Like many CIOs, Jackie Lucas believes Meaningful Use is the right thing to do because it’s moving the industry forward. But she also believes the planning and execution of such a major initiative left something to be desired. Lucas would have liked to see a more holistic, layered approach to health IT that addressed workflow concerns — something more like the deliberate strategy that she has tried to implement at Baptist Healthcare. In this interview, Lucas talks about the challenges community hospitals face in adopting CPOE and meeting quality measures, the experiences she has had in maintaining multiple vendor partnerships, and what healthcare CIOs can learn from other industries.
- About Baptist Healthcare
- Working with employed and independent docs
- Running 5 McKesson shops (almost live on 10.3.1) and 2 Meditech shops
- “Being that we’re not a teaching organization, we have some challenges on the community hospital side that they may not encounter”
- Quality measures, problem lists
- The right governance for change management
If you’re an unemployed physician, you’re going to use our electronic health record in the practice. We’re going to be employing your staff and certainly you’re going to be an employee of this system, verses affiliated physician, who is going to make those decisions for him or herself.
Our clinical focus, like everybody else in the country, is in trying to be prepared for Meaningful Use. I think we have some challenges in the community hospital side that teaching organizations may not encounter.
For the independent or affiliated doctor that has to bring their bottom line in and provide the best quality care for their patient—just like with all of us in this healthcare reform movement—there’s just so much pressure on them. Every minute you take away is a minute they can’t see a patient.
You’ve got to sit down and figure out, where does the data have to be to report correctly? Who’s going to be entering the data? How are you going to make sure the data is getting entered?
I think that early on, we all focused on that CPOE bar. Everybody was so focused on CPOE that maybe we didn’t understand how the measures were being applied in the software, the workflow—all of those pieces.
Guerra: Good morning, Jackie, thank you for joining me today. I look forward to chatting with you about your work at Baptist Healthcare System.
Lucas: Good morning.
Guerra: Why don’t we start out with a little overview of Baptist Healthcare. I see that it’s the largest non-for-profit in Kentucky, with five acute care hospitals and more than 1,600 licensed beds. So tell me a little bit about that, and whether you have any owned clinics, ambulatory clinics—that type of thing.
Lucas: We do. We actually own five hospitals and manage two facilities, so we’re actually a seven-hospital system. We have an insurance company in Lexington called Bluegrass Family Health, and we have a number of urgent care centers and physician practices. We serve pretty much every area of healthcare, and we actually operate most of the Walmart Express clinics in the state of Kentucky in our markets.
Guerra: So when you say you have an insurance company, is that like the Kaiser model where it’s a closed loop system?
Lucas: No, it’s an insurance company operating primarily in the central Kentucky area and actually down in to Tennessee. Bluegrass Family Health is a very traditional insurance company; it is not a closed model.
Guerra: Okay. What’s your component of physicians? Do you have a lot of employed physicians or a lot of independents in the community referring in? What’s the mix?
Lucas: We have more independent and affiliated physicians than we have employed physicians. That is our model. We support both, but the majority of our physicians would be affiliated and independent physicians at all of our hospitals. We have more employment in Louisville and Lexington than in our more rural areas like Corbin and Paducah.
Guerra: Have you seen a big difference in the uptick among the physician population between the employed and independents? I mean, the owned physicians are employees; they ideally have to listen to what you’re asking them to do. But as a CIO, how do you handle those two populations of physicians?
Lucas: We really haven’t looked at our employed physicians as owned physicians. We still very much work with them in a similar situation to the affiliated physicians. We very much respect them as physicians and clinicians. They still have a very active role in their practice. With our affiliated physicians, in all due honesty, we haven’t made a big difference. Probably the biggest difference for us is if you’re an unemployed physician, you’re going to use our electronic health record in the practice. We’re going to be employing your staff and certainly you’re going to be an employee of this system verses affiliated physician, who is going to make those decisions for him or herself. And we’re going to work to integrate that data and interface it. So I haven’t seen a big difference; certainly on the hospital, inpatient side, we work with both groups in a very similar manner. So the only real difference at this point is their practices.
Guerra: Right, so just because they’re employed physicians, it doesn’t mean you can sort of send out a memo and they’re all going to march along. It’s more collaborative than that.
Lucas: It’s much more collaborative than that, and in all due honesty, if you looked at the areas where there that are not physicians in our health system, we don’t have a tendency to send out a memo and this is how it is. We’ve always been a very collaborative organization. We operate in different markets across the state of Kentucky, so we always take in to account what works in a particular hospital; what works across our organization. We take a real team approach. With all of our IT projects, we bring together a team from each hospital as one big project team. A lot of discussion goes on in figuring out what’s the right way to do it, and if there’s some variation, how we can accommodate that. So we’ve really taken in that same model and applied it to our physician related implementations.
Guerra: So, you have five owned hospitals and two that you manage. Tell me about the inpatient acute application environment—who your core clinical vendor is, and if you have one for all of them, or if the different hospitals have different core vendors.
Lucas: In our owned facilities, we have partnered with McKesson since 1998, so the majority of our clinical and financial applications are McKesson. The two managed facilities are Meditech hospitals, and those decisions were made before we picked up management contracts with them.
Guerra: Among the five owned facilities, if you have a patient who’s in one facility and then they wind up in another one of the owned facilities, what kind of information sharing or data availability do you have there?
Lucas: At this time, the way that the data would be shared is we would be able to have the physician or the clinician view it through our portal. We’ll be replacing our main frame before ICD-10, so we are going to be doing an EMPI. But at this point in time, it would be a view versus the full integration of that data.
Guerra: What version are you on of McKesson? Are you on Horizon?
Lucas: We’re on Horizon for our clinicals. And we’re kind of working through what we’re doing with our financial side with McKesson. We’re on one of their older revenue cycle products.
Guerra: On the Horizon side, do you need to take an upgrade? I know they have that new version.
Lucas: We are almost live on that newest version.
Guerra: And what is that?
Lucas: 10.3.1. We actually went to 10.1 last year. Some of the customers stayed on 7.6 or 7.8 and made the move. But we went ahead and went to 10.1 As large as we are, we felt it was better to go half the way or three-quarters of the way, and not have as large of an upgrade to get to Meaningful Use. So we are working on our 10.3.1 upgrade right now; we’ll be live this summer.
Guerra: So you’ll be live this summer. Do you have a sense of what 10.3.1 offers? Some customers were looking for some improved integration between the modules inside the McKesson family.
Lucas: Honestly, I have to say we’re so focused on Meaningful Use, on ICD-10, and on our ambulatory that we may have not looked at that as closely, but it’s certainly not coming up. It is one of the issues with that upgrade.
Our clinical focus, like everybody else in the country, is in trying to be prepared for Meaningful Use. I think we have some challenges in the community hospital side that teaching organizations may not encounter. So I think there’s some extra work involved when you’re a community hospital trying to meet Meaningful Use.
Guerra: You mean around CPOE and physician documentation, these types of things?
Lucas: Absolutely. I spent 9 years in a teaching organization before I came to Baptist, and when you have medical students and you have residents, it’s a very different world from when you’re operating in community hospitals where you have employed physicians and you have independent affiliated physicians. Having worked both of those, it’s just a very different focus. The independent affiliated physician is generally not employed by the university. A lot of times when you’re a teaching facility, the physicians are employed by the university. They’re in a model where there is not as much pressure on them, sometimes, for productivity. I never want to make sweeping comments because you can find every situation somewhere. But for the independent or affiliated doctor that has to bring their bottom line in and provide the best quality care for their patient—just like with all of us in this healthcare reform movement—there’s just so much pressure on them. They’re being asked to pick up additional work and being asked to change processes. They want to provide the best quality care, but every minute you take away is a minute they can’t see a patient.
For all physicians, when it comes down to it, what they’ll have to sell is their time. And that’s very precious when you’ve got to make best quality care, be able to pay your staff, provide insurance—all those types of things. It’s just very different. In teaching, you have the medical students, you have the residents there—they can do a lot of those Meaningful Use items. I’ve never broken it down, but I bet if you sat down with the teaching facility that’s at or near Meaningful Use and you charted out their workflow, and then you came over to a community facility and charted out their workflow and who’s doing it, I think you’d see a really big difference.
Guerra: Especially when we start out with pretty low levels of CPOE. Even if you have a large amount of hospitalists and certainly if you have residents, you can get those numbers right off the bat.
Lucas: Right. They’re probably are already there, right off the bat. What’s interesting is I’ve done a little bit of research on this, and I haven’t found a whole lot, but we’ve really been digging in with our work groups on meaningful use. And sure, CPOE can be challenging, but that’s not as much of a challenge as these quality measures—how you’re going to get that information in when you have to hit 80% and a 100% on some of those. That’s really the challenge, and I’m not entirely sure that everybody out in the industry has picked up on that in trying to work through those workflows. We’re finding that to be the most challenging piece of this.
With our CPOE, we have two ways to meet that. We’re going to have T-systems in our emergency department, and we have a large admission right into both inpatient and observations from our ED, especially on our larger hospitals. So we’ll have the T-system product that we will be deriving CPOE from, and we’ll also have the McKesson Horizon Expert Orders on our inpatient side. So we felt really good about the 30% of the patients with the medication orders. What we’re really finding the most challenging is these quality measures.
Guerra: When you say getting the quality measures, you mean creating the workflows to capture the data that’s going to be required, and then getting that data into a form that CMS is going to want it ultimately when you have to report it electronically.
Lucas: Absolutely. You spelled it correctly. I’m not sure that people have really sat down with these measures, especially for instance, the problems list. Getting a codified problems list and getting that information entered in exactly the place where your HIT partner or vendor has prescribed that for entry. Who’s going to be entering that information? That’s additional workflow in most hospitals today, because you’re generally putting that problems list as being codified for billing after discharge. This has got to be done concurrently. So those are the types of things where you’ve really got to sit down and discuss those measures with your partner or vendor.
And it certainly may be more than one, because you’ve got T-systems and McKesson, and for some places, it might be even more vendors. And you’ve got to sit down and figure out, where does the data have to be to report correctly? Who’s going to be entering the data? How are you going to make sure the data is getting entered? We have work groups working on this, and these are the pieces we’re starting to see. CPOE at 30%—that’s really not the bar here.
In our organization, the bar is these quality measures, and I think that might be some of the frustration for the hospital folks involved in working on this—maybe not as much IT, but we have very good scores on quality measure now. So some people are saying, ‘We have these really good scores and we really do well with that, now here are these others that are different. How does that all fit together?’ So those are just some of the things that are starting to bubble up from our organization.
Guerra: When we talk about these things, I’m thinking about how long it takes to change processes, especially if you’re not working on a dictatorial autocratic environment. There are so many meetings. First of all, to get all of the relevant people together for a meeting, have the meeting, introduce the topic, have everyone throw out their ideas, think about it, meet again, sit around—it takes forever. It takes months to get any sort of movement and there’s not that kind of time here, it seems.
Lucas: There really isn’t. And so what we’ve been trying to focus on this having the right people in the meeting, making sure the right information is available to those folks as best we can. And I think everybody knows that it can be confusing because of the number of places you can find interpretations and re-interpretations of Meaningful Use. We’re trying to have a good understanding of the Meaningful Use requirements or measures, and then try to have the right people in the room and be able to facilitate that conversation with people that can really explain it. You also have to have your vendor partners at the table—T-systems, McKesson, etc—those folks have to be involved, because a lot of this really is working with how that software has been written and certified to meet the Meaningful Use requirements. I have not done this research at a very deep level, but I’m the making assumption based on conversations I have had that if you took several different vendors’ software and you looked at where and how these measures are being met—are they all certified and do they meet the collection. And is not meant to be a negative comment, but I think you’re going to see quite a bit of variation. So you’re going to figure that in to your workflow.
Guerra: I’m just literally thinking about how hard it is to get five high-level, almost C-level people in the room at the same time, and have them all show up. You can get everyone you want, but if one key person has something come up and doesn’t make that meeting, it’s time to re schedule and talk about it two weeks later. It just takes time, right?
Lucas: It really does. And we’re fortunate in that for years, we’ve had a good video teleconference system. So we’re able to have all those people not be in the same room, but still be able to see everything. We use desktop video and we use our video equipment to get people together.
And we’ve been doing these implementations for a long time. When we went into the strategic partnership direction, we were a best-of-breed IT shop until 1998, when we went with the decision that we would have partners, and those were the places where we’d get most of our software, hardware—as much of our technology as possible. Since we did that, we worked through a project management-program management philosophy that’s really worked very well for us. So we have a system project owner who is a vice president at one of the hospitals or might be a director, and they really own those functional decisions. We have a representative from every hospital, and we make those decisions together. And that is really working well for us in this process, because we’ve been doing that for so long and people really know how it works, so they bring the people to the table. And if they can’t be at the table, they have someone else there who they trust making that decision.
So we usually can move pretty quickly and we have these work groups together that are interdisciplinary—we have physician, nursing, medical records, and our quality group. We have these folks together looking at this and figuring out where’s the right place to collect this data, what makes the most sense.
And pharmacy has to be engaged on many of these too. For the venous thromboembolism and stroke indicators and measures, you’re going to have pharmacy involved with the physicians. We have these work groups working and it’s really in the last 30-60 days that we really started understanding this as we did a deep dive in to this with our vendor partners. How are we going to collect this? What is the workflow going to look like? Where’s the logical place to collect this? How are we going to make the changes with physicians with the different groups that are involved?’
I don’t know how in-depth other organizations have gone. I’ve talked to some teaching organizations that are ahead of us in trying to do their attestation. I’ve talked to some community hospitals that are nowhere far as far long as we are. But it’s really important to look at this and understanding these measures. I think that early on, we all focused on that CPOE bar. Everybody was so focused on CPOE that maybe we didn’t understand how the measures were being applied in the software, the workflow—all of those pieces. The different vendors—Meditech, McKesson—are just really starting to roll out across their base this certified software, so a big piece of that is, how has your partner or vendor interpreted that? How have they written it? How does it fit in to the workflow?
If anyone hasn’t done that, I would really encourage them to start really taking a look at that and mapping it out and getting work groups together—and certainly including that partner or vendor of your hospital, depending on the size, whether you’re a single hospital or if you’re a multi-entity, really pulling that together and mapping it out and understanding it.