For Cathy Crowley, the path that took her to the CIO position at Columbia Memorial Hospital wasn’t a typical one. It was the economic downturn that steered her away from consulting and into the temporary position that eventually became full-time, but it was her proficiency for implementations and multitasking that has kept her there. Crowley is leading the way as Columbia Memorial Hospital — a 192-bed acute care facility that includes a long-term care site and several practices — seeks to achieve interoperability despite having three different systems. In this interview, she discusses how her organization has been able to leverage government dollars, the challenges in working with community practices, and the importance of being able to navigate the hospital politics involved in vendor selection.
- About Columbia Memorial Hospital
- On ACOs
- eClinicalWorks on the ambulatory side
- Meditech in the hospital (Magic 5.6)
- Allscripts in the ED
- “I think our interfaces have tripled in the last few years “
- “My biggest challenge here is to try to maintain three systems”
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We’re certainly not saying that we’re going to be an ACO next year, but we’re looking at what the demands are and making sure that we are positioning ourselves well to handle that direction and do what we need to do to stay competitive.
We’re sending over a patient information reconciliation form, which is what the long-term care facilities need to look at if they’re evaluating a patient coming to them. And we’re working with HIXNY so that whenever we have one of those forms, they could then push it out to the long-term care facilities in the area so that they can evaluate patients without needing to come in and look at charts.
We’re trying to get everything in place so that by the time we do it, we will at least have everybody up and used to using computerized systems. We’re putting in advanced clinicals, so our providers will be used to doing documentation using these systems.
Resources are so tight, and you have certain people that just know eClinicalWorks and a few people that just know Meditech, and that’s a challenge. It’s not as easy for somebody who does eClinicalWorks to take a call and help a customer who’s having a problem with the nursing module.
Make sure you have a test script so that you almost don’t have to think about it—you go in, you put your patient in, you know you’re going to do this, and the interfaces are built in as part of that script.
Guerra: Good morning, Cathy. Thanks for joining me to talk about your work at Columbia Memorial Hospital in the greater Albany area.
Crowley: Thank you for having me on the call.
Guerra: I saw Hudson—is that the name of the town, or where exactly are you?
Crowley: Hudson is the name of the town. It’s about 30 miles south of Albany. And we border Massachusetts.
Guerra: How’s the weather up there?
Crowley: Actually right now it’s quite nice at this time of year. It’s in the 50s, maybe even close to 60.
Guerra: Are the winters are rough over there or not so bad?
Crowley: I don’t love the snow, so I would say that we definitely have a winter here.
Guerra: All right, great. So why don’t you want to tell us a little bit about the health system first. I believe you have one hospital, long-term care, and some primary and specialty care centers. But why don’t you give us an overview of the organization so we understand the scope of what you’re dealing with.
Crowley: Okay, I think if you had asked me the question about a year or two years ago, and said, ‘Are you a community hospital?’ I would’ve said ‘Yes, we are.’ But in reality, we really are a large multi-specialty group with $36 million in annual revenue. We have a large outpatient ambulatory service center with about 30 different clinics and specialties. Fifth-eight percent of our acute care revenues come from the outpatient services, and we also have a long-term care facility attached to us. So we’re very multifaceted. We have a number of different kinds of businesses going on to meet the healthcare needs of today. We also have 74 employed physicians, 15 directly contracted physicians, mostly down in the ED, and then we have 24 nurse practitioners PA, nurse, midwives – so a total of 113 providers.
Guerra: So you’ve got it all.
Crowley: Yes, we do have it all. I think we would say we consider ourselves really a healthcare system. Some of the real pluses for us are that we really have good geographic coverage—we really extend to counties in an area where people would not always be going up to Albany, and then ideally we have a group employed physician model that will lend itself well to healthcare reform.
Guerra: Right. So the main hospital is a 192 beds, is that correct?
Crowley: Correct, we have a license for a 199 actually.
Guerra: Okay, so you really could see by what you offer—from primary care to inpatient to long-term care to ambulatory—that you really have a vested interest in becoming what everyone says is going to be an ACO and the whole idea of continuing of care and handoffs from one setting to the next. So you’re really right in line with making all that work.
Crowley: Correct. I mean, we’re certainly not saying that we’re going to be an ACO next year, but we’re looking at what the demands are and making sure that we are positioning ourselves well to handle that direction and do what we need to do to stay competitive.
Guerra: All right, so one of the core premises of any ACO is information flowing between venues. So let’s talk about your core systems and then we’ll talk about what connections you have or what integration or interfaces you have going on. Let’s do this logically. Let’s start with the ambulatory offices—both primary care and the specialties. Do you have a consistent rollout of EHRs in the owned centers?
Crowley: Yes, we do have eClinicalWorks in all of our centers. We put it in about a year and a half ago. We did it actually over a five-month time span, so we put it in 28 practices in about four months, which was quite a challenge. But we were also very lucky that we did it in conjunction with the HEAL 5 grant, which did give us some reimbursement for putting in the EMR. We had some deadlines because of that grant. But eClinicalWorks is in all of our practices and it’s in most of the community practices in the area. There’s really only one large practice in the area that’s on a different EMR and that’s Greenway.
Guerra: Okay. We’ll talk a little bit about the HEAL 5 grant a little bit later on. So you have a pretty solid rollout in the ambulatory world with eClinicalWorks. What about in your hospital—what do you have in there?
Crowley: We have Meditech.
Guerra: Okay, Meditech. And we’ll talk a little bit later about your career. I saw that you worked for Meditech a few years ago, right?
Crowley: Yes, it was a few years ago. Time does go by fast.
Guerra: And we’ll go into that too. What do have you going on for the Meditech-eClinicalWorks information exchange?
Crowley: We have a couple of different things going on. We connect through HIXNY, which is our health information exchange, and then we have a large number of interfaces going back and forth. We are in the process of going live with our lab-rad bidirectional interface. The challenge with that is the workflow changes within the hospital. The software piece for the providers to do the ordering is pretty straightforward, but it is a lot of workflow changes. So that’s probably been our most challenging project since we’ve gone live with eClinicalWorks. And I would tell you that I with our interfaces, we’re putting a spreadsheet together in the next couple of days, but I think they’ve tripled in the last two years.
Guerra: Wow. I guess when you have disparate projects and you need that information flowing, you have to do those interfaces. So even a cloud-type scenario wouldn’t get you away from that—or would it?
Crowley: No, not really, and I’ll talk a minute about the cloud, but the other thing to consider in our scenario is we have Allscripts in the ED. We actually deal with three different vendors. And of course that’s a real challenge because we did meet Meaningful Use this year, but we needed to make sure we had any information that was in Allscripts for ED through port within our Meditech applications. We had to do a number of rewriting the standard report for quality measures to make sure we captured the information where we were doing it. So it’s definitely a challenge having the different systems.
Guerra: Let’s round out the picture. What about in the long-term care facility. Does that use a different system?
Crowley: No. We use Meditech to do the billing, and they may even try to use it for some nursing documentation, but right now they are not highly wired. Besides billing, we don’t do a lot of clinical documentation there.
Guerra: Do you think you’re going to have to get there eventually?
Crowley: We definitely have to get there. Actually as part of our HEAL 5 grant, we are trying to come up with some solutions—not just for our long-term care, but also for the facilities in the area. We’re sending over a PIR (patient information reconciliation) form, which is what the long-term care facilities need to look at if they’re evaluating a patient coming to them. And we’re working with HIXNY so that whenever we have one of those forms, they could then push it out to the long-term care facilities in the area so that they can evaluate patients without needing to come in and look at charts.
Guerra: Let’s talk a little bit about how you got to where you are today from a software point of view. I imagine Meditech is the oldest or the longest implemented of the three systems we’re talking about, which will be Meditech, Allscripts, and eClinicalWorks. So, which came next, was it the ED product or the ambulatory product?
Crowley: It was Allscripts.
Guerra: Okay, so tell me approximately when that happened. You’ve been there about three and a half years, so were you there for the Allscripts products selection?
Crowley: No. AllScripts actually came in around 2004. Meditech I think was in the late 90s, but it could have been 2002—I wasn’t here. They put in Meditech first, but around the same time they started putting in Allscripts.
Guerra: Okay that was before you, so we really can’t delve into that too much—the thought process of evaluating the Meditech offering and that kind of thing.
Crowley: Well we’ve had plenty of discussions over that again because of the integration that’s really needed between the two. At that time, Meditech did not have the EDM product available so it was not an option for them. Even a few years ago, we did look at doing a transition to that because we needed to do a major upgrade of the Allscripts application. And also the hardware was quite expensive. We did go and look at it and we decided at the time that Allscripts was a better fit for us instead of trying to change. If we go to 6.0, we may look at that again.
Guerra: What version of Meditech are you on now?
Crowley: Magic 5.6—pretty much the latest because we did get the Meaningful Use upgrade.
Guerra: When you took that upgrade, was 6.0 a consideration, and if not, why?
Crowley: Money and resources. There are so many projects that are on our plate right now to even think about trying to do a complete upgrade for all of the Meditech applications. It was a little bit out of our reach. We do have it in mind, but probably not until around 2015. We’re trying to get everything in place so that by the time we do it, we will at least have everybody up and used to using computerized systems. We’re putting in advanced clinicals, so our providers will be used to doing documentation using these systems. I’m not a big fan of being a beta. We just don’t have the resources here to go down that path.
Guerra: So is it fair to say Allscripts is safe in the ED for a while? You wouldn’t upgrade to Meditech ED module on 5.6, would you?
Guerra: So they’ll be there for a while.
Guerra: Okay. And you were there for the eClinicalWorks selection, right?
Crowley: I was most definitely here for the eClinicalWorks selection.
Guerra: You can’t forget it, right?
Guerra: So let’s go back. You’re already dealing at that point with the Meditech- Allscripts integration and seeing what that takes, so you go down the road of looking at an ambulatory product. Was LSS an option? Would that have provided you with a better situation in terms of integration than what you’re dealing with?
Crowley: Oh absolutely. We looked at five different vendors and we rated them on a number of criteria. Integration was one and financial was another, but clinical got rated more in the evaluation. When we did this, we were also doing it with our community physicians. So we were trying to come up with one solution that we thought everybody in the area could use so that we really could share knowledge, and not just data, and help each other adopt EMRs, which was part of the HEAL 5 grant.
So not only did we have to take in our considerations of what was best for the hospital, but what was best for the community. And when we did the evaluation, eClinicalWorks came out on top. They were used by a large percentage of practices in the area.
Guerra: And when that was made known, did you say, ‘Oh boy.’
Crowley: Yeah, I mean if I told you my biggest challenge here—and what will be the challenge going forward—it’s to try to maintain three different systems; trying to get the reporting done that you need and the skill sets. Resources are so tight, and you have certain people that just know eClinicalWorks and a few people that just know Meditech, and that’s a challenge. It’s not as easy for somebody who does eClinicalWorks to take a call and help a customer who’s having a problem with the nursing module. It’s next to impossible.
Guerra: I see what you’re saying. You’re talking about cross-training your staff to be able to handle any calls to come in regarding these three systems.
Crowley: Right, but that’s a good point. It’s not just my staff. You have to think about the providers and most of our providers are trained on eClinicalWorks and Meditech because we use Meditech PCI and in the ED they actually have to know a little bit about all three systems.
Guerra: Yeah. Talk to me about upgrades. You’ve got three systems now, so you take them all and get all the interfaces written that you want, but at one point or another, each of those three is going to need an upgrade—some major and some minor. Talk about how upgrades affect interfaces that are in place. Do they have to be revised, completely redone, and then retested? How does that work?
Crowley: The most important thing is that you really develop a solid project plan in order to test them. We did have to upgrade all three systems this past spring, so we upgraded Meditech, eClinicalWorks to 9.0, and even Allscripts. So that was a challenge. In some ways I call it the Big Bang theory because we all did all three very close together. The advantage of doing that is we really did the interface testing pretty much at one time, as compared to if we had done one in the fall and then waited four months and did another in the spring. You’re going to be retesting those interfaces all over again.
The biggest takeaway I have from our last experience was that we needed to develop scripts. Really make sure you have a test script so that you almost don’t have to think about it—you go in, you put your patient in, you know you’re going to do this, and the interfaces are built in as part of that script. We did not, to be honest, have to do a whole lot of rewriting of the scripts for our last interface. But that’s going to vary upgrade to upgrade. With some upgrades it’s going to be pretty straightforward, and then you’re going to get that upgrade where almost everyone of them will have issues.
Guerra: When eClinicalWorks came to the top, did you try to advise or counsel anyone—your CEO or CFO—and say, ‘That’s fine, but here’s what it’s going to take.’
Crowley: I think so. I certainly would say our CFO very much wanted LSS. From his standpoint it was by far the best option because of course he’s geared to looking at it just from a financial standpoint. But while I think I understood what the challenges would be, I also felt that we were making the right decision because I did not get buy-in from the executives nor did I get provider buy-in for LSS. So had we gone down that path without that buy-in, no matter how much I said it was smooth for IT, I just don’t think it would have been successful.
Guerra: At any point did the scenario come about where you said, ‘We’d love to have acute ambulatory integration or hospital-physician practice integration. LSS is not going to work; therefore, let’s revisit the whole Meditech situation. Maybe we want to get on a on a system where we can be on one inpatient and outpatient. Or was it never even a consideration to get off Meditech?
Crowley: It was never even a consideration, and for a couple of reasons. One was that we were putting in the EMR, again on a time constraint because of the HEAL 5 grant. We certainly didn’t have the resources to also look at trying to do a whole vendor selection and come up with another alternative. Plus, overall we’ve been happy with Meditech.
I think for our environment, Meditech is a good fit. We have billing down pat. We have our abstracting down pat. That’s very important to our core business. So to take on switching that out at the time—no, it wasn’t even addressed. I think we were focusing on trying to get the advanced clinicals going since we had all of our core applications up. And to be honest, I’m not sure that besides Epic, there would have been another vendor out there that could do the complete package. I know Siemens right now is trying to come up with a more robust package but overall we do have executive buy-in for Meditech in terms of the core HIS, so while we may not have had it for LSS or for the ambulatory side, we definitely have support for the inpatient side.
Guerra: How would you describe the sustainability of having those three products? How would you just communicate what it takes?
Crowley: That’s a great question. I don’t think I really have.
Guerra: You just do it, right? Because you have to do it. But if you thought about it, how would you describe what it takes from the IT shop?
Crowley: I think it’s going to be the major P’s which is planning, planning, prioritizing, and understanding the projects it will take in order to keep everything going. So you really need to understand that when somebody says, ‘I want to do this project for ECW,’ you have to say, ‘Okay, wait a minute, is that going to impact the interfaces that we’re doing? Is that going to impact something that we’re doing on the inpatient side and can we do that?’ So the biggest area that we need to get stronger at here really is I think understanding the scope of projects and understanding how to plan and keep all of the items in sync. But it’s a huge challenge.