Stephen Stewart, CIO, Henry County Health Center, Chapter 1

Stephen Stewart is one of many CIOs who believe that Meaningful Use is happening too quickly. In fact, he believes that delaying Stage 2 isn’t just a smart idea; it’s a necessary step to avoid the perfect storm of requirements that would inevitably cause undue stress. In this interview, the CIO of Henry County Health Center — a southwest Iowa-based system that includes a 25-bed critical access hospital, a long-term care facility, and physician offices — talks about the process of attesting to Stage 1, his organization’s EMR journey, and the benefits and drawbacks of being a small facility. He also provides insights on why it’s better to lead than to manage, how to handle pushback from physicians, and what it takes to cultivate an environment that enables the staff to thrive.

Chapter 1

• About HCHC
• Independent vs employed physician practices
• Running CPSI
• Henry County’s CPOE journey
• “Sometimes, there are huge advantages to being small”
• Attesting for Meaningful Use

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Bold Statements

This is a one-hospital county. And in that regard, I think they look to us first, but they hold us accountable for doing our jobs well to continue to sustain that position, and I think it’s a relationship that works out really, really well.

Sometimes it just seems like some of these things are really crazy and they’re almost at the opposite of each other. But what we found is when you bake them down into small chunks and analyze what’s really out there and start to make progress toward things, it becomes more manageable.

The flipside or the disadvantage of being small is that from a human capital perspective, sometimes resources are extremely tight. But from talking to my colleagues in much larger facilities, they face the same dilemma.

It’s not that we don’t have moments when we debate topics and things the physicians would like to see happen differently, but as a group, they recognize the big picture. They buy in on the concept that both in their practice and in the hospital, the EMR journey is really going to help provide for better patient care and better patient outcomes, and give them better access to information.

We called our fiscal intermediary and said, ‘Okay, what do we do next? Where is the form that I need to fill out?’ They said, ‘We don’t have one. CMS doesn’t have one.’ So that was an interesting process to go back and forth through our fiscal intermediary and with CMS to work through the process of what and how they wanted the data submitted.

Guerra:  Good morning, Stephen. Thanks for joining me today to talk about your work at Henry County Health Center.

Stewart:  Good morning, Anthony.  How are you?

Guerra:  I’m doing great.  I’m doing great.  Let’s start off by talking a little bit about your organization.  I understand you’re in Mount Pleasant, Iowa.  Maybe you can tell us about the size, the scope, and those types of things.

Stewart:  We’re located in the southeast quadrant of Iowa, about 60 miles north of the Missouri border and 25 miles west of the Illinois border.  The county is about 23,000 people and the city is about 10,000. We’re a critical access hospital that was founded in 1920. And in addition to the hospital, we have a 49-bed long-term care unit on site and a dialysis center. We have several physician clinics located on campus—some independent and some employed—all of which fall under the purview from an IT perspective for support from us. We are about a $50 million-per-year, gross revenue, critical-access hospital, with about 330 FTEs in the hospital proper and about 500 FTEs on campus from the independent clinics and the dialysis center and all those other functions that are here. So that’s us in a nutshell.

Guerra:  How many beds did you say for the main facility?

Stewart:  Twenty-five.

Guerra:  Okay, so 25 at the main hospital, 49 at the LTAC, and $50 million a year. For a critical access hospital, are you average, small, or large for that sort of figure?

Stewart:  There are 84 or 85 critical access hospitals in the state of Iowa and on a gross revenue basis we’re certainly in the top quartile. So I would say we’re larger than average, but the bed size in critical access hospitals can range from as low as 6 or 7 to 25 as the max. We happened to be licensed and staffed at 25. So yes, we’re larger than average, but not the biggest by any stretch of the imagination.

Guerra:  You said you have some owned practices—do you have any hospitalists? Is that how it’s set up?

Stewart:  We employ a general surgeon and two OB-GYNs today and five emergency room physicians. Also located on campus is a private independent practice of family and internal medicine that has 12 providers. And additionally located on campus, there is an ophthalmologist who is independent, and the family medicine guys are independent, I should add. There are three podiatrists, and we have the dialysis center, a dental clinic, and an optometrist’s clinic, and in addition to those things, we also are the ambulance service for the county and the public health agency for the county.

Guerra:  You’ve got some independent physicians there, but usually when we talk about independent physicians, we talk about them in light of them having choice. They can go to your house or they can go to one down the street. But you don’t have one down the street, right?

Stewart:  The closest one is about 25 miles away.

Guerra:  So they’re not going anywhere else.  It’s almost the same dynamic as an employed physician, I would guess.

Stewart:  No, the dynamic is clearly different than that.

Guerra:  Okay, tell me about that.

Stewart:  Their clinic is independently owned and operated, and they chart their own policy and procedures and make their own decisions. Certainly they have the ability to refer to much larger facilities within 25 to 50 miles. I can’t draw the analogy to employed physicians for that group, but you are right, this is a one-hospital county. And in that regard, I think they look to us first, but they hold us accountable for doing our jobs well to continue to sustain that position, and I think it’s a relationship that works out really, really well.

Guerra:  Right. I know you’ve got CPOE going.  What’s your main in-patient clinical vendor?

Stewart:  CPSI.

Guerra:  And you’ve been working with them since 2004?

Stewart:  Correct.

Guerra:  Okay, I know you attested to Stage 1 and I read your columns that you wrote about doing that. I loved the introductory sentence of your first column that I found. Maybe you had written one before this, but it said, ‘Sometimes I just feel like a dumb pig farmer from Iowa who got in way over his head.’ That’s probably one of my favorite opening sentences I’ve ever read.

Stewart:  I think everybody in health care today and in health IT, sometimes we wonder whether we’re coming or going. Things are changing very rapidly and very quickly. There are new challenges in front of us and things are evolving daily as the rule-making process progresses on, and lord only knows what’s going to happen as a result of the super committee and the budget deliberations in Congress. So it’s a state of flux.

And I guess with that initial comment I was saying that maybe I’m not the sharpest tack on the board, but sometimes it just seems like some of these things are really crazy and they’re almost at the opposite of each other. But what we found is when you bake them down into small chunks and analyze what’s really out there and start to make progress toward things, it becomes more manageable. From our perspective, it really starts with the vision from the top-down; from our board of trustees who are elected public officials through the entire organization. It begins with the vision that this health IT journey really is about patient safety outcomes and enhancing patient care. Our CEO said it really well. He said, ‘I really don’t care about the stimulus dollars. Those are nice things if we could make them happen. What’s right for our patients long-term?’ And we all reasserted the fact that what we’re doing is right for the patient long term.

Back in 2004 when we acquired the CPSI system, we started the journey then. Coming out of the box, we installed what CPSI calls ‘point-of-care,’ and what others might call nursing notes or nursing documentation’  That was the first step toward an electronic medical record. We put in the pharmacy system, the RIS system, and the lab system and everything is integrated and tied together. Then one of the next steps was to implement what CPSI calls ‘chart link,’ which is the physicians’ portal on the world to access the information. And then in October 2008, we implemented CPOE. In February 2009 when President Obama signed the HITECH Bill, or the ARRA and HITECH was part of it, suddenly CPOE took on a new dimension, but we had already begun the process.

I think one of the things that we’re really fortunate about is sometimes there are huge advantages to being small. We can be more agile. We don’t have to turn the Titanic. Sometimes I feel really blessed that my medical staff consists of 31 or 32 individuals, because we have the opportunity to get to know each other personally and work together on a personal level rather than a group dynamic. The flipside or the disadvantage of being small is that from a human capital perspective, sometimes resources are extremely tight. But from talking to my colleagues in much larger facilities, they face the same dilemma. So I chose to look at the ‘being small’ part as more of an advantage than it is a disadvantage.

We’re also blessed with an extremely progressive-thinking medical staff. The family medicine group that I was describing to you began their electronic medical record journey in 1999. So they were actually doing an EMR well before the hospital started down that path. The hospital had made an attempt in the early part of the decade—2001 or 2002—on our old system with a third party product for in-patient documentation. And whether it was the products or the implementation—I’m not sure which because it was before my time—that initiative failed.

Our medical staff stuck with us and when we started the new journey with CPSI, they supported us. It’s not that we don’t have moments when we debate topics and things the physicians would like to see happen differently, but as a group, they recognize the big picture. They buy in on the concept that both in their practice and in the hospital, the EMR journey is really going to help provide for better patient care and better patient outcomes, and give them better access to information. So they’re very good and very willing to collaborate and work with us. That’s not to say that sometimes they don’t tell us ‘no’ because they do, but for the most part when they say ‘no’ on an issue, the next sentence is, ‘How do we get to the end, because the way you’re proposing doesn’t work for us?’ If we dig on it long enough, we can usually come up with a path that achieves the objective and has the least impact on their workflows but gets accomplished what we need to get accomplished.

So with all those things from the early beginning when the rules were finally published, we formed an EMR Steering Committee a long time ago that charted the course and planned out the phased implementation of the things that we’ve done since the 2004 install. And when the proposed rule came out, that committee went through the initial proposed requirements and evaluated where we stood and we found that with CPOE implemented, that we were in very, very good shape. There were a few things that needed to happen. Our software vendor, CPSI, had to bring out a module that they called ‘Medication Management,’ but that was basically where med reconciliation and the problem list were housed. They had to do a few other things like changes in the system to go to a person profile where certain things are stored at the personal level and not the account levels so it’s more viewable throughout the entire system. But with the things we had done up until the time, we knew we were in pretty good shape and we established an objective that we were going to complete the journey and that we wanted to attest as early in the attestation period as we possibly could.

In September of 2010, we installed the beta version of the final modules from CPSI in our test environment and worked through those, and then installed them live about 30 days later. We had some adventures because it was new stuff, but CPSI was a great partner and we worked our way through those problems and by the first of January, we were at a point where we could begin collecting our data and we did. When attestation day rolled around on April 18, we were in a position where we could attest to all of the objectives, and we did so.

We had an interesting experience following that. We knew that the way critical access hospitals got reimbursed was different than PPS hospitals, so we knew that our reimbursement was tied to our non-depreciated assets required to run a certified EHR.  So we spent some time accumulating that list of assets right off of our fixed asset listing from our system, and then reviewed them with our auditor and we said, ‘Okay, everything’s just great. We’re ready to go.’ And we called our fiscal intermediary and said, ‘Okay, what do we do next? Where is the form that I need to fill out?’ They said, ‘We don’t have one. CMS doesn’t have one.’ So that was an interesting process to go back and forth through our fiscal intermediary and with CMS to work through the process of what and how they wanted the data submitted. But we got all that done on June 28,and I am pleased to report that on August 29, we actually got paid by CMS. And I believe—I have been told, anyway, from our fiscal intermediary—that we were the first critical access hospital in the country to actually be paid.

We had qualified much earlier under the Iowa Medicaid program because Iowa Medicaid was one of the first to get up and running—not the first,  but one of the first five, six or seven. And we did not have to attest for that, but our CEO said we’re not going to apply for the Medicaid funds until we know we’ve done it right by the rules that CMS has established. So the fund application or the reimbursement application process was two-fold. It was going on with Iowa Medicaid and with CMS at the same time. Iowa Medicaid was much more prepared because their formulation for reimbursing a critical access hospital was all tied to about 10 or 12 different statistics that came off of your cost report and that we actually received payment for in July. So it worked out pretty well.

Chapter 2