Barbara Riddell, VP/CIO, Atlantic General Hospital, Chapter 1

Most CIOs have experienced a major change at one point in their careers. But they’re rarely as drastic as the transition Barbara Riddell made when she went from Tenet Health, a corporation that includes 49 acute care hospitals in 11 states, to Atlantic General Hospital, a relatively small system with a patient output that fluctuates by season. And as Riddell has learned, a smaller organization does not necessarily mean less complexity. In this interview, she talks about having the right team in place to prepare for data exchange, how vendor agreements are like a marriage, and the added pressure that smaller organizations face in getting it right the first time.

Chapter 1

• About AGH
• “How you manage a record for a population that’s coming and going?”
• The importance of real, regional HIE
• Becoming an Allscripts (Eclipsys) inpatient shop
• Goldilocks governance —not too much, not too little
• Keeping RCM (Keane) in place
• Contracting for security: “You’ve got to keep us whole”

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Bold Statements

They like me to time the go-lives for the fall and winter. One way or another, you’re doing some kind of building and design in the summer. But it’s a different kind of set-up when you have to look at timing everything so that you go live between Thanksgiving and Christmas.

For it to be meaningful for our physicians and for the community, I really have to be able to exchange that data and have that seamless communication between the doctor’s office and the ED and the inpatient setting, and then back out to wherever that person’s home is.

Having that record be electronic and being able to make sure that all the treatment for that patient is seamless and that the doctor and the nurses have exactly what they need at their hands when they’re making decisions to care for that patient is paramount to what we need to do.

If there’s any questions they have or anything that they need to understand before they go forward, we work hard to make sure that they understand the big picture and where we see ourselves going in the future so that as a state, we’re not all doing something different.

In the end, we liked the Allscripts platform. We liked the idea of the integration. I like where Allscripts is going in terms of the fact that it’s a sequel environment and they have a strong partnership with Microsoft. When you’re small, you need to make this investment one time.

Guerra:  Good morning, Barbara. Thanks for joining me to talk about your work at Atlantic General Hospital.

Riddell:  Thanks for having me.

Guerra:  Why don’t we start out by talking a little bit about the organization and going from there?

Riddell:  Okay, it is a small community hospital, about 62 beds, and it was built about 15 years ago by the community. We’re located in Berlin, Maryland, which is about six miles south of Ocean City, Maryland. I don’t know if you’ve ever been here on a vacation, but in the summer, we get about 450,000 new visitors a week. It’s a great East Coast attraction. It’s a nice place to visit. The community did not have a hospital in this particular area just a few years ago, and decided to build that both to support the local folks and also the visitors. Our emergency room sees about 40,000 patients a year. We’re awfully busy in the summer and really quiet in the winter.

Guerra:  Right. I recently spoke to the CIO at Cape May Hospital and he has the same type of thing with the huge influx in the summer and then very quiet in the winter.

Riddell:  Yes. Our fastest growing population is about 70-73 years old. So folks are retiring here, and you do have that population to serve as well.

Guerra:  And does that present you with some special challenges? For example, you want to have even staffing and workflow, but you don’t have that because things get really crazy. Are you able to do big projects in the winter when things are quieter—that type of thing?

Riddell:  Exactly. They like me to time the go-lives for the fall and winter. One way or another, you’re doing some kind of building and design in the summer. But it’s a different kind of set-up when you have to look at timing everything so that you go live between Thanksgiving and Christmas. We have some January go-lives as well. We’re pretty busy.

The other thing is understanding how you manage a record for a population that’s coming and going. And so the whole concept of an HIE has become really important for us because a large majority of people are coming here while they’re on vacation, and then they find themselves going back home to a PCP, and we need to make sure they take that record and that experience with them. It’s really important.

Guerra:  Yeah, that’s a very interesting point. A lot of people have been saying lately that for HIE purposes you don’t need to get crazy. If you’re in New Jersey, how often do you need to pull a record of someone in California? So you need to look at the most efficient use cases and look at that circle around your organization realistically in terms of this circle will capture 90 percent of the activity that the patient’s going to have, and we’re not going to worry about extreme use cases. But your circle would be a bit larger than the average circle, because you’ve got people coming on vacation. Is there a general place they’re coming from, or does it just have to be a pretty big circle?

Riddell:  Generally I will tell you we’re definitely supporting Delaware a great deal, because we’re very close to the Delaware border. We get a lot of folks from Ohio, Pennsylvania and New York, and you see a few folks from Connecticut. It’s funny, you start to notice license plates in the summer. And you’ll get a few folks that come up from Virginia, so particularly the neighboring states. You’re really getting a lot of folks that are finding time to either escape for the week or get away for a weekend and come over to the shore.

And unfortunately, sometimes you get sick or things happen. And so we try to be that community hospital. So we’ve got some local doctors’ offices right in by Ocean City on 10th Street. And certainly we’ve got the helipad; if something really bad happens, we typically would stabilize a patient. And depending on the circumstance, take them to somewhere more trauma-oriented. But we certainly handle a large amount of folks in the summer.

Guerra:  So does this idea of having a larger circle for your needs, does that inform your HIE thinking and the kind of structures and the kind of organizations that you are looking to get involved in?

Riddell:  It does. You know, it makes it much more meaningful, much quicker than us. In some cases you might be able to take it slower and want to start exchanging data. But for it to be meaningful for our physicians and for the community, I really have to be able to exchange that data and have that seamless communication between the doctor’s office and the ED and the inpatient setting, and then back out to wherever that person’s home is. You know, it becomes that much more important.

Guerra:  And certainly back out to their home. That seems to be the hardest part. I mean the other stuff is somewhat within your purview, right?

Riddell:  Right. We had a case this summer where someone was receiving treatment for pregnancy at home and got sick here. And certainly we took care of her and she was very happy to have a place to go. But we wanted to be able to communicate what had occurred here back to her OB-GYN in her home state. And so that becomes pretty important, particularly when you’re treating something that is maybe an ongoing condition.

Luckily everything was okay with mom and baby and it was just a matter of making sure we communicated her event to her doctor. So we’re still dealing with the days of faxing and paper, but our goal is to become able to show that information electronically, encrypted, and in real time.

Guerra:  Does one of the formats seem resonant to you more than another? The CCD—is that what you think will work for the future of exchanging data?

Riddell:  I think the CCD is going to become an important part of the data structure. One of the things I’m working on forming is a data governance team, because we have lots of different folks who are concerned about the data. And we don’t want people making decisions in a silo. So part of our governance will be to bring all of those members—the HIM team, the HIE team, and folks who are concentrating on 5010 and ICD-10. And we’re going to set down some governance around the data structure to improve our understanding of the CCD, but also to understand what are the other requirements for reporting that we need, or what might be unique to us because we are a facility that sees a lot of visitors.

Guerra:  You mentioned having a helipad. Is that pretty unusual for a facility your size? That sounds pretty sophisticated –pretty forward-thinking or advanced for a small hospital.

Riddell:  I think it’s pretty forward-thinking. We’ve got a young CEO, Michael Franklin, and he’s a great visionary. And those are key for us to be able to communicate and collaborate when we can take in accident victims. We do some highway accidents, and we can get an accident victim in and get them stable, and if it’s something that requires anything beyond our skill set, we certainly can quickly get that patient to either a neighboring hospital or a trauma unit—all the way to Baltimore if we need to, to Johns Hopkins.

So I think it’s been a very valuable thing. And it’s important; unfortunately we see the type of summer time accidents that happen when young people are mixing alcohol with their vacation or accident victims while they’re out fishing and boating. You want to be able to rescue that patient that quickly, and having that helipad is really nice to get them to your front door and get them stable.

Guerra:  And then from your point of view it’s getting the record there electronically and that type of thing.

Riddell:  Exactly. We want a clean hand-off. So having that record be electronic and being able to make sure that all the treatment for that patient is seamless and that the doctor and the nurses have exactly what they need at their hands when they’re making decisions to care for that patient is paramount to what we need to do.

Guerra:  You may have mentioned this, but I saw two two figures for the number of physician offices and I guess these are owned by Atlantic General—is it 15 or 25, or somewhere in the middle?

Riddell:  So what we have is 15 affiliated, which would be physician-owned or AGH-owned practices, and then we have non-affiliated physicians, which would be physicians that are practicing in our community and own their offices, but where we are working collaboratively to help them get their EMR connected to the HIE, and make sure that those physicians have the records they need. They tend to do admitting in this community, and so they would be folks who work very closely with us.

Guerra:  So you have about 15 owned and 10 independents that work with you?

Riddell:  Yes.

Guerra:  Okay, let’s going to talk about you acquiring the Allscripts product which they inherited from the merger with Eclypsis, Sunrise Clinical Manager, but from reading the situation, it seems to me that a good place to start would be talk about your ambulatory environment. So we have the 15 owned practices—did you have Allscripts Ambulatory EHR in all those owned practices?

Riddell:  We had Misys. We had already made a choice a couple of years ago to install Misys. And this year, we did take on the upgrade and upgraded in May, and so all of our affiliated offices have the pro application in their office, Allscripts Pro. We have a local vendor that we work closely with and he’s a vendor reseller for Allscripts as well. And so several of the non-affiliated docs have chosen the Allscripts MyWay, which is a great smaller version of the application for maybe a single doc or smaller offices.

And so we work closely in tandem with our IT vendor where those physicians are engaging in purchasing MyWay and getting that up and rolling. If there’s any questions they have or anything that they need to understand before they go forward, we work hard to make sure that they understand the big picture and where we see ourselves going in the future so that as a state, we’re not all doing something different. We’re moving toward the goal of joining of CRISP, which is the HIE for Maryland.

Guerra:  Right. So you came in about a year ago, from what I gather.

Riddell:  Exactly.

Guerra:  And when did the selection process or the idea for selecting an inpatient EHR come about? Was that before or after you joined?

Riddell:  I would say they’ve evaluated it a few times. Being a small facility, they had made a huge investment with another vendor. And quite honestly, when I came in there were different versions, so the revenue cycle had just taken an upgrade in that application, but other areas of the hospital hadn’t made a choice. They were using some of the clinical pieces of the application but hadn’t taken an upgrade. So when I came in, I wanted to open that back up and evaluate that vendor and their strategy, where they were going, and try to understand what the requirements were for our needs and where we needed to go.

And so we launched a huge vendor selection process in the middle of my Allscripts upgrade in the outpatient area. As soon as I came in, they were in the eleventh hour of making an ED selection and had it narrowed down to five vendors. And so we circled the wagons and closed that up and managed to make a selection by February this year. We’ll be live with Allscripts ED by November of this year.

So it seemed a natural progression to go ahead and incorporate the Allscripts product in the vendor selection for the inpatient. And to be honest with you, we have a huge selection team—nearly everyone in the hospital participates. It’s different when you come from a corporate office. I came from Tenet and when we evaluated products, we brought in several consulting groups to help us evaluate and we made a selection. And we came forward and announced, ‘Hey guys, here are the choices.’ I came here and it’s a very collaborative environment.

So we took longer than I would have liked for us to really get sure of buy-in and bring everybody to the table and bring the vendors in. Luckily, it’s a pretty place to invite a vendor to. So we invited them here a few times and made some visits, and the team truly made the selection that we would go with Allscripts in the inpatient areas as well.

Guerra:  Can you tell me who the previous inpatient vendor was for clinical?

Riddell:  We had Keane, the iMed product. And they had upgraded their pharmacy prior to me getting here but had not made the commitment to go ahead and upgrade clinical. So we met with the vendors that we were evaluating as part of the inpatient selection. But in the end, we liked the Allscripts platform. We liked the idea of the integration. I like where Allscripts is going in terms of the fact that it’s a sequel environment and they have a strong partnership with Microsoft. When you’re small, you need to make this investment one time. So we wanted to be pretty sure that we are making the right choice. We think we found a very good partner in Allscripts, and we’re very pleased. We are keeping Keane in the revenue cycle area. So we’re very pleased with Keane’s performance in revenue cycle and we will continue with that product there.

Guerra:  These days, do you need a growing amount of integration between clinical and financial processes, and do you think you think you can achieve that tying Allscripts to Keane?

Riddell:  You do that integration. And it’s going to become very, very critical. We are confident in that because of Allscripts’ ability to integrate in the past—and they’ve integrated with Keane. We’ve already visited a couple of sites where they have Keane and Allscripts. So we did look at that. We wanted to stick with Keane since the revenue cycle team is pleased with that product. And we made a huge investment there. We didn’t want to have to rip out and start over there as well.

So we made sure to visit several sites. And in fact, we’ve become good friends with folks in Ohio at Joint Township particularly because they have the same combination as us. But even here in Maryland, there are a few hospital clients that have the same combination.

Guerra:  And you really don’t want to tinker with the revenue cycle if you don’t have to, right?

Riddell:  I really don’t want to.

Guerra:  You’d be very unpopular, very soon.

Riddell:  Coming from outside of the eastern shore and joining this hospital and having most recently come from Texas, I’m already introducing more change than you could imagine. So I needed to not upset my CFO.

Guerra:  Right, certainly. Those A/R days can get up pretty fast if you have a bad install, right?

Riddell:  And she’s doing really well right now, so I want to keep her where she’s at, so we brought the revenue team along on this clinical decision. They went to the site visits with us because we really needed their buy-in too, because although we’re keeping Keane, we will change some of their processes. So we needed to be one team.

Guerra:  Tell me about the level of integration between the existing Allscripts/Misys/Eclypsis products. They’re under the same umbrella now, but are they operating off a single database or getting close to that?

Riddell:  We will be very close to that, particularly on the Sunrise. Almost everything we’re going to put in is honestly going to be the Sunrise product. Now, we do have the Allscripts ED product. We did bake in the option of putting in Sunrise in the ED, but there again, I am installing that product right now to go live in November, and it’s a best-of-breed product. It really is. So I’m going to have to evaluate next year—do we go ahead and build out the Sunrise ED, or do we go ahead and integrate with Allscripts? And we were clear in our contract how we wanted to handle that. We were very specific. And I think we had good partners at the table with Allscripts. They understood the situation we were in. We bought Allscripts ED before the ink was really signed on the Eclypsis deal. And so basically, we went in to contract saying, ‘You’ve got to keep us whole.’ That would be a lot more change if I have to go ahead and build another ED product next year. So we really did bake in some terms and conditions so that we were sure that we can be whole by the time we come out of this thing.

So there will be good integration. We actually added a few pieces to make sure we’ve got what they call the Allscripts Community Works Model and we will have a master patient index—across the outpatient area, all the way through the inpatient, so that we were sure we would achieve that full integration.

Guerra:  Right.

Riddell:  Now you have to call me in a year and see if I still have hair. And we’ll figure out if it worked, but that’s the goal. And we worked really hard on the contract. We actually delayed signing the contract by an additional 22 days so that we could go back to the table and make sure that we looked at those pieces and parts and really sewed everything up so that we could come out of this hopefully with a truly integrated system.

Chapter 2