Like many rural systems, Centra Health serves a large geographic area — which requires supporting physician practices with different needs and expectations. It’s a challenge that Ben Clark, VP/CIO, welcomes with open arms. Now in his ninth year as the head of IT, Clark has spent a total of 23 years at Centra, a nonprofit system that includes three hospitals, as well as health and rehabilitation centers, a regional cancer center, and physician practices. In this interview, he talks about being a McKesson shop surrounded by Epic organizations, the importance of staying ahead in terms of Meaningful Use, balancing the needs of different specialties, and the challenges that both his team and physicians face in connecting the continuum of care.
Chapter 2
- ICD-10 — “We’ve worked very hard to make that a non-IT problem”
- It should be postponed — “Something’s gotta give”
- Are computer-assisted coding and natural-language processing ready for primetime?
- Easing down the ACO road
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Bold Statements
ICD-10 is a very big deal. We have worked very hard here to make that a non-IT problem—that is a clinical coding and financial problem. The IT piece of that is just to ensure that all the applications are compliant.
We’re spending our time in that environment, waiting to see how this ACO is going to shake out. We’re not going to be a pioneer; we’re not going to jump on that right now.
I just finished Meaningful Use for this year, so I have the time to turn the attention to it. A health system that is just getting started down the path of Meaningful Use and ICD-10 and is dealing the pressures of the new health care program—I don’t know how they’re going to do it.
There’s just a natural discussion that says, if you can pull out of a dictated note everything that’s needed, why do you need a template-based physician notes product which is going to be very complicated to install as well?
That’s one of the challenges here. The vendors that do computer-aided coding and assisted coding are not necessarily the vendors that are building the templates. So you’ve got this natural competitive juice flowing between these two trying to explain who has got the better product right now.
Guerra: Is it the top thing on your plate—integrating with both the owned and the non-owned practices?
Clark: In IT, it’s hard to say there’s ever one top thing, because we have many top things. It is one of the many. The last pieces of paper that I have left in my organization today are physician notes, so that is a top priority. This ambulatory integration is certainly a top priority. So it’s one of the top priorities, absolutely.
Guerra: What are some of the others? I could enumerate what they might be: ICD-10 conversion, ACO transformation, and whatever that means to you or anyone out there. It probably means different things to different people. But what are your thoughts around that?
Clark: ICD-10 is a very big deal. We have worked very hard here to make that a non-IT problem—that is a clinical coding and financial problem. The IT piece of that is just to ensure that all the applications are compliant. So that’s my part of it, but I’m doing everything I can to stay out of the workflow and all of the other things that are going to go into ICD-10. It’s a big deal, but I am but one member of the rather large committee assigned to be ready for that little event in October of 2013.
In terms of ACOs, we at Centra management have probably taken kind of a “look and see, but not jump” approach. We have just taken on a Medicare Advantage plan. We were doing a lot of work with PACE products for managing the elderly. These are all at-risk projects. We have a very small 35,000-live PPO and so we are taking what we’re learning from the PPO, from PACE, and from our Medicare Advantage program and trying to learn how to manage populations, the decapitated environment—those types of things. We’re spending our time in that environment, waiting to see how this ACO is going to shake out. We’re not going to be a pioneer; we’re not going to jump on that right now.
Guerra: Regarding ICD-10, you mentioned that you were doing everything possible to not get sucked into being the one who leads this. Do you think there is a natural tendency, for whatever reason—and maybe you can tell me why—for the CIO to get sucked into that, if he or she doesn’t make sure it doesn’t happen?
Clark: In my environment—and that’s all I can really speak to, I probably have the strongest project management team. It’s well-defined. It’s a process. It’s work. People understand it. They very much want to pull that kind of group together for the ICD-10. And so it was asked. We talked about it, but that’s really not the purpose of our project management team, and we found a way to participate but not have ownership.
Guerra: Is that going well or is that rubbing some people the wrong way who say, ‘Ben, why don’t you just take this?’
Clark: So far it’s going fine. We are in the process of validating and making sure that all of the IT systems are where they need to be. They are not; they won’t be until the first quarter of next year. Centra has strong leadership around clinical coding and has some strong leadership in the financial areas, and I think they’re okay with it. They’re not at all anxious about IT not having the lead.
Guerra: John Halamka, as you may know, is the CIO at Beth Israel Deaconess Medical Center in Boston.
Clark: The ‘geek doctor,’ yes.
Guerra: Right. He has written in multiple posts that he thinks ICD-10 should be postponed and that there needs to be another cost study of the program, because he was finding that it is costing much more than the government has projected. Can you give us your thoughts around whether it should be postponed and what you’re seeing in terms of the cost that your organization will have to absorb?
Clark: I don’t believe that it’s going to be postponed. I am not nearly as connected as some people, such as Dr. Halamka. I’m not as nearly connected so I can’t say, but my feel and my read is it’s been postponed too many times and it’s not going to happen.
