past, you allow variance. ‘This person is not performing well, so let’s just stick with it.’ And they’ll just say, ‘No, it’s time to make a replacement here.’ They do everything for the better of the project.
Guerra: Just explain that example to me a little more in terms of how that works.
Belmont: Okay. So if a red flag pops up—in fact, in the meeting I was just in, which involved the revenue cycle, there were some tough decisions on payment posting. And they gave us some monthly status report—a very detailed status report that goes up to the executives, and we were turned red on a couple of topics on the revenue cycle. And they basically came in and said, ‘Here’s a problem, you haven’t made this decision.’ So we just sat down for an hour and hammer through it and came out with a good decision.
In other cases when I’ve been on projects, you kind of blow through the stop signs. The red flag goes up and you say, ‘Okay we’ll just going to make that up in the air,’ to use an airline term, and you never do. You never can make it up in the air. So they are quick to bring it to your attention and address it in a timely fashion and not let the project suffer for lack of a decision or a poor performer.
Guerra: So you’re talking about when someone has not embraced the system in the way it’s supposed to be used, possibly overlooking that and just letting them work the way they used to work or do a work-around, whereas Epic will jump in and say, ‘No, this person is not using the system properly. You need to address this.’
Belmont: Agreed. And one of the mantras we adopted was, ‘Integration will tramp preferences.’ That’s the common theme, a common drumbeat. So when someone says, ‘I don’t want to do it that way. I want to do it my way.’ We sit them down and say, ‘Can you live with the integrated version of this?’ And it’s tough, but at the end of the day, it works. We’ve rarely had to deviate from where the product is. Now we’re not in production, so maybe in a year we can have another conversation, but it feels pretty good right now.
Guerra: There are two different areas that you might get pushback or variance. One is order sets and creating standardized order sets by specialty. But then the other element I’d like you to address is a general pushback against what would be considered a generic primary care EMR by specific specialty groups. So you have the order set discussion and then you have a specialist pushing back and saying, ‘This EMR wasn’t that design for me. I want something that was made for cardiology,’ or whatever the specialty may be.
Belmont: Right. Cardiology is one of the areas that we’re not going to implement. Epic’s Cardiant package is a little immature for us at this point. We see where it’s going and we’ve talked to the developers and we like the direction, but we have a fairly well-developed cardiology package. So we’re going to use that for the majority of time. We’re going to build some of the workflows into Epic, but for the most part, we’re going to still use our old package.
But other than that, all of the specialists have invested a lot of time in looking at the workflows, and they can absolutely live with it. In fact, when the head of our transplant looked at it—and this is a great story—he said, ‘This is great. What do you need from me?’ And I said, “Well, I need a resource from your department.’ And he happened to have some people in the room. He said, ‘Okay, take that guy right there.’ And he just ponied up one of his resources on the spot. But I think we’re used to using an EHR and everybody is very comfortable with the Epic platform. It works quite well. So I haven’t had any pushback on that yet.
The only pushback we’ve had—and I think we’re going to overcome that using the information exchange functionality within Epic—is that we have a couple of contracted practices that come in. For example, in our Baton Rouge area, we have a neonatologist that is not an Ochsner employee, and he has his own system because he services multiple NICUs in the area. And we’re probably going to integrate with that more so than drive him to Epic. We have put a stake in the ground and said that the legal medical record is going to be Epic, and he’s okay with that. But that’s the only area right now that we have some pushback.
Guerra: Take me through the cardiology issue. And keep in mind that the goal of these interviews is to help your colleagues who listen to them and read them figure out how to navigate some of the stuff that you have so that we can all learn from each other. So in that situation where the cardiologist says, ‘That’s just not going to work for us right now.’ You want to roll out the Epic package, but it didn’t work out that way. Do you have any information or advice from navigating those waters that you can give your colleagues?
Belmont: Yeah, I think you don’t want to hunker down and say, ‘It’s Epic or nothing,’ because there are operational concerns that you absolutely have to consider. The ability to capture a lot of the information from the cardiology equipment and the cardiology rooms, for example, is missing in Epic, and that would have been a major setback operationally for our cardiology department. So we said ‘Okay, this is not something that we’re going to push too hard.’ And that’s when we said, ‘Let’s look at the Epic timeline as far as developing this.’ They actually looked at what we do and said, ‘Okay, this makes sense,’ and Epic basically said, ‘It makes sense for you to stay where you are in cardiology.’
So I think that from an IS perspective, you can’t muscle the technology into the operations. You have to collaborate with the operational owners to make sure that this is a fit. Because you don’t want to reduce productivity and absolutely you don’t want to impact patient care in any way.
Guerra: But at the same time, you can’t buy Epic and then have five different specialties using departmental systems, right?
Belmont: Ideally, you don’t want to do that. I mean, that’s not uncommon, but in the new world with Epic, and the way the product has matured, I think it works quite well in most of the departments. , I’ve been around the industry, and it’s become pretty common, as Epic has been rolled out over the years, to see pieces and parts of Epic and pieces and parts of others. But we consciously decided not to go with a best-of-breed or a cluster approach. We said we’re going to go all-in with Epic as much as possible, and our executive team is living up to that.
Guerra: So you’re pleased that you have an almost-complete Epic rollout except for cardiology.
Belmont: Yes. And you know, we had a couple of concerns in ED, but our ED physician looked at it and said, ‘You know what? I can live with that.’ And the integration does make it easier to swallow. Now that you can see the entire patient episode in one system without them having to jump out of systems, he’s fine with it.
Guerra: Were you on of a vendor package in the ED or was it a home-grown system?
Belmont: We were on a vendor package. In fact, we had VitalWorks, which was purchased by Cerner, which we had to sunset. Then we went to Allscripts, which was the old A4 product. We had just finished that two years ago, and it was getting adopted quite well, and they’re fine with flipping again.
Guerra: They are?
Belmont: Yeah. We have to do some building, there’s no doubt about it, but that’s just because we’re a fairly mature user of automated ED systems.
Guerra: Right. And you probably tell them, ‘Listen, this is going to be it for a while. We’re not going to flip you again.’
Belmont: They’ve heard that before, though.
Guerra: ED is definitely the flashpoint in my mind of the best-of-breed versus enterprise, so it’s pretty impressive that you got to buy-in there.
Belmont: Yeah, our ED department has done quite well, and they’re on the maturity scale where they’re more into analytics now. They’re way beyond online documentation and the patient management. They’re heavily into statistics and the BI side.
Guerra: Right, and that’s the next level. Most organizations are getting a foundation in, and then the next step will be the business intelligence. But as you said, your EDs are already there. Do you agree that that’s sort the progression of the industry?
Belmont: Absolutely. I have three big strategic initiatives, one of which is the core system. Epic is part of the core system upgrade, but business intelligence and improving the user experience are my other two major things I’m working on over the next three to five years.