Guerra: So you think it should be postponed?
Clark: I just finished Meaningful Use for this year, so I have the time to turn the attention to it. A health system that is just getting started down the path of Meaningful Use and ICD-10 and is dealing the pressures of the new health care program—I don’t know how they’re going to do it. So yes, I would say something’s got to give, but I don’t believe it will.
Guerra: And what about the cost?
Clark: We’re projecting right now a $7 to $10 million hit in the first year of ICD-10 going live. Those are just some estimates. It comes from McKesson. It comes from what our coding staff. I think that they’ll become as proficient with ICD-10 as they are with ICD-9. Our compadres across the ocean have been using this for a long time, and they seem to be able to make things work. Believe me, we’ll have a lot of trouble making it work. It’s just getting there.
Guerra: I’m not sure if you know the answer to this, but have you budgeted a dip in reimbursement for when the crossover happens?
Clark: Yes, that’s actually the $7 to $10 million I was referring to. The costs of getting there are buried in a lot of upgrade costs that we’ll be doing anyway. So it’s hard for me to say, ‘It’s costing me this amount of money for ICD-10.’ We can say, ‘I’ve got about $3.5 million budgeted,’ but it’s certainly not all for ICD-10.
Guerra: Do you go to the CHIME Fall Forum?
Clark: I’m scheduled to, yes.
Guerra: I’m going to be moderating a town hall session there. In helping me prepare, what is the hardest part of ICD-10 is that other CIOs out there may be just grappling with or scratching their head about, and are not sure which way to move forward? Any thoughts on that?
Clark: For me, what I’m grappling with is a very strong push out of clinical coding for this computer-assisted coding and this natural language processing, and how that’s going to relate to the template-based physician notes that we’re looking at deploying, and how we’re going to match those up. There’s just a natural discussion that says, if you can pull out of a dictated note everything that’s needed, why do you need a template-based physician notes product which is going to be very complicated to install as well? And so we’re trying to figure out how good computer-assisted coding is going to be and is that going to have a bearing on these template-based products for physician notes that we’re looking at.
Guerra: So it’s an interesting situation. You have to wait and see, but then it’s like a chicken or the egg thing, right? If we go with these templates and then the natural language processing is good enough, we didn’t need these templates, but if natural language processing isn’t good enough, then we need these templates.
Clark: You got to have it, that’s right. So you’re hedging your bets. It’s an expensive solution—both of them are, and we’re currently marching down the path for both of them. So we’ll see how that goes.
Guerra: If you don’t have the template screens from the vendor, what do you have? So if you don’t go to those templates, what are you using for your online or electronic documentation that the natural language processing would work within?
Clark: What they put in their progress note today, they would just dictate it. Just like they’re doing today—we dictate and it gets transcribed on a piece of paper or an electronic document gets created. This would not really change that. Physicians, I think, will love this, because they really don’t like sitting in front of a computer and typing out stuff.
Guerra: Or clicking on checkboxes, things like that.
Clark: That’s right.
Guerra: So how do you determine the state of natural language processing?
Clark: I’m very much in the early stages of just trying to understand the vendors and the vendor offerings. I would say that the majority of my research to date says it’s not quite there, but it will be.
Guerra: So the question is, like you were saying, what do you do?
Clark: Exactly, and when.
Guerra: And God bless the vendors, they’re always going to give you optimistic forecasts, right?
Clark: That’s one of the challenges here. The vendors that do computer-aided coding and assisted coding are not necessarily the vendors that are building the templates. So you’ve got this natural competitive juice flowing between these two trying to explain who has got the better product right now.
Guerra: Right. And we’re talking about McKesson in your case, right?
Clark: That’s correct. Horizon Expert Notes is their product, and it does some things very well that computer-assisted coding cannot do today.
Guerra: And these are big bets you’re making, both in terms of investment and the risk to inaccurate coding that will have your claims reimbursements dropped through the floor.
Clark: Yeah, and resource as cost too. There are a lot of people who are going to go into figuring out all of this, and you go down the path of one that’s just abandoned. That will be a tough problem.
Guerra: Any which way it goes, I would imagine you need a whole cadre of people to look at this on the backend before it goes to the insurance companies—whether the docs are just coding in the templates or whether it’s natural language processing, someone has got to be reviewing this before it goes out, right?
Clark: Right, the clinical coding and documentation team, yes.
Guerra: Right. So how good does it have to be before it gets to them? And I don’t know if I’m getting into areas that are not your expertise, but any thoughts around that?
Clark: You’re really getting on the fringe of my abilities here.
Guerra: We’ll pull back.
Clark: It’s an art, this coding, and it’s really outside my paygrade.
Guerra: I remember that famous answer from Mr. Obama. All right, let’s pull back. (laughing)
